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AccretivePas Update March/April 2015/Vol. 5, No. 2 : Page 1

ACCRETIVE HEALTH UpDate Hospital Industry Newsletter ® MACs heading down a Slippery Slope from Medical Necessity to Quality of Care Ronald Hirsch, M.D. “Don’t confuse me with the facts; my mind is already made up.” This is how William Malm, the senior manager at Craneware describes the two recent notifications by two MACs who have made up their minds that they need to enter the realm of risk assessment and quality of care, a territory where they do not belong. My investigation of this was first inspired by denials of outpatient ureteral stents by CGS, the Jurisdiction 15 Medicare Administrative Contractor (MAC). In January, CGS posted to their web site the results of their probe audit of outpatient claims for ureteral stent, CPT code 52332. They reported an as-tounding 89% error rate on 99 reviewed claims, noting lack of medical necessity in the majority of cases. Realizing that most patients would not agree to ure-teral stent placement unless there was a clear indication, I asked CGS for details of the rationale for the denial and was told that only denied hospitals can get that information. Fortunately two loyal Monitor Monday listeners contacted me and provided details of their denials noting that their claims were denied for lack of a urinalysis or urine culture in the medical record. Then on February 10, perhaps in response to my inquires, CGS released “Cystourethroscopy with Inser-tion of Indwelling Ureteral Stent (CPT Code 52332): Documenting Urinalysis to Support Medical Necessity” with a detailed explanation of their documen-tation requirements to determine medical necessity. This included the requirement for “documentation of urinalysis (or urine culture or dipstick) results performed prior to the proce-dure, including treatments, if needed to treat identified infection.” In their narra -tive, CGS relates that patients who un-dergo endourologic manipulation with untreated bacteruria are more likely to have infectious complications, increas-ing the length of stay and cost of care. Apparently in an effort to confuse read-ers and equate medical necessity with risk assessment, CGS also posted as a reference an article by Nina Youngstrom in Report on Medicare Compliance that discusses the medical necessity require-ments for total joint replacement, which include an adequate trial of conservative non-operative management. While requesting documentation that the patient has urinary tract obstruction and therefore has medical necessity for a ureteral stent is appropriate, the pres-ence or absence of untreated bacturia has absolutely nothing to do with the medical necessity for the stent. If the patient requires an intervention, it is the duty of the physician and patient to as-sess the risks and benefits of proceeding with that medically necessary interven-tion and not the decision of the MAC. To apply this to joint replacement, if a Continued on page 2… March/April 2015, Vol. 5, No. 2 in this issue: MACs heading down a Slippery Slope from Medical Necessity to Quality of Care ................................. 1 Aetna Lawsuit against Texas Hospital Reveals Coding Confusion ............ 3 Post-hospital provider choice – how is your process? .................. 4 Home Health Certification – Is CMS making an about face on the face-to-face? ...................... 6 Everyone's a Critic except when it comes to Themselves. . . . . . . . . . . . . . . . . . 7 Strange Bedfellows join to defeat Common Enemy . . . . . . . . . . . . . . . . . . . . . . . 8 Medical Necessity 2015 – AccretivePAS presents to local Southern California Hospitals at St. Francis Medical Center .......... 10 401 N. Michigan Ave. Suite 2700 Chicago, IL 60611 tel: 312-931-3007

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