This week’s updates include revisions to State Operations Manual (SOM), Appendix A -Survey Protocol, Regulations and Interpretive Guidelines for Hospitals; Claim Status Category and Claim Status Codes update; and more!
The utilization review (UR) process is a required process to determine if the care a physician provides the patient is medically necessary and reimbursable by the payer source. While the exact definition of medical necessity varies amongst insurers and government agencies, section 1862 (a)(1)(a) of the Social Security Act provides the basic groundwork, stating, "Notwithstanding any other provisions of this tile, no payment may be made … for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member."
Identify the new audit process that will be used by one of the two quality improvement organizations in charge of short stays under the 2-midnight rule.
Physicians are constantly reminded that healthcare is undergoing significant change. October 2015 marked one more landmark change: the shift to ICD-10. Many physicians have worried about the transition and likely dreaded the loss of familiar terms, efficiency, or income. How can coders, HIM professionals, or clinical documentation improvement (CDI) specialists engage with physicians to help them now that ICD-10 has been implemented? Let's explore some strategies.
Regulations adopted in October 2013 allow hospitals to bill Part B for inpatient cases that are internally reviewed and "self-denied" within one year of the date of service. But utilization review staff are unsure when to use the old condition code 44 process and when to opt for the new process using condition code W2. Operationalizing these rules can prove to be challenging, causing recoding, rebilling, and expensive slowdowns in the revenue cycle.
