Revenue cycle exercise
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
• 410.00-410.92 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
• 413.0-413.9* 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.
1. What went wrong in the revenue cycle?
2. How would you suggest rectifying this issue?
3. How will your team monitor improvements?