Archives (248)
OIG Semiannual Report Notes Potential Overpayments for Outpatient Services
By Karen Long
Provider errors, unallowable services and insufficient documentation caused Medicare to overpay for outpatient services, according to the Office of Inspector General’s Semiannual Report for April through September.
OIG recommended that contractors implement “system edits to identify line item payments that exceed billed charges” and to use audit results it notes in the report. The reports include six jurisdictions.
·Palmetto GBA (Jurisdiction 1) – Almost 70 percent of the 1,323 selected line items for outpatient services were incorrect and included overpayments of about $7.5 million that had not been returned, OIG stated.
·Noridian Administrative Services (Jurisdiction 2) – Almost 70 percent of the 1,340 selected line items for outpatient services were incorrect and included overpayments of about $6.2 million that had not been returned, OIG stated.
·Noridian Administrative Services (Jurisdiction 3) – Almost 85 percent of the 1,913 selected line items for outpatient services were incorrect and included overpayments of about $5.8 million that had not been returned, OIG stated.
·National Government Services (Jurisdiction 8) – About 68 percent of the 1,407 selected line items for outpatient services were incorrect and included overpayments of about $7 million that had not been returned, OIG stated.
·First Coast Service Options (Jurisdiction 9) – Almost 78 percent of the 326 selected line items for outpatient services were incorrect and included overpayments of about $1.7 million that had not been returned, OIG stated.
·Highmark Medicare Services (Jurisdiction 12) – Almost 57 percent of the 739 selected line items for outpatient services were incorrect and included overpayments of about $532,000 that had not been returned, OIG stated.
For more on the Semiannual Report, visit http://oig.hhs.gov/reports-and-publications/archives/semiannual/2011/fall/HHS-OIG-SAR-Fall2011.pdf.
3 RACs Post New Issues
Region A, B and D recovery auditors posted issues recently. See below for more information.
Inpatient hospital
|
Name of issue |
Date posted or approved |
Regions/states where it is active |
Description of issue |
Document sources |
|
Medical necessity review – MS-DRG 483, major joint-limb reattachment procedures of upper extremity with CC/MCC |
11/22/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 607, minor skin disorders without MCC |
11/22/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 337, peritoneal adhesiolysis without CC/MCC |
11/22/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 620, OR procedures for obesity with CC |
11/22/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 988, nonextensive OR procedure unrelated to principal diagnosis with CC |
11/22/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 417, laparoscopic cholecystectomy without C.D.E. with MCC |
11/22/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 083, traumatic stupor and coma greater than one hour with CC |
11/22/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 909, other OR procedures for injuries without CC/MCC |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 582, mastectomy for malignancy with CC/MCC |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 908, other OR procedure for injuries with CC |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 880, acute adjustment reaction and psychosocial dysfunction |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 841, lymphoma and nonacute leukemia with CC |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 139, salivary gland procedures |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 578, skin graft except for skin ulcer or cellulitis without CC/MCC |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 478, biopsies of musculoskeletal system and connective tissue with CC |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 026, craniotomy and endovascular intracranial procedures with CC |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 914, traumatic injury without MCC |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 441, disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 004, tracheostomy with mechanical ventilation 96+ hours or principal diagnosis except face, mouth and neck without major OR |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 907, other OR procedures for injuries with MCC |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 133, other ear, nose, mouth and throat OR procedures with CC/MCC |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 809, major hematologic-immunologic diagnosis except sickle cell crisis and coagulation with CC |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 707, major male pelvic procedures with CC/MCC |
11/21/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Acute kidney failure |
