News: Simple omissions represent greatest denial reasons, Palmetto GBA says

Not medically and reasonably necessary. Records not submitted. Lack of inpatient admission orders. Information submitted doesn’t support the services supplied for the dates billed.

These four, seemingly simple, reasons represent the top denials for Palmetto GBA, Medicare Administrative Contractor for Jurisdiction 11 (North Carolina, South Carolina, Virginia, and West Virginia) Part A providers, according to a review of denials from October through December.

To avoid future denials facilities should:

• Submit documentation to support that services were medically necessary on an inpatient basis instead of a less intensive setting
• Include all clinical information for the dates of service billed such as physician progress notes, physical examinations, assessments, diagnostic tests and laboratory test results, history and physical, nurse’s notes, consultations, surgical procedures, orders and discharge summary and any other documentation to support the inpatient admission
• Include documentation of services, medication and medical interventions performed in the Emergency Department
• For elective surgical procedures, include documentation to support the necessity of the procedure including pre-surgical interventions and outcomes”

"As you review records on the floor, take note of these documentation suggestions and determine if you can confidently say the record passes muster and the services can be deemed reasonable and necessary,” says Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, C-CDI, CCDS, former ACDIS Advisory Board member.