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."
After several delays, ICD-10 implementation is finally upon us. The healthcare industry has spent years planning, training, and testing?and now the moment we have all been waiting for has arrived. But don't breathe a sigh of relief just yet.
Each new CMS fiscal year, MS-DRG weight and classification changes in the CMS IPPS final rule are closely scrutinized by the coders and clinical documentation improvement (CDI) specialists on the CDI team to identify any potential impact on documentation capture and code assignment processes.
Provider-based clinics and departments are increasingly common, but the rules for provider-based billing can often be confusing, especially given recent changes to modifiers and place of service codes.
CMS released its proposed rule for stage 3 of the Medicare and Medicaid Electronic Health Records (EHR) Incentive Programs (https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-0668...) in March. The intention is to simplify the EHR Incentive Programs, drive interoperability, and allow providers to further focus on patient care. The rule proposed a transition to a single meaningful use stage, with stage 3 being the final stage in the program. It would incorporate portions of stages 1 and 2.
Having recently returned from teaching the HCPro Accreditation Specialist Boot Camp, I was reminded that our medical staffs continue to have challenges with documentation requirements that have existed at least as long as most of us have been HIM professionals. I thought it was a good time to remind HIM professionals and their medical staff of 12 documentation requirements that are still a major focus during Joint Commission surveys, and persist in being a record completion challenge.