11/18/11 |
RAC Region B |
The MS-DRG validation determines whether the principal diagnosis and all secondary diagnoses identified as CCs and MCCs are actually present, correctly sequenced, coded and clinically validated. When a patient is admitted to the hospital, the condition established after study found to be chiefly responsible for occasioning the admission to the hospital should be sequenced as the principal diagnosis. The other diagnosis identified should represent all (MCC/CC) present during the admission that impact the stay. The POA indicator for all diagnoses reported must be coded correctly. Reviewers will validate MS-DRGs with an acute kidney failure diagnoses that affects the MS-DRG assignment. |
CMS Pub. 100-08 chapter 6; 2007 Change Request 5679 |
|
Disorders of pituitary gland and hypothalamic control |
11/18/11 |
RAC Region B |
The purpose of MS-DRG Validation is to determine that the principal diagnosis and all secondary diagnoses identified as CCs and MCCs are actually present, correctly sequenced, coded and clinically validated. When a patient is admitted to the hospital, the condition established after study found to be chiefly responsible for occasioning the admission to the hospital should be sequenced as the principal diagnosis. The other diagnosis identified should represent all (MCC/CC) present during the admission that impact the stay. The POA indicator for all diagnoses reported must be coded correctly. Reviewers will validate MS-DRGs with a diagnosis of a disorder of pituitary gland and hypothalamic control that affects the MS-DRG assignment. |
CMS Pub. 100-08 chapter 6; 2007 Change Request 5679 |
|
Excisional debridement |
11/18/11 |
RAC Region B |
The purpose of MS-DRG Validation is to determine that the principal diagnosis and all secondary diagnoses identified as CCs and MCCs are actually present, correctly sequenced, coded and clinically validated. When a patient is admitted to the hospital, the condition established after study found to be chiefly responsible for occasioning the admission to the hospital should be sequenced as the principal diagnosis. The other diagnosis identified should represent all (MCC/CC) present during the admission that impact the stay. The POA indicator for all diagnoses reported must be coded correctly. Reviewers will validate MS-DRGs with a procedure code of 86.22 and for diagnoses that affect the MS-DRG assignment. |
CMS Pub. 100-08 chapter 6; 2007 Change Request 5679 |
|
Nutritional disorders |
11/17/11 |
RAC Region B |
The purpose of MS-DRG Validation is to determine that the principal diagnosis and all secondary diagnoses identified as CCs and MCCs are actually present, correctly sequenced, coded and clinically validated. When a patient is admitted to the hospital, the condition established after study found to be chiefly responsible for occasioning the admission to the hospital should be sequenced as the principal diagnosis. The other diagnosis identified should represent all (MCC/CC) present during the admission that impact the stay. The POA indicator for all diagnoses reported must be coded correctly. Reviewers will validate MS-DRGs with a nutritional disorder diagnosis that affects the MS-DRG assignment. |
CMS Pub. 100-08 chapter 6; 2007 Change Request 5679 |
Short-term Acute Care Hospital
|
Name of issue |
Date posted or approved |
Regions/states where it is active |
Description of issue |
Document sources |
|
Acute inpatient hospitalization – ventricular shunt procedures with CC (DRG 032) |
11/20/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub.100-08 chapter 6 |
|
Acute inpatient hospitalization – ventricular shunt procedures with MCC (DRG 031) |
11/20/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub.100-08 chapter 6 |
|
Acute inpatient hospitalization – ventricular shunt procedures without CC/MCC (DRG 033) |
11/20/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub.100-08 chapter 6 |
|
Acute inpatient hospitalization – revision of hip or knee replacement with MCC (DRG 466) |
11/20/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub.100-08 chapter 6 |
|
Acute inpatient hospitalization – amputation for circulatory system disorders except upper limb and toe with MCC (DRG 239) |
11/20/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub.100-08 chapter 6 |
About the Author
Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, the nation's leading independent authority on home healthcare business, regulation and reimbursement.
Contact the Author
To comment on this article please go to editor@racmonitor.com
Readmissions 101: Evaluating Patient Returns to the Hospital
By Ralph Wuebker, MD, MBA
Reducing avoidable readmissions rapidly is becoming one of the biggest hot-button issues for hospitals, and it’s a matter that involves both medical necessity compliance and patient care concerns.
