News

Q: We are having difficulty getting our patient financial services group to route claims back to us that hit edits for lack of a medically necessary diagnosis. We have found one procedure-to-diagnosis pairing that is faulty because it is a crossover from a local coverage determination (LCD) that has multiple procedure codes related to a procedure. One of the procedure codes happens to be on this claim, but as a standalone procedure and not as part of the service described by the LCD. How do we get them to understand that the edit is not always correct for the individual situation?

This week’s updates include substantial revisions to QIO Manual for reviews involving potential administrative sanctions; Comprehensive Care for Joint Replacement Model (CJR) provider education; and more!

Despite industry pushback and several delays, ICD-10 implementation has, against all odds, gone relatively smoothly for the vast majority of providers, leading CMS to tout its success in a recent blog post from Andy Slavitt, CMS’ acting administrator. 

An international task force with expertise in sepsis pathobiology, clinical trials, and epidemiology released updated definitions for sepsis and septic shock this week, which were last revised in 2001.

Q: We are having a heated internal discussion regarding reporting drug infusion charges when a multi-lumen catheter is being used. Nursing wants to charge for both lumens as if they were a separate line because they are hanging different medications and fluids through each one. When we tried this on a claim, the edits were either saying we needed to append a modifier for one of the initial hours of service or we hit the medically unlikely edit because of too many units. How is this supposed to be reported?

Recent national coverage determination transmittals could mean changes to coverage of certain preventive services. Referring providers, revenue cycle and integrity staff, and others dealing with coverage of these services should be aware of and make adjustments to their processes accordingly.

There are two newly approved Recovery Auditor issues.

This week’s updates include Critical Access Hospital (CAH) Recertification Checklist for evaluation of compliance with the location and distance requirements; core quality measures collaborative release; and more!

Q: How does TOB 131 bump against TOB 121 in regard to the 72-hour rule?

CMS won’t release guidance on the payment impact of Section 603 of the Bipartisan Budget Act of 2015 until the 2017 OPPS proposed rule, but the American Hospital Association (AHA) has weighed in with a letter to Congress urging the government to reject further site-neutral payment policies.