Health Information Management

News: CMS approves first of RAC medical necessity reviews

CDI Strategies, August 19, 2010

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The Centers for Medicare & Medicaid Services (CMS) recently approved the first “medical necessity review” audits for the recovery audit contractor (RAC) program, according to an August 10, 2010 American Hospital Association (AHA) release.

CMS takes the position that the decision to admit a patient is a “complex medical judgment” made by the patient’s physician after consideration of the severity of the signs and symptoms; medical probability of an adverse outcome for the patient; and the need and availability of diagnostic studies.
A RAC will have to find clear evidence in the medical record using CMS and clinical guidance to make the opposing determination that the physician’s judgment was correct, says Debbie Mackaman RHIA, CHCO, regulatory specialist for HCPro, Inc.
The newly approved audits include 18 types of inpatient hospital claims and one durable medical equipment claim. On August 12 CGI, the Region B RAC, released its list which included common items such as syncope, kidney and urinary tract infections, and respiratory disease.
Other RAC as of press time had not released their lists of medical necessity audit items. It is unclear as to which RACs will post which issues to their websites, as required by CMS. According to the AHA, these issues, as well as the accompanying additional documentation requests (ADR), are expected to be released within the next two weeks.
When providers receive these ADRs, they should take the time to carefully review all documentation well in advance of receiving the review results letter, suggests Mackaman.
“The review should involve clinical staff and CDI specialists, as well as a physician advisor in preparation for a denial and possible appeal,” she says. “Knowing where you stand and being prepared to take on the denial will save critical time as these issues continue to unfold.”
Editor’s Note: ACDIS members received this news alert on Wednesday, August 11. Visit the Revenue Cycle Institute to read the complete report.

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