4.3 Inpatient-only procedure denials Subdomain IV.A.1 Apply policies and procedu

Question

4.3 Inpatient-only procedure denials Subdomain IV.A.1 Apply policies and procedures for the use of data required in healthcare reimbursement subdomain Ill.?.4 Perf orm quality assessment, including quality management, data quality, and identification of best practices for health information systems subdomain IV.A.1 Manage the use of clinical data required by various payment and reimbursement systems Your organization just opened a new service line: outpatient spinal fusions. The first cervical spinal fusions were done last week, and your coders have coded 10 of them. Unfortunately several weeks and another 25 procedures later, you get a memo from the business office stating that there are denials on the Medicare fusions (17 to date). The billing manager states that it is something about a status indicator "C." She would like you to review the CPT code assignments and help determine what the problem is and how it can be resolved because the charges for these procedures exceed $35,000 per case. After reviewing the cases, the CPT codes assigned are correct. 22551-arthrodesis cervical 22845-anterior instrumentation 22851-use of biomechanical device (cage) 20936-autograft of bone from same site "denotes a status indicator of C for that CPT code 1. Explain to the billing manager what status indicator C means. 2. In order to facilitate a prompt resolution to this issue, you and the billing manager decide to create a process improvement team. Decide what hospital departments should be part of the team. 3. Brainstorm at least three possible solutions to the problem.

Explanation / Answer

1.Status indicator "C" means that the HCPCS is not payable if performed in either an out patient or ASC setting.
2.The team should consists of hospital orthopedic surgeon,former practice administrators and nurses.
3.Possible resolutions for the problem are-
1)resubmit the claims after correction.
claim return to provider(RTP)-A claim RTP means the provider can resubmit the claim once the problems are corrected.
2)appeal for the payments .
Line Item denial -claim can be processed for payment with some line items denied for payment.The item cannot be resubmitted but can be appealed.
3) correct and resubmit for processed payments.
Line item rejection -claim can be processed for payment(cannot be appealed but can be corrected and resubmitted)

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