When bills are submitted to Medicare and the procedure codes (CPT/HCPCS) do not match the diagnostic codes (ICD-9), the claims will not be paid by Medicare.
Medicare continually sets regulations to determine the services it deems as "medically necessary." For a procedure to be considered a "medical necessity," the diagnosis of the patient must support the procedures that have been ordered by the physician. Many bills are rejected or denied because they do not contain proper billable diagnosis (ICD-9) and procedure (CPT/HCPCS) code combinations.
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Missing just one Medicare regulation update can cost your facility tens of thousands of dollars in unpaid claims.
Updating Medicare regulations and codes to meet "medical necessity" standards is a difficult challenge for healthcare providers. Regulations change regularly and updating your system can be complex and time consuming. Continually submitting bills that do not meet "medical necessity" guidelines can put your hospital at risk of being fined for non-compliance. In today's healthcare environment, fines can impact the bottom line as well create unfavorable publicity for the hospital and staff physicians.
ABN Registrar Software:
- Continually updates Medicare guidelines as determined on a state-by state basis
- Interacts with registration software to pull codes from the Chargemaster
- Alerts you as to whether the patient meets the “medical necessity” requirements
- Generates Advanced Beneficiary Notices (ABN) for patients that do not meet the medical necessity or potential frequency limitations
- Recognizes potential rejection of claims before they are submitted to Medicare preventing unpaid bills
- Provides compliancy verification to ensure error-free Medicare billing
- Provides reporting tools to analyze patient flow of non-medical necessity patient services vs. medical necessity patient services classified by hospital, physician and user as well as usage of the ABN form
- Prevents healthcare providers from being fined for non-compliance of the “medical necessity” regulations
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