Tip: Reviewing medical necessity of inpatient denials
Case Management Weekly, December 8, 2010
A two-step approach may be helpful when reviewing the medical necessity of an inpatient denial. Begin the review by determining whether the case meets inpatient screening criteria used by the facility. Case management, utilization review, or other clinical staff may complete this first step; it needn’t include a physician reviewer. If a case meets screening criteria applicable at the time of the admission, consider an appeal.
If a case fails to meet screening criteria, move on to step two, a physician advisor review of the case. Some cases won’t meet screening criteria, but based on Medicare’s inpatient guidelines, nevertheless qualify for inpatient admission. If a physician advisor determines that a case meets Medicare requirements for inpatient admission and your facility decides to appeal the case, the physician advisor’s review may serve as the basis of your appeal statement.
This week’s tip is adapted from The RAC Survival Guide: Successful Management of Recovery Audit Contractors published by HCPro, Inc. For more information on this book or to order your copy, visit the HCMarketplace.
Do you have a question about a case management topic? Send it to Associate Editor Ben Amirault at email@example.com. An answer to your question might appear in a future issue of Case Management Weekly.
- Complications from immobility by body system
- Differentiate between types of wound debridement
- Note similarities and differences between HCPCS, CPT® codes
- What does case-mix index mean to you?
- Pneumonia with a negative chest x-ray: Clinical diagnoses, physician documentation, and coding guidelines
- OB services: Coding inside and outside of the package
- Don’t forget the three checks in medication administration
- What is the difference between an IPA and a medical group?
- Fracture coding in ICD-10-CM requires greater specificity
- ICD-10 tip: Coding for infectious and parasitic diseases
- How coders can build a successful relationship with their physicians
- Note from the Instructor: Provider-Based vs. Freestanding Locations: Financials Flip-flop with New Packaging
- No Match, no problem: Recruitment and beyond
- Improve documentation with 15 tips for timely record completion
- HIPAA: Safeguard Residents’ PHI
- Got stickers? How one PA hospital uses labels to reduce medication errors
- Follow these tips to properly report bladder catheter codes
- Clinical competency committee composition
- Charge for venipuncture separately
- Alarm management plans that improve patient safety