Q: We are experiencing post-payment audits that result in denials of inpatient claims. Our coders and CDI leaders are vehement that the patient meets MCG and/or coding guidelines, but the payer is using clinical results from the patient as their justification. It seems as if they are ignoring all established guidelines. If these are inappropriate denials, how do we fight them?
Under the No Surprises Act, how do we document that a patient has been informed that a provider is out of network and still wishes to receive that provider’s services?
Q: Is there any CMS guidance on designation of patient provided/supplied drugs on claims, such as information on revenue codes, HCPCS codes, and quantity?
Q: How should we bill for trauma activation without pre-hospital notification and how should we capture charges for these services? Do we bundle the charge in with the facility evaluation and management (E/M) code?
Q: Can you tell me if your facility charges a triage charge for the ED? If a patient comes in and gets triaged, has vitals taken, protocol for labs, and then leaves, do you charge a Level 1 Triage for this or write everything off? Also, do you charge a suture fee if the patents comes in to ED for just suture removal?
Q: Our system has a new vendor that is helping with charge capture. We were discussing surgery level charges and a comment was made about rounding that surprised me: We don't have to follow rounding rules to select the additional 15 minutes after the first hour. The vendor acknowledged that Medicare does have rounding rules, but because the rounding rules are not listed in or specifically tied to any surgery documentation, then the rounding rules don't apply to surgery. If the total surgery time was 61 minutes, then we would have one first hour charge and one additional 15-minute charge. The vendor assured us that this was a common practice throughout all hospitals. Is this true?
