· The availability of diagnostic procedures at the time when and at the location where the patient presents.
While the release provides additional clarification and information for providers, further action is also needed, according to Donna Wilson RHIA, CCS, CCDS,senior director at Compliance Concepts in Wexford, PA.
"The Guidelines on Hospital Inpatient Admission Decisions release is a valuable tool for providers to reference given the recent wave of medical necessity issues released by RACs nationwide. However, hospital providers have been using screening criteria as a guide all along in determining medical necessity."
She continued, "Clinical judgment based on documentation in the medical record is the best defense. Providers should examine any and all medical necessity denials to determine when an appeal is warranted. Engage your medical staff in the review process—hospitalists, physician advisors, specialists, and of course, the attending physician—should all be actively involved."