In Coding
Apr 5th, 2019
“Medical necessity” is difficult to define, with as many different interpretations as there are payers; however, most definitions incorporate the idea that healthcare services must be “reasonable and necessary” or “appropriate,” given a patient’s condition and the current standards of clinical practice. Yet typically, the decision as to whether services are medically necessary is made ...
In Coding
Jan 23rd, 2019
Prior to receiving medical care, some potential patients may ask for a meet and greet visit with a physician. We expect this kind of “shopping around” when it comes to other types of purchases, and it’s become more common in healthcare. For example, many expectant parents now interview obstetricians before deciding who they’d like to ...
Know what payers are looking for in subsequent hospital care claims, and how to give it to them. Medical necessity is the No. 1 consideration when selecting an evaluation and management (E/M) service code. Without medical necessity to support billed services, your practice is put at a serious noncompliance risk. Consider, for example, one payer’s ...
In Billing
May 25th, 2018
Spondylolisthesis is a perfect example of why ICD-10 requires improved clinical documentation. In ICD-9, Acquired spondylolisthesis was reported with one code, 738.4. In ICD-10, there are 14 codes: M43.00 Spondylolysis, site unspecified M43.04 Spondylolysis, thoracic region M43.05 Spondylolysis, thoracolumbar region M43.06 Spondylolysis, lumbar region M43.07 Spondylolysis, lumbosacral region ...
In Audit
Nov 22nd, 2017
The Office of Inspector General (OIG) is recommending Rush University Medical Center, Chicago, Ill., refund $10.2 million in Medicare overpayments based on an audit sample of 120 inpatient and outpatient claims. Rush allegedly did not fully comply with Medicare billing requirements for 57 of the claims, resulting in overpayments of $814,150 for the audit period (2014-2015). The OIG ...