The Centers for Medicare & Medicaid Services (CMS) reports that 18 percent of Medicare patients are readmitted within 30 days of discharge, and the agency believes that many of these readmissions are avoidable and/or unnecessary. A growing number of programs across the country have demonstrated improvements in the discharge and aftercare process, also known as care transitions, and such improvements can result in a significant reduction in readmissions, reducing overall healthcare costs and improving care quality.
For several years CMS has indicated that rising numbers of readmissions, and especially readmissions clinically related to an initial hospital stay, were responsible for a large portion of Medicare costs. A landmark New England Journal of Medicine article published in 2009 identified a 19.6 percent rate of readmission within 30 days, increasing to 34 percent at 90 days, for Medicare fee-for-service beneficiaries. The study noted that half of those readmitted within 30 days lacked evidence of a physician office visit occurring between discharge and readmission.
At the same time, CMS noted that hospitals were being rewarded for readmissions via additional DRG reimbursement. Medicare Quality Improvement Organizations (QIOs) long had been responsible for monitoring readmissions by performing occasional audits, however this was not effective in reducing overall readmission rates. It has been estimated that Medicare could save an estimated $12 billion through improvements in care transition at the time of hospital discharge. Policymakers have incorporated financial disincentives in the Inpatient Prospective Payment System (IPPS) to take effect in FY 2013 to encourage further reduction in the rate of related, avoidable readmissions in several key diagnostic categories, including heart failure, acute MI and pneumonia.
The drivers of readmissions vary from hospital to hospital, encompassing factors involving both unplanned as well as scheduled readmissions (such as surgery or other elective procedures).
The main emphasis of Medicare’s readmission reduction initiatives, including the QIO-led Care Transitions pilot programs in 14 communities across the U.S., has been on identifying the key components of improved discharge and aftercare that contribute to readmission reduction. QIO support for readmission reduction has been expanded under the Integrate Care for Populations and Communities (ICPC) initiative, which builds on the successes of the Care Transitions projects during the last three years. More information is available online at http://www.cfmc.org/integratingcare/Default.htm.
Due to a wide range of illnesses that can lead to readmission, it can be challenging for hospitals to determine where to focus their limited resources. Some factors to consider when evaluating the drivers of readmissions are:
- Patients – Initial efforts should focus on the key diagnoses reported nationally under the Hospital Compare program. Many programs have centered their efforts on heart failure patients, with successful reductions following redesign of their discharge process and improvements in medication reconciliation. Other workable strategies include creating tighter links as they pertain to planning, fostering improvements in communication through office-based physician follow-up and employing the use of outreach strategies (telephonic or home visits) to promote self care and treatment adherence.
- Admission Source – Transfers from skilled and long-term care facilities may have higher readmission rates than most other patients. It may be necessary to get together with staff from post-acute facilities and jointly review cases, looking for opportunities to improve communication or follow-up care.
- Attending Physicians – Some physicians or specialties may have significantly higher rates of readmissions than others. It is prudent to identify and monitor these particular groups and consider collaborative strategies tailored to the types of patients and circumstances involved.
Related and Unrelated Readmissions
There are several definitions and viewpoints to consider when determining if a particular readmission was related in some way to an initial hospital stay. It is not difficult to look for readmissions with the same DRG or ICD-9 diagnosis codes, however this approach fails to identify readmissions that involve complications or worsening of an initial illness, medication intolerance, or other events that may be clinically linked to the initial stay. For example, prolonged use of a urinary catheter may be linked to a readmission for sepsis several days following treatment for a stroke. Signs of impending infection, such as a rising white blood cell count, pyuria, or altered mental status may be evident at the time of discharge, however the handoff from the hospital to an outpatient provider may be a barrier to management of a UTI, which could have prevented the need for readmission. Other barriers, such as medication adherence or transportation to the physician’s office, may be of a social nature, however education and care coordination resources can address those issues as well.
