Clinical validation reviews and queries ensure that the documented diagnoses and clinical indicators hold up to inspection. Use these strategies to head off clinical validation reviews and improve documentation.
Q: How should we handle denied claims when the payer refuses payment under the billed status? Do we need to document that the status was changed only because the payer did not agree to any other options?
Managers should not assume that they can review every guideline, every item in Coding Clinic, or every coding-related issue targeted by the OIG or Recovery Auditors. However, those issues that have been identified as the result of denials, external coding audits, or quality initiatives should surface to the top of the audit list for the coding manager.
As Medicare Advantage makes strides to becoming the new norm, organizations need to establish new processes, educate staff, and advocate for patients. Learn how your organization can keep pace with change before it’s too late to catch up.