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Baptist Health System (BHS) in Birmingham, AL, made little progress in its efforts to check procedures in advance for medical necessity until it offered physicians a guidebook, says Becky Miller, director for compliance, patient business services. Code First: Medicare Medical Necessity Reference lists the procedures for which the Baltimore-based Health Care Financing Administra tion (HCFA) requires that medical necessity be shown and the diagnoses codes (ICD-9-CMs), with their descriptions, that support each procedure, she adds. (See excerpt, p. 124.)
Although Alabama’s Medicare intermediary, as is true in other states, issues monthly bulletins called LMRPs (local medical review policies) that notify providers of tests for which medical necessity must be shown, those bulletins "don’t give full descriptions, just codes," Miller points out.
Developed at hospital
Code First is the brainchild of David Alligood, a finance department employee at Cullman (AL) Regional Medical Center, one of 10 BHS hospitals. Alligood worked with the hospital’s medical records director and Miller to compile the guide, and Cullman’s chief financial officer "pushed the buttons" to make it a reality, Miller says. Since mid-July, BHS has distributed some 1,500 guides to physicians, who "really like them," she says. "We’ve gotten good feedback. We really made little progress until we came up with this as a tool."
Because HCFA continually modifies and adds to the medical necessity guidelines, the book "was only good for one month," she says, and updates must be distributed each time an LMPR bulletin is received. To promote use of the guide, BHS has set up meetings and hosted breakfasts and luncheons for physicians and their staffs, she notes.
The Montgomery-based Alabama Hospital Association has approached Cullman Regional Medical Center officials about possibly endorsing the guide for more widespread use, notes Sandra Holmes, RN, BSN, clinical revenue specialist for the BHS consolidated business office.
Part of her role in the medical necessity effort, she says, is to emphasize the significance of those Medicare regulations to physicians and their office staffs, as well as to hospital personnel.
"I explain what we’re trying to do, that this is required by federal law, and from the clinical side, interpret some of the diagnoses and concerns, Holmes adds. "I train [hospital] personnel on how to input the information into our computer system to check the diagnosis and how to ask if another diagnosis is appropriate. They can offer assistance, but it is against the law to tell the physician what code to use."
Sometimes matching diagnosis to procedure becomes a matter of semantics, she says. "Some of the physicians were ordering bone density studies, and the diagnosis was post-menopausal.’ That diagnosis Medicare doesn’t cover. Ovarian failure’ is the diagnosis we must have. Well, what is meno pause but ovarian failure’?"
In other instances, BHS has asked for clarification of contradictory or illogical medical necessity rules, Holmes says. For example, she adds, the diagnosis of "long-term headache" is acceptable justification for a computerized axial tomography (CT) scan if it is made in the emergency department, but not if it is made in a physician’s office.
"We haven’t received an answer yet, so right now we have to follow the Medicare [guidelines]," she says. "We ask the physician if there are other symptoms, another reason [for the CT scan]. We ask them to think it through, what they are looking for."
Holmes designed an advance beneficiary notice (ABN) form (see p. 125) that — under the new BHS policy — must accompany the order for any lab test that may not meet medical necessity, she says. The forms will be available at physician offices, as well as for use by home health nurses who may draw blood from patients in their homes, Holmes adds. "Patients have the right to refuse to have the test done or can agree to pay if Medicare doesn’t cover it."
Some health care providers, in their zeal to ensure reimbursement, are having patients sign ABNs across the board, Miller points out. This "blanket" signing of waivers is not only illegal, she says, it gives the patient a false sense of security.
Those hospitals "are asking patients to sign the same form they signed the week before, and maybe that time the test was covered," she adds. "When you slap [the form] down routinely, they think it’s just another piece of paper, but the whole point is to alert them. You are to get the waiver signed only if you suspect the test may not be paid."