What went wrong in the revenuecycle?

Reference no: EM13900654

You are the revenue cycle coordinator for Anywhere Hospital. The decisionsupport department at Anywhere Hospital is concerned because the volume of remittanceadvice remark code #M39 (The patient is not liable for payment for this service becausethe advance notice of non-coverage you provided the patient did not comply withprogram requirements.) on Medicare remittance advice logs has increased over the pastthree months. Further analysis of the denied claims shows that 75 percent of the claimshave code 93798 (physician services for outpatient cardiac rehabilitation with continuousECG monitoring) present. Therefore, they are requesting that the revenue cycle teamperform further investigation for thisissue.

After auditing the remittance advice logs and medical records for a sample ofcardiac rehabilitation claims, the revenue cycle team has determined that medical necessityis not being met for code 93798. Further, they have discovered that a new LCD wasissued for code 93798 in October (three months ago). The only ICD-9-CM diagnosis codesthat support medical necessity for code 93798are

• 410.00-410.92 Acute myocardial infarction of anterolateral wall episodeof care unspecified through acute myocardial infarction of unspecifiedsitesubsequent episode ofcare

• 412 Old myocardialinfarction

• 413.0-413.9* Angina decubitus through other and unspecified anginapectoris

• V45.81 Post surgical aortocoronary bypassstatus

* There is no specific code assigned to stable angina. Therefore, thesecodes should be used to identify stable angina and documentation shouldsupport thatdiagnosis.

Further, around $20,790.00 has been written off due to ABNs not being issued forthis cardiac rehabilitationservice.