“Finally Friday!” Alternative Facts in Documentation and Denials

Friday, November 3 2017

Alternative Facts in
Documentation and Denials


When Your Data and Documentation Go Bad

appeal academy | medical audit

But some people want to insist that it’s a banana, and they feel they can either (a) prove it, or (b) ignore the fact that they can’t prove it and simply declare it so by fiat or pure hubris or both. And then there’s the ones who will just let you call it a banana and that’s ok with them.  But they might change their mind. What’s all that got to do with hospital billing?  Keep reading…

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THIS WEEK, we are taking a break from our continuing a series of talks and discussion on PEPPER reports (but stay tuned for emails about the rest of the series and more), so we discuss the concept of “alternative facts” recently made famous by Kellyanne Conway, aka Propaganda Barbie, and now being supported by various claims review organizations, including those employed by Medicare and commercial payors.

Recently, Dr. Maria Johar, our resident working Physician Advisor, posed a set of questions on the rac-relief Google Group, about several billing scenarios which may or may not be appropriately billed as Part A, inpatient stay. The scenarios presented some rather “gray” areas involving exceptions and exclusions that CMS has attempted to address in Transmittal 234, dated March 10, 2017, which added Section 10.2 to Medicare Benefit Policy Manual, Chapter 1, entitled, “Hospital Inpatient Admission Order and Certification.”

Dr. Johar listed 4 scenarios:

  1. The Patient leaves AMA / Elopes ( Yes it is an exclusion for a Part A payment) but the ADMIT order was not cosigned yet
  2. The Patient dies (ADMIT order not cosigned before death)
  3. The Patient transferred in an urgent crisis (ADMIT order not cosigned before transfer)
  4. The Patient dies before the EMR could be updated with no admit order placed, but the Patient did have a (unscheduled, urgent, emergent inpatient-only) procedure or intervention

The question, then, was how would you bill that?

  • Would you bill Part A due to the (demonstrable) “intent” present in your documentation?
  • Would you bill a “No Part A” due to the lack of a signed order?
  • IF you are billing Part A, does the length of time before the order was signed make a difference? (< 24 hours or > 24 hours)

Now… I’m a process guy, so while I think Dr. Johar’s examples and questions are great – for ME, they started me thinking about questions that I, as a manager and not a clinician, would want to be asking…

My Basic Starting Point:
This is not a clear cut case.
Can we AFFORD to bill this as Part A?
And what makes you think so?

SO… THIS week, our Panel will be discussing :

  • HOW would you bill each scenario?
  • WHAT makes you think you can or cannot bill Part A?
  • WHAT support can you offer to an auditor who denies the claim?
  • WHAT has the payor involved done with similar claims before Transmittal 234?
  • WHAT has your experience with that payor been like before before?
  • HOW do you determine whether to appeal this if you are denied?

So join us, share your own insights and bring your questions for us!

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Handouts for This Show


Fact Sheet OPPS 2018 124.82 KB 35 downloads



OPPS 2018 Final Rule 5.95 MB 37 downloads



Transmittal 234 - March 10 2017 121.38 KB 26 downloads



MLN Matters® Number: MM9979 46.53 KB 25 downloads



MLN Matters®Number: SE1333 Revised 116.12 KB 89 downloads


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