Pre-service coverage analyses

In light of the Targeted, Probe & Educate pre-payment audits as well as Recovery Auditor audits focused on medical necessity and coverage, I am curious how many organizations have implemented some type of pre-service coverage analysis where the patient records from the physician scheduling a procedure are evaluated prior to the procedure to determine if all the coverage requirements of the applicable NCD and/or LCD are met prior to the procedure being performed?


  • We currently do this in our Wound Center, but we have always done it due to the expense of those services (skin substitues, HBOT, etc).  Now that we are under a TPE for Wound Care, we are finding that although we meet medical necessity a lot of the documentation is scattered through out the medical record.  We are discussing easier ways to get the information to our MAC and exactly who should do this.

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