Q&A: Pre-service coverage analysis for medical necessity

Q: In light of the Targeted Probe & Educate (TPE) pre-payment audits, as well as Recovery Auditor audits focused on medical necessity and coverage, I am curious how many organizations have implemented some type of pre-service coverage analysis. When a physician schedules a procedure, do you evaluate the patient’s record prior to the procedure to determine whether all of the coverage requirements of the applicable National Coverage Determinations and/or Local Coverage Determinations are met?

A: We currently do this in our wound center, but we have always done it due to the expense of those services (skin substitutes, HBOT, etc.). Now that we are under a TPE for wound care, we are finding that although we meet medical necessity a lot of the documentation is scattered throughout the medical record. We are discussing easier ways to get the information to our MAC and exactly who should do this.

Note: This question can be found in the coverage section on the NAHRI Forums where you can find answers to questions on a variety of topics from billing and claims to compliance to reimbursement. This question was answered by Terri Rinker, MT (ASCP), MHA, Revenue Cycle Director, Community Hospital Anderson in Anderson, Indiana.

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