Intersect Healthcare urges CMS to clarify the modified and codified “reasonable and necessary” definition and consider how the MCIT Program will affect hospitals. The letter also notes that Interest Healthcare does not support effecting a modified and codified definition of “reasonable and necessary” as well as the FDA’s Breakthrough Program through the MCIT unless the agency considers clinical evidence supported by the practice of medicine.

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The Journal of AHIMA’s March 2019 issue included an important article regarding recent upticks in commercial payer denials—specifically coding denials. Co-authored with Yale New Haven Health, the article encourages AHIMA members to build knowledge, awareness and understanding of emerging trends as the first step toward “creating a proactive appeal strategy.”

The full article is available at http://bok.ahima.org/doc?oid=302681#.XJKFCqeZO2k and a summary of our key takeaways is listed below.

Be Aware of Coding Denial Trends

Four denial trends for coders to know are highlighted in the article. Building awareness of these trends across the entire revenue cycle team is recommended—including communication with coders, physicians and clinical documentation improvement teams.

Heightened focus on clinical validation. Coders should know the difference between coding denials and clinical validation denials. Payers are using a combination of clinical and coding references, making it hard to determine the type of denial.

Shift from inpatient to outpatient denials. Outpatient denials are the new wild west for payers. Inconsistent timelines, difficulty getting responses and overall ambiguity are common. Because outpatient cases typically represent lower revenue, the cost to appeal must be carefully considered.

Higher volume of HEDIS and Risk Adjustment requests. Larger volumes of records are being requested, which increases operational costs in HIM. Curb these expenses by including limits in the number and types of medical requests that may be submitted by payers.

Queries and review dates subject to payer scrutiny. Payers have heightened their scrutiny of queries. The article provides three recommendations to ensure queries are complete and appropriate.

The post Coding Denials: Four Trends and Six Tips from Journal of AHIMA appeared first on PayerWatch.

Permission to reproduce granted by RACmonitor

By Denise Wilson, RN, MS, RRT

EDITOR’S NOTE: With Hurricane Irma expected to impact Miami-County today, this story, updated from a news alert posted last week on the ICD10monitor website, offers lessons learned for hospitals and caregivers in the path of Irma.

Our thoughts continue to go out this week to the people of Texas, especially the first responders and caregivers and all who have been impacted by Hurricane Harvey. Harvey made landfall in Texas on August 25th as the strongest hurricane to hit the U.S. in more than a decade. Since Harvey’s landfall, southeast Texas has experienced catastrophic flooding, devastation of homes and loss of lives.

When catastrophe strikes, America’s hospitals are provided administrative relief from medical review and some benefit integrity responsibilities (absent any determination of fraud or abuse) by the Centers for Medicare & Medicaid Services (CMS). This is done automatically, so to speak, without the affected hospitals having to request it. The president declared a state of emergency for Texas on Aug. 25 and U.S. Department of Health and Human Services (HHS) Secretary Thomas Price declared a public health emergency for Texas the next day, allowing CMS waivers to be put in place based on Section 1135 of the Social Security Act.

Some of these waivers include exemption from noncompliance with the Emergency Medical Treatment and Labor Act (EMTALA) for transferring an individual to another hospital when that individual has not been stabilized, if the circumstances of the catastrophe warrant the need for the transfer. Also waived are limitations on payments for healthcare items and services furnished to individuals enrolled in a Medicare Advantage plan when care is provided by healthcare professionals or facilities not included in the plan’s network.

Chapter 3 of the Medicare Program Integrity Manual, Section 3.8, Administrative Relief from Medical Review During a Disaster, outlines the administrative flexibility available to Medicare Administrative Contractors (MACs) and Recovery Audit Contractors (RACs) during this time. A disaster is defined by CMS as a catastrophe that causes enough damage to destroy medical records, interrupt normal mail service, or otherwise significantly limit a provider’s daily operations.

CMS defines different types of administrative relief from audits based on whether the provider was directly affected by the disaster, meaning actual medical records were destroyed, or whether the provider was indirectly affected by the disaster, meaning mail service was interrupted. If you are a provider who has suffered such an event, be sure to understand what relief is available from CMS and ensure that future audits and denials take into account the period of time when the catastrophe occurred.

Mother Nature will always be a force with which to be reckoned. It’s my sincere hope that the caregivers in Texas will be provided all of the support, resources, and relief they require to manage the devastating effects of Hurricane Harvey and give care and comfort to those in need.

The post Regulatory Waivers, EMTALA Exemptions Effective During Hurricane Harvey appeared first on PayerWatch.