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Dont' be the Queen of Denials ! (or King as the case may be)

Ranking among the top three reasons for Medicare denying payments are improper documentation (documentation does not support medical necessity) and coding errors. Because of this fact, it seems appropriate to spend some time talking about these issues. My next few blogs will address the rules, but more importantly how to teach people to comply with them.

What is medical nesessity and how do we provide evidence of it?

Simply put, medical necessity is the patient's need for complex nursing care, medical management and intensive therapy. Medical documention ought to specify why patients require these services. Simply stating it is not enough. The claim for this need must be supported. That means, pre-admission screening and admission documentation, in particular (those conditions present at admission) are supported in a comprehensive manner. Each condition needs to appear on a physician problem list, be coded on the IRF-PAI, be described in the the nursing initial assessment and detailed on the therapists initial evaluation. With proper checklists in place, this can actually be done efficiently. What a great beginning this would be. We'll talk about it more as this series of blogs continues.