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The New York Post ran a story that caught my attention regarding a recent study conducted by a research team led by University of Pennsylvania psychologist and author Angela Duckworth, PhD. Dr. Duckworth chose my alma mater, the United States Military Academy and the cadets who attended over a 10-year period, as her study subjects. […]
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Professional advancement in the healthcare business sector requires ever-increasing substantive knowledge. Unfortunately, technical mastery is not enough. Employers often look for candidates with more skills, specifically soft skills, when hiring or promoting Soft skills are those things we all need to succeed in the workplace. Everyone can benefit by developing their soft skills. Here are […]
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I would appreciate some feedback on coding ER Critical Care for the facility side as I am coding for a new situation. The patients have been transferred from one ER dept to a second for a higher level of care. The patients have been diagnosed & possibly treated at the first ER dept but need a neurosurgi or other consult and are then generally admitted at the second hospital. They may undergo full body CT scans & receive IV meds at the second ER dept in addition to a neurosurgi consult or they may just have the consult. I am coding for the second ER facility which follows adapted ACEP facility level coding guidelines. The dxs the trauma patients have include subdural hematoma or vertebral fx unstable or pulmonary contusion or a combination of fxs and head & body injuries.
My question is whether the visit at the second ER dept qualifies for critical care. The guidelines say that possible critical care interventions include ‘major trauma care/multiple surgical consults’. The ER MD is stating critical care has been provided at the second ER so this along with the dx tells me that there is much concern for ‘life threatening deterioration in the patient’s condition’. I am unsure whether neurosurgi consult alone is enough to qualify for critical care especially as the patients have been stabilized to a degree at the first hospital. The cases I am struggling with are NOT the ones where the patient requires emergent endotracheal intubation or CPR, etc. I would like to understand better what constitutes ‘major trauma care’.
I welcome your thoughts on this topic. Thank you,
Ellen
Thanks in advance for your input! If you have any reference material that would be greatly appreciated, too.
Claim denials cost the medical industry over $ 1 million, annually. How much of that comes from your practice? You spend time interpreting sometimes confusing health plan benefits and coverages and wordy coding guidelines. You go through time-consuming prior authorization processes. And you sign up for a payer’s electronic funds transfer and post claims per their […]
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The provider will then submit a dispute with altered, not amended documentation, not corrected, completely altered, and request payment for the Prolonged Service.
We are working towards education of the provider in the hopes that they are unaware that this is illegal but we need to provide them with all of the proper documentation to support our determination that they cannot do this. We have the Medicare Guidelines on how the amendments, corrections, and addendums are supposed to be done, MLN Matters SE1237. What I’m looking for are specific guidelines or Medicare requirements stating that these cannot be added after a claim has been denied for level of service just be able to get paid for the level of service.
Can anyone help with this?
I’m trying to find documentation from CMS or the False Claims Act that specifically indicates that it is fraud or false reporting of claims to bill out a lower level code for reimbursement when the higher level code that actually occurred is not payable due to the fact that an authorization was not obtained. Since the lower level does not require an auth and auth wasn’t obtained for the actual level of care that was provided, I’m being asked to downcode to the level that does not require an auth. This is not just for one claim here or there, this is between 50-80% of the services provided where auths weren’t obtained for the correct level of care so the provider wants them downcoded to the level that doesn’t require an auth.
Does anyone have documentation that they could send me from CMS or from the False Claims Act that specifically mentions downcoding abuse.
Thank you for your help!
