decisionhealth Newsletters, Coder Pink Sheets - 2012 Issue 1 (January)
Getting Paid: MACs launch prepay review of high-cost ortho surgeries
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Article Overview
This article explains how Medicare Administrative Contractor review initiatives are affecting orthopedic practices performing major joint replacement and spinal fusion procedures. It outlines the documentation and policy areas practices should review, why these audits matter financially, and the general steps clinicians and coders use to prepare for contractor scrutiny. The piece is intended for orthopedic coders, auditors, practice managers, and physicians who need to understand current Medicare review activity and coverage requirements.
Why This Topic Matters
High-cost orthopedic surgery claims can be denied when documentation does not support medical necessity, so practices need to understand contractor review activity and stay aligned with coverage and recordkeeping expectations.
Article Sections
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Joint replacement under scrutiny
This section describes Medicare contractor review activity affecting major joint replacement claims in selected states and explains the general reasons these claims are being examined.
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Tighter rules for spinal fusion
This section covers review activity involving spinal fusion and related back and neck procedures, including the role of a local coverage determination and the broader scope of audit activity.
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Four steps to pass review
This section outlines broad documentation review and auditing considerations for orthopedic practices preparing for payer scrutiny.
What You Will Learn
- Which orthopedic service categories are being targeted by Medicare contractor review activity
- What general documentation areas practices should evaluate before audit review
- How local coverage policies and audit processes affect orthopedic claim review
- Who may use this information to prepare for medical necessity scrutiny
Who Should Read This
- Orthopedic coders
- Medical auditors
- Orthopedic practice managers
- Physicians
- Revenue cycle staff
Codes Discussed
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