Read the article Diagnosis Coding and Medical Necessity: Rules and Reimbursement by Janis Cogley.

This article discusses how Medicare carriers and fiscal intermediaries (FIs) use coverage determinations to establish medical necessity. When the condition(s) of a patient are expected not to meet medical necessity requirements for a test, procedure, or service, the provider has the obligation under the Beneficiary Notices Initiative to alert the Medicare beneficiary prior to rendering the service. The Medicare beneficiary is notified via the Advance Beneficiary Notice (ABN).

The Medicare beneficiary may choose to complete the ABN and provide out-of-pocket reimbursement for the service, or may elect to not have the service performed. If the provider fails to alert the Medicare beneficiary with an ABN, then the facility may not balance bill the patient for the non-covered charges denied by the Medicare Carrier, FI, or MAC.

Scenario

You are the revenue cycle coordinator for Anywhere Hospital. The decision support department at Anywhere Hospital is concerned because the volume of remittance advice remark code #M39 (The patient is not liable for payment for this service because the advance notice of non-coverage you provided the patient did not comply with program requirements.) on Medicare remittance advice logs has increased over the past three months. Further analysis of the denied claims shows that 75 percent of the claims have code 93798 (physician services for outpatient cardiac rehabilitation with continuous ECG monitoring) present. Therefore, they are requesting that the revenue cycle team perform further investigation for this issue.

After auditing the remittance advice logs and medical records for a sample of cardiac rehabilitation claims, the revenue cycle team has determined that medical necessity is not being met for code 93798. Further, they have discovered that a new LCD was issued for code 93798 in October (three months ago). The only ICD-9-CM diagnosis codes that support medical necessity for code 93798 are

410.00410.92 Acute myocardial infarction of anterolateral wall episode of care unspecified through acute myocardial infarction of unspecified site subsequent episode of care

412 Old myocardial infarction

413.0413.9* Angina decubitus through other and unspecified angina pectoris

V45.81 Post surgical aortocoronary bypass status

* There is no specific code assigned to stable angina. Therefore, these codes should be used to identify stable angina and documentation should support that diagnosis.

Further, around $20,790.00 has been written off due to ABNs not being issued for this cardiac rehabilitation service. Consider these issues. What went wrong in the revenue cycle? How would you suggest rectifying this issue? How will your team monitor improvements?

Please note: The article above is for educational purposes only for this course. From October 1, 2015 forward the United States utilizes ICD-10.

Answer the following questions.

Choose all answers that apply:

After reading the article, analzye the scenario. In the future, how could this type situation be avoided?

		Notify patient that services are not expected to be paid by Medicare and have patient sign the Advance Beneficiary Notice.
		Link all patients with outpatient cardiac rehab with continuous ECG monitoring to a diagnosis code in a range of 410.00-410.92 regardless of documented diagnosis.
		Review all LCDs on a timely basis and implement appropriate procedures.

What action should your team take in order to monitor improvements?