Tip: Conduct a chart audit
Patient Access Weekly Advisor, March 26, 2008
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Hospitals are susceptible to the greatest losses in the area of medical necessity for outpatient tests and services. An effective medical-necessity auditing and monitoring process is a simple way to cut your losses and boost revenue. A chart audit should focus on the following:
- Verification of correct CPT-4 and ICD-9 code assignment based on the documentation of medical records
- Review of the appropriate NCD or LCD to determine whether the test was medically necessary
- Appropriateness of denial
- Whether a valid ABN was obtained; if so, whether the appropriate modifiers/condition codes were used on the claim
- Whether the incorrectly coded claims that Medicare denied can be resubmitted for payment, determining which denials the facility can appeal
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