Wiki Pre-Payment Audits from Medicare

[efuhrmann]

I would like to hear if anyone else is experiencing these lovely audits from Medicare? The codes that are being looked at(from my clinic) are mostly 99204, 99205 and 99215's. I agree with Medicare on their findings 75% of the time. The problem I have are inpatient consults(in theory), that, as instructed are coded 99231-99223. After reviewing the notes Medicare is determining these are not medically necessary and give us ZERO DOLLARS in reimbursement.
Is there anyone else out there willing to share their experience with these audits? Does anyone know how to appeal these determinations?

 

[kagal0816@verizon.net]

Prepayment Audits

Hi - I work in Orthopaedics and not only are we getting hit with audits on the office visit levels, but our hospitals are getting hit with DRG 470 prepayment audits also.

When sending in records, I always include a letter with the medical records indicating where the pertinent information can be found in the packet. If there is a rejection, I review the information and file an appeal based on what I believe is missing or inaccurate in their refusal to pay for services. Auditors (and their company's contracts) are based on their ability to review information and make a determination.

Prior to sending office records for level of service, I first audit the record and see the level I come up with, and then based on this information draft my letter.

I was not clear on what exact information you needed, so I hope that this helps.

Karen Gallagher, CPC, COSC

 

[suemt]

I'm trying to determine if Novitas in CO is doing global prepayment reviews, or if they are targeted prepayment reviews. Usually I can look this up on the MAC's website, but the Novitas website is under construction. Does anyone know the reasoning behind these reviews?