Case Management

Denial prevention via records and contract language

Case Management Monthly, June 1, 2010

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Documentation by the medical staff is one of the pillars that lead to reimbursement success. 

Most physicians and their extenders do not think in terms of claims denial prevention, but rather in terms of how to document clinical findings, symptoms, and signs, and what the plan of care will be. 

However, the medical record also needs to stand as proof to an outside agency (e.g., the Quality Improvement Organization responsible for determining the medial necessity and status of the admission) that the medical care provided by the physician and the facility was warranted and actually performed. 

In executing a plan to prevent denials, clinical documentation improvement specialists and case managers should work together to educate the medical staff about the need to describe the acute episode in such a manner that will unequivocally demonstrate that the patient cannot be treated at a lower level of care. 

Denial prevention does not exist in case management alone. Case management staff, medical staff, executives, admissions, registration, health information management, nursing, and any other department that has a hand in the business side of patient care must share it. 

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Case Management Monthly.

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