Medicare Review Audit

espforu

Guru
Local Chapter Officer
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140
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NAPLES, FL
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Good Morning,

Has anyone appealed a Medicare focused review? I have a provider where Medicare did a review and has down coded many of his visits based on Medical necessity. I understand on many of them the justification, but there are several which I am agreeing with the providers coding.

I noticed on this review Medicare is not using a coder but a RN. Is this the norm for them? Does the nurse understand the MDM component?

Any thoughts are greatly appreciated. I just do not want to appeal and he be a target of future audits. I know all auditors have their own opinion.

Thanks !
 

mray85

Networker
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94
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Richardson, TX
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A Registered Nurse goes through more education in regards to A&P, disease process, etc. than us coders do. I know a few RNs who work for insurance companies and they know coding just as well as I do, if not better. Use of RNs for medical review is the norm for most insurances.

In your case regarding EM, I would not appeal them. If Medicare is down coding the visit then that is a big flag. Commercial insurances can be subjective, but I would follow the guidelines set forth by CMS. There is a manual that explains the components and such.
 

thelton

Networker
Local Chapter Officer
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91
Location
Farmington, AR
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I respectively disagree with the statement "don't appeal". I have appealed many claims down-coded by Medicare successfully. I use the MAC's own audit form and annotate the documentation for each element of the history, exam, and MDM. I also send a letter with the reconsideration request summarizing the documentation. That said, I don't appeal the few that I agree with the down-coding but those are by far the minority. It is my opinion that it could also raise a "red flag" with the MAC if you don't request a reconsideration for the ones that were down-coded in error not to mention you are leaving reimbursement on the table that your doctor should have.
 

espforu

Guru
Local Chapter Officer
Messages
140
Location
NAPLES, FL
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Thank you both for your opinions on this. There are only 3 charts out of 40 reviewed which I disagree on. It is not a lot, however we would like to understand the rational for the decision.

Screenings (Depression, alcohol, etc.) and Prolia injections but what it looks like was when the records were sent, the office did not send the documentation proving time or the justification on the injection just the visit not for the injection and not the history. The provider wants to have these reviewed. I do not think this would be a red flag if we ask for this. Or will it?
 

mitchellde

True Blue
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13,490
Location
Columbia, MO
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I am not sure why the notes for the onjection would be separate from the visit notes and why they were not sent as a pRt of the request. However, if the record was not audited with complete information then by all means appeal. Be sure to explain why this extra information was not included for the initial review.
 

teresabug

Expert
Messages
407
Location
Buckeye, AZ
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one reason may be the EHR software being used. The group I audit for use Nextgen EHR. The providers sometime "forget" to finalize the chart note when they do a procedure. When this happens, the procedure data does not print out on the master note. The data is indeed in the patients' chart but it does not print out in the master note. Some providers still on paper charts more than likely use a separate template for procedures. Maybe the staff member that sent in the documentation forgot to make a copy of the procedure note...
 
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