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Medicare: A Case Study

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Medicare will allow for subsequent nursing facility care that monitor and evaluate residents at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. The doctor’s note indicated that the beneficiary was evaluated for a chronic medical condition. The documentation submitted did not support the need for weekly evaluation and management; there was no indication of any new significant medical issues that would necessitate the increased frequency of the service. There was no indication of symptoms or physical findings that documented the medical necessity for a repeat examination. The visit was included in the procedure (17250- chemical cauterization of granulation tissue) allowance performed on the same day. The beneficiary was a 77 year old woman who had 3 …show more content…

The wounds that were located in the left sacrum and left hip had been present for more than 41 days and had serous exudate. The wound in the right hip had been present for more than 35 days and also had serous exudate. The provider cauterized the wound in the left sacrum after administering a local anesthetic and applied a special dressing to all 3 wounds. The plan was to follow-up “within 7 days.” The only documentation submitted was the “Wound Care Specialist Evaluation” for the date of service (07/22/2014) and there was no information of the initial assessment or subsequent visits. It was not documented when was the last time the beneficiary was evaluated, prior to the date of service in question. The QIC’s letter stated that Medicare will allow for subsequent nursing facility care that monitor and evaluate residents at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter. However, the payment history was not provided in order to determine when the previous service for the same issue was billed and

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