Revenue Cycle

From the field: Physician order claim denial to favorable result

Medicare Update for CAHs, December 14, 2011

A RAC coordinator in Region C recently reached out to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc. with a question about a specific claim denial.

The provider stated that Connolly denied a claim at their facility due to the physician not signing the telephone order to change the patient status from observation to inpatient. However, in defense of the patient case, the treatment was medically necessary by all documentation, so the provider wanted to know if there is a case for an appeal.

Hoy replied that the Program Integrity Manual – which contains audit standards – specifically states in the signature section that Conditions of Participation (CoPs) are not conditions of payment. The requirement that a verbal order be signed within 48 hours (or state-specified timeframe) is a Medicare Condition of Participation (CoPs). This appears to mean, according to Hoy, that if you don’t have a verbal order countersigned within 48 hours, you may have violated the CoPs, but it does not preclude payment for the claim.

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