By Stacie L. Buck, RHIA, CCS-P, RCC, CIRCC, AAPC Fellow
A long term project of mine started with a frantic phone call to my office one day. The person on the other end of the phone was going through a massive prepayment review with their Medicare contractor. Approximately 2-3 months before that call came, the Program Safeguard Contractor began requesting records for some claims. At that time no one thought much of it, but over time the number of requests continued to increase and eventually the provider found themselves on 100% prepayment review. Why? The contractor was denying 60% of the claims for medical necessity. The claims denial rate continued to hover around 60%, keeping the provider at 100% prepayment review month after month. By the time my phone rang, thousands of claims were pending with the Medicare contractor and the turnaround time from the medical reviewers was extraordinarily slow.
This nightmare scenario could have been avoided if the provider had performed its own internal audit of coding and documentation practices utilizing an independent third party. Once the root cause was identified, we were able to resolve the issues within a couple of weeks. However, the damage was already done and hundreds of claims were still sitting unpaid and under review, with the provider missing out on one-third of their revenue stream for several months. It took approximately 18 months after this nightmare began to finally bring it to a close after writing well over one thousand appeals.
So what was found to be the trigger for this prepayment review? Lack of proper documentation including incomplete/invalid diagnostic test orders and radiology reports not containing adequate documentation to support the CPT® codes that were billed on the claim were the cause.
Don’t let this happen to your facility! Join me for my session, “Covering Your Assets: Avoiding Common Risk Areas in Diagnostic Radiology,” on Tuesday, July 24 at 2:15 PM at the AHRA 2018 Annual Meeting & Exposition. This informative session will feature a discussion on the following topics:
- Diagnostic test order requirements – who can order tests and when
- Common documentation problem areas – including 3D rendering, CTA, duplex exams
- ICD-10-CM diagnosis coding – choosing the correct primary diagnosis code to support medical necessity
- Local coverage determinations – more than just a list of “payable” diagnosis codes
See you in Orlando!
Stacie L. Buck, RHIA, CCS-P, RCC, CIRCC, AAPC Fellow is the president & senior consultant at RadRx. She can be reached at firstname.lastname@example.org.