星空入口

Sidestep Top Medical-Necessity Denials

Certain claim rejections run rampant in most hospitals, usually because of ambiguous local medical review policies (LMRPs) or vague documentation. The good news is they're all preventable.
 
Is your facility falling prey to these common medical-necessity traps? Give yourself a checkup:
 
Cardiology diagnoses: The major culprit in these denials is tricky LMRP treatment of 786.50 (Chest pain, unspecified), says Darren Carter, MD, president of Provistas in New York City. Ask your fiscal intermediary (FI) about its policy, he says. Unless a more specific code is appropriate, use 786.59 (Other symptoms involving respiratory system and chest) for patients with cardiac symptoms this code is equally valid and gets far fewer denials, he explains.
 
Magnesium tests: You've got two weapons against these lab claim rejections: physician education and separating magnesium tests from other ordered tests. Magnesium is an electrolyte useful for multiple diagnoses, but FIs won't pay for many of them because local medical review policies let them slide. So if a patient has multiple diagnoses, make sure you clearly indicate the diagnosis for which magnesium was ordered.
 
Outpatient prothrombin (PT) time tests: These denials are the easiest ones to curb physicians just need to document explicitly that the patient got the test for Coumadin therapy. This cue rings immediate bells with coders to use V58.61 (Long-term [current] use of anticoagulants). But because there's almost no other reason to use PT and physicians don't remember that coders don't code from the lab tests themselves, they often forget to write down "Coumadin."
 
Although many facilities share these denials, keep in mind that particular frequent-rejection areas depend on the range of services that your hospital offers, regardless of whether you're billing for your physicians and whether you're analyzing your remittance advices on an ongoing basis, Carter says.


- Published on 2003-06-01