News: Denials for Inpatient Surgical Procedure May Cross to Physician Claims

If the hospital documentation, including history and physical and progress notes, doesn’t support medical necessity of an inpatient surgical procedure, the physician’s Part B claim for performing the procedure would be denied. A recent transmittal (Transmittal 541) to Program Integrity Manual continues to allow the denial of the physician’s claim without requesting records from the physician, meaning the physician’s claim may be denied based on the hospital record, writes Kimberly Anderwood Hoy Baker, JD, CPC, regulatory specialist for HCPro, in a recent MedicareMentor Blog.

The transmittal still applies to just MAC and ZPIC reviewers, although Recovery Auditors can request approval to review related claims through their standard issue approval process. Even the MACs and ZPICs, however, must get approval from CMS before starting these reviews and the MACs must post their intention to do so on their website 30 days prior to starting the reviews.

Although many CDI programs do not review surgical cases (at least in ICD-9), the crossover between hospital and physician claims in this regard may represent one more reason for program expansion.