Health Information Management

News: Recovery Auditors continue medical necessity reviews

CDI Strategies, April 11, 2013

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Medical necessity for cardiovascular procedures is the top overpayment issue for three out of the four Recovery Auditors in FY 2013 first quarter (October 2012–December 2012), according to the most recent release of improper payment statistics.

Diversified Collection Services (Region A); CGI, Inc. (Region B); and Connolly, Inc. (Region C) each listed this as their top issue. HealthDataInsights (Region D) listed medical necessity for minor surgery and other treatment billed as an inpatient stay as its top issue. To date, Recovery Auditors have collected $3.9 billion in overpayments and uncovered $302.6 million in underpayments.
Medical necessity is also a theme in the most recent issue of the Medicare Quarterly Provider Compliance Newsletter. Volume 3, Issue 2, January 2013 references medical necessity for the following:
  •  Back and neck procedure excluding spinal fusions. Recovery Auditors found a significant percentage of claims for MS-DRG 491 to be not medically necessary for the setting billed. Recovery Auditors also found that patients didn’t meet criteria for inpatient admission due to a lack of intraoperative or postoperative complications and because the recovery phase was within expectations for the procedure. CMS provides two clinical examples that demonstrate these points.
  • Syncope and collapse. Recovery Auditors found that the signs and symptoms documented weren’t significant or severe enough to warrant an inpatient admission. CMS provides two clinical examples that demonstration this point.
  • Other musculoskeletal system connective tissue operating room procedure with CC. Recovery Auditors found that requirements for inpatient status as outlined in Medicare’s regulatory documents had not been met. CMS provides two clinical examples of improper setting that demonstrates this point.
For more information about whether documentation supports the medical need for services rendered, view the Medicare Program Integrity Manual, Pub 10008, Chapter 3, Section 3.2.3 A.
Editor’s Note: This article originally published on

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