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Research Article  |   December 1989
A Medical Review Approach to Medicare Outpatient Documentation
Author Affiliations
  • Claudia Allen, MA, OTR, FAOTA, is an Occupational Therapy Consultant, Blue Cross of California, Van Nuys, California
  • Mary Foto, OTR, FAOTA, is a Senior Allied Health Consultant, Blue Cross of California, Van Nuys, California. (Mailing address: 5th Floor, Allied Health Medical Review, PO Box 70000, Van Nuys, California 91470)
  • Terry Moon-Sperling, OTR, is an Occupational Therapy Consultant, Blue Cross of California, Van Nuys, California
  • Dorothy Wilson, OTR, FAOTA, is an Occupational Therapy Consultant, Blue Cross of California, Van Nuys, California
Article Information
Advocacy
Research Article   |   December 1989
A Medical Review Approach to Medicare Outpatient Documentation
American Journal of Occupational Therapy, December 1989, Vol. 43, 793-800. doi:10.5014/ajot.43.12.793
American Journal of Occupational Therapy, December 1989, Vol. 43, 793-800. doi:10.5014/ajot.43.12.793
Abstract

Blue Cross of California has recognized the problem of reimbursement delays due to Medicare claims that have been returned or denied. The information in this article applies to the medical review process and suggests an interpretation of the new Medicare outpatient guidelines used by the Blue Cross of California Medicare reviewers. As a solution to the problem of delayed reimbursement, medical reviewers—who are also practicing occupational therapists—offer an explanation of the Medicare review process and suggestions for correcting technical billing errors. Methods for keeping complete and timely medical records are discussed, with the suggestion that clinicians follow these methods from the start of care. A process for documentation is presented that will clearly prove to the medical reviewer the need for the special skills of an occupational therapist. This article also proposes reasons for noncoverage because of insufficient medical necessity. It is important to note, however, that variance between fiscal intermediaries’ interpretations and requirements exists nationwide. This article, therefore, represents only one fiscal intermediary’s approach to reviewing claims and medical records.