One important definition of a “related” readmission is contained in Medicare’s QIO Manual, Chapter 4, Section 4240: “Readmission Review.” When considering if a particular readmission is related to an initial hospital stay, QIOs are directed to perform an analysis of the medical records from both the initial and subsequent admission(s), specifically looking for evidence of incomplete care or premature discharge during the initial stay. Factors to be considered include patient stability at the time of discharge and the potential presence of a problem requiring subsequent care following the initial admission.
Another issue to be considered is whether a readmission was related to technical problems, such as scheduling of tests or procedures (i.e., “unavailability of surgical suite,” “the surgeon became ill,” etc.).
Under the QIO Manual, hospitals may be denied payment if the QIO determines that any of the following three circumstances existed (emphasis added):
-The readmission was not medically necessary (i.e., outpatient care would have been appropriate);
-The readmission resulted from a premature discharge from the same hospital ; or
-The readmission was the result of circumvention of Medicare policy by the same hospital.
The QIO Manual focuses on a limited subset of readmissions: generally those cases in which the hospital is found to have contributed directly to the need for readmission or in which the hospital could have avoided readmission by providing outpatient or observation care.
Medicare has undertaken a shift to a much broader definition of related readmissions as required by the Patient Protection and Affordable Care Act (PPACA), Section 3025, “Hospital Readmissions Reduction Program.” While the details of this new approach still are being worked out and will not take effect until FY 2013, the basic concept is that many readmissions likely will be deemed to be related to the initial stay unless there is clear evidence that the admissions are unrelated. An example of an unrelated admission would be a patient who is involved in a car accident with multiple trauma within 30 days of an admission for pneumonia. The PPACA requires CMS to develop a mechanism to adjust readmission rates such that an accurate identification of hospitals with excess readmissions can be made, leading to reduced DRG reimbursement for those target hospitals.
Utilization review committees should be aware of overall and DRG-specific readmission rates for their facilities, and conduct internal review projects to better understand the issues and identify opportunities to improve care transitions and support patient care following hospital stays. In an era of reduced lengths of stay and limited resources, paying attention to aftercare is more important than ever. Identifying related, potentially avoidable readmissions is the first step toward achieving this goal.
About the Author
Ralph Wuebker, MD, currently serves as Vice President of Executive Health Resources’ (EHR) ACE (Audit, Compliance and Education) Team. This group of physicians conducts audits and regular visits to EHR’s client hospitals to provide ongoing education on a variety of topics including Medicare and Medicaid compliance and regulations, medical necessity, Recovery Audit Contractors, utilization review, denials management and length of stay.
Contact the Author
To comment on this article please go to editor@racmonitor.com
Recovery auditors will examine claims before they are paid as part of a new demonstration starting Jan. 1.
The prepayment audits, which CMS announced Nov. 15, will conduct those audits on “certain types of claims that historically result in high rates of improper payments,” CMS noted.
The demonstration will target seven states “with high populations of fraud- and error-prone providers,” CMS stated – California, Florida, Illinois, Louisiana, Michigan, New York and Texas. RACs also will conduct prepayment reviews in four states with “high claims volumes of short inpatient hospital stays,” CMS said – Missouri, North Carolina, Ohio and Pennsylvania.
The goal of the demonstration is to prevent improper payments and avoid the “pay-and-chase methods” of post-payment reviews, CMS states.
For more, visit the CMS website at www.cms.gov.
Region D posts hospital issues
DCS Healthcare, the RAC for Region A, posted 15 new inpatient hospital issues.
HealthDataInsights, the RAC for Region D, posted seven issues for short-term acute care hospitals and one issue for long-term acute care hospitals. See below for more information.
Inpatient hospital
|
Name of issue |
Date posted or approved |
Regions/states where it is active |
Description of issue |
Document sources |
|
Medical necessity review for MS-DRG 129, major head and neck procedure with CC/MCC or major device |
11/18/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 055, nervous system neoplasms without MCC |
11/18/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 919, complications of treatment with MCC |
11/18/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 493, lower extremity and humerus procedure except hip, foot, femur with CC |
11/18/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 884, organic disturbances and mental retardation |
11/18/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 497, local excision and removal internal fixation devices except hip and femur without CC/MCC |
11/18/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 989, nonextensive O.R. procedure unrelated to principal diagnosis without CC/MCC |
11/18/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 167, other respiratory system O.R. procedure with CC |
11/18/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 343, appendectomy without complicated principal diagnosis without CC/MCC |
11/17/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 947, signs and symptoms with MCC |
11/17/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 920, complications of treatment with CC |
11/17/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 626, thyroid, parathyroid and thyroglossal procedures with CC |
11/17/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 134, other ear, nose, mouth and throat procedures without CC/MCC |
11/17/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 741, uterine, adnexa procedures for non-ovarian/adnexal malignancy without CC/MCC |
11/17/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review for MS-DRG 035, carotid artery stent procedure with CC |
11/17/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
Short-term acute care hospital
|
Name of issue |
Date posted or approved |
Regions/states where it is active |
Description of issue |
Document sources |
|
Acute inpatient hospitalization – disorders of liver except malignancy, cirrhosis or alcoholic hepatitis with CC (DRG 422) |
11/3/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub.100-08 chapter 6 |
|
Acute inpatient hospitalization – disorders of liver except malignancy, cirrhosis and alcoholic hepatitis without CC/MCC (DRG 443) |
11/3/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub.100-08 chapter 6 |
|
Acute inpatient hospitalization – hypertensive encephalopathy with MCC (DRG 077) |
11/3/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub.100-08 chapter 6 |
|
Acute inpatient hospitalization – hypertensive encephalopathy without CC/MCC (DRG 079) |
11/3/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub.100-08 chapter 6 |
|
Acute inpatient hospitalization – traumatic injury without MCC (DRG 914) |
11/3/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub.100-08 chapter 6 |
|
Acute inpatient hospitalization – disorders of the biliary tract with MCC (DRG 444) |
11/3/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub.100-08 chapter 6 |
|
Acute inpatient hospitalization – disorders of the biliary tract with CC (DRG 445) |
11/3/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub.100-08 chapter 6 |
Long-term acute care hospital
|
Name of issue |
Date posted or approved |
Regions/states where it is active |
Description of issue |
Document sources |
|
Long term care hospital |
11/3/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1; CMS Pub. 100-04, chapter 3; CMS Pub.100-08 chapter 6 |
About the Author
Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.
Contact the Author
KLong@decisionhealth.com
Comment on this Article
editor@racmonitor.com
EDITOR’S NOTE: Last week on Monitor Monday, our weekly poll asked listeners if they were satisfied with their RAC’s outreach efforts. Only 10 percent said they were “satisfied and well informed.” Thirty-four percent responded that they were “not satisfied” and “not well informed.” An astonishing 56 percent asked, “What Outreach?”
When attempting to blow up ignorance, there is nothing quite as satisfying as being the guy who lights the fuse.
Since my first article on the subject of poor RAC provider outreach appeared here on Nov. 2, the feedback I have received on my conclusions has verified my suspicions. I’ll detail those below, but first I’d like to fill in the blanks that remained as my last article went to press.
In the Beginning
As a reminder, I sent e-mails to DCS, the Region A RAC, and Connolly, the Region C RAC, requesting schedules for upcoming provider outreach education sessions. I received a response from DCS asking for my provider NPI number so my request could be sent to the “correct area.”
When I responded that I worked for a provider financial management company representing clients in New York and Connecticut, I received a response from the same person (she must have been the “correct area” all along) stating that DCS would be presenting a joint outreach webinar with NGS in February for providers in those states. I also was told that I should check the NGS website “later in 2011 or early 2012 for updates.”
Tracking Down the MAC
That covered only two of the 11 states under the DCS umbