RAC: AICD as inpatient procedures

[suzanner]

We have recieved a number of RAC denials from 2004 and 2005 for AICD implantations billed as inpatients. Does anyone have any advice for getting these overturned?

[krubinmd]

We have had success in appealing these. Here are some of the basic principles:

1. Use the inherent weaknesses in InterQual.
The RAC uses InterQual, which is inherently prejudicial against short stays and is considerably different from the Medicare criteria for inpatient status. Occasionally, InterQual sounds totally brainless, the way the Rationales are constructed. Use common clinical sense and write your appeals to focus upon the ccs (comorbidities and complications).

2. Use risk.
InterQual does not take into account risk, so in your appeal, emphasize the risks your patient had (if any).

3. Use the Medicare reg which states:
Just because the procedure fits an APC (ambulatory code) doesn't mean the patient might not need a higher level of care.

4. Use the Milliman argument. New ICDs implanted for the indication of dysrhythmia (as opposed to merely meeting the MATIT II indications), meet Milliman criteria for inpatient status. Remember, InterQual is not the gospel, it's merely one set of criteria. Milliman's another.

5. Use the reviewer's errors.
The RAC's reviews are frequently sloppy, incomplete, inaccurate. Pointing out those errors will strengthen your appeal.

6. As in all appeal work, good writing engenders success.
Remember: unlike in clinical documentation, when writing appeals, LESS IS MORE. Decide upon an argument or line of reasoning and stick to it. Don't bore the medical director with extraneous verbiage. "Brevity is the soul of wit." ...Shakespeare

7. Check our this great service: www.expertappeals.com (http://www.expertappeals.com/)

I hope you find these tips useful.
-KR