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Surgery: Know the Rules for Status, Location and Medical Necessity

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Enhance your organization's ability to generate full, compliant payments for surgical procedures by clearly understanding each payer's rules for surgery status, medical necessity and site of service.

Price: $229.00

Product Code: AR081320


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Why are there are so many claim denials for surgical procedures? Often healthcare organizations don't possess a clear understanding of the various payers' unique rules and coverage policies. One payer may cover a surgical procedure under all circumstances, while another will cover the same procedure only if the patient meets certain criteria or only if the procedure is performed in a specific setting.

Many facilities have used the Two-Midnight Rule as a guide for status determinations, but its application to surgery patients only adds to the confusion. On top of that, if the patient is a Medicare beneficiary, you can't call the payer to get an authorization for most surgical procedures.

For this RACmonitor webcast, Dr. Ronald Hirsch takes a deep dive into surgery status, medical necessity and site-of-service rules, using case examples and payer policy excerpts to reinforce key points. What's the inpatient-only list, and how is it properly applied? How do you determine whether non-inpatient-only surgery should be classified as inpatient or outpatient? How should you use observation status following surgery? Join us for answers to these and other revenue-critical questions!

Why This is Relevant:

Surgery is an enormous driver of revenue, to the point that it can make or break a healthcare organization's bottom line. This is especially true for procedures that involve implanted devices costing thousands of dollars — which cannot be recouped if the claim is denied. Avoiding denials and ensuring clean claims depends on strict adherence to the rules of each payer (Medicare and non-Medicare) for surgery status, medical necessity and site of service.

Learning Objectives:

  • Understand the proper determination of surgery status
  • Review medical necessity guidelines for surgery
  • How to correctly apply observation services to surgery patients
  • Understand site-of-service guidelines and their application
  • Identify the revenue implications of surgery status

Who Should Attend:

Those who will benefit most from this webcast include staff in utilization review, revenue cycle, revenue integrity, case management and compliance, as well as chief financial officers, physicians and physician advisors, and billing and coding professionals.


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