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!
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.
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."
With the transition to ICD-10, some documentation issues have required the capture of new information while others involve updated, modified, and otherwise expanded documentation needs. As we gain experience with ICD-10 and more questions are answered, physicians, coding professionals, and other clinical staff must continue training in clinical documentation improvement (CDI) and ICD-10. Now comes the hard work: ensuring consistency and reliability of ICD-10 coded accounts and the analytics that will be the outcome of ICD-10 data.
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.
