Payors requesting Code removal
Looking for how others handle denials for Clinical Validation when payors request that we remove codes from the claims, or we won't receive any payment? Is this a compliance issue if the hospital removes the codes that the provider documented well within the chart that they feel they were treating? Coding does place a query to validate prior to billing but providers often stand by their professional opinion, so the code does go out on the claim. Thinking how this impacts quality outcomes and rankings, denials, payments, ethical practice etc.
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Appeal!!!! Fight like heck!!!! Payers should not be able to make up their own definitions of diseases!!!
Now if the patient is on 2 liters of oxygen and the doc writes "acute respiratory failure" then you don't fight.
Be sure your finance team know about these and get the contract changed to forbid payers using their own definitions.
Also for MA plans, ask "so since you are denying this diagnosis, are you also withdrawing the corresponding HCC from your Medicare reports? to not do that would be fraud."