What basis do the RACs use to deny cases based on medical necessity?
The RACs have not established new arguments or support to uphold medical necessity denials. Most of the denials are based on the same protocol other audit agencies follow when reviewing cases for medical necessity. Why is there a RAC focus on ICD-9 procedure code 86.22 – Excisional Debridement? Unlike a lot of coding guidance, the documentation requirements for use of excisional debridement codes are black and white which provide RACs with firm support if the documentation deviates from the standard requirements. In addition, the use of 86.22 versus an alternative procedure makes a different in the payment level.
