Wiki Addendum after denial

[carol ann]

I hope someone can give me some answers. We have alot of denials for labs and radiology that were not checked for medical necessity. They were submittied to medicare and were denied. For instance-PT, PTT test. All which have LMRP/NCD. Can i go back now, query the Dr., get a new Diagnosis and resubmit? Or should i just let it go and move on.

 

[btadlock1]

I hope someone can give me some answers. We have alot of denials for labs and radiology that were not checked for medical necessity. They were submittied to medicare and were denied. For instance-PT, PTT test. All which have LMRP/NCD. Can i go back now, query the Dr., get a new Diagnosis and resubmit? Or should i just let it go and move on.

In situations where you have a claim denial for lack of medical necessity, you may sometimes need to ask the doctor for clarification on a portion of the medical record that was difficult to interpret, or where their rationale (behind the patient's diagnosis/treatment) isn't clear.

That doesn't mean that they can add details that didn't really exist before the claim denial; if the doctor does have a basis for adding a Dx to a note (after the claim denied), it had better be a good reason - that comes with explaination. A doctor that habitually leaves important details out of documentation should be informed of the risks that they are taking; a payer audit, or worse - an RAC audit , could lead to tens of thousands of dollars in refunded payments, fines, and possibly their ability to participate with Medicare/Medicaid. Willful neglect is viewed as harshly as fraud. Tread lightly, and remember; you code for accuracy of the visit, not for payment. The doctor has to follow the same rules with his/her documentation.
Okay, I'll get off my soapbox now...

 

[MMAYCOCK]

Corrections are a legitimate occurance in documentation of clinical services

I hope someone can give me some answers. We have alot of denials for labs and radiology that were not checked for medical necessity. They were submittied to medicare and were denied. For instance-PT, PTT test. All which have LMRP/NCD. Can i go back now, query the Dr., get a new Diagnosis and resubmit? Or should i just let it go and move on.

This is from CMS:

Amended Medical RecordsLate entries, addendums, or corrections to a medical record are legitimate occurrences in documentation of clinical services. A late entry, an addendum, or a correction to the medical record, bears the current date of that entry and is signed by the person making the addition or change.
When making a correction to the medical record, never write over, or otherwise obliterate the passage when an entry to a medical record is made in error. Draw a single line through the erroneous information, keeping the original entry legible. Sign and date the deletion, stating the reason for correction above or in the margin. Document the correct information on the next line or space with the current date and time, making reference back to the original entry.

Here is a link to a good detailed explanation of what types of corrections/amendments are appropriate.

https://www.noridianmedicare.com/pro...reprint.pdf?

While I agree that corrections should not be made just to get paid, I do believe that if the denial triggers the review which shows the need for correction, the correction should be made and a correct billing submitted.
It may be a good idea to review all before they are billed so you can guide the physicians to correctly document the needed information before you bill. After 3 months or so of doing this, you should have much better documentation and as a result, reduced denials.
Melanie