tci Medicare Compliance & Reimbursement - 2014 Issue 7

Denial Management: Refresh Documentation Know-How for Total Joint Replacements -- or Risk Claim Denials

Dodge denial code 5J504 (Need for service/item not medically and reasonably necessary). A new wave of audits may threaten claims for total joint replacement (TJR) procedures in 2014, at least for physicians and hospitals who fail to revisit existing guidelines for documenting medical necessity for DRG 470. Background: In 2011, MACS and then RACs began auditing and denying numerous claims for procedures including lower-extremity TJRs, after prepayment probes and other audits revealed that providers failed to make an adequate case for the medical necessity of the expensive procedures.  Recently, recovery auditor Connolly Inc. added to its CMS Approved...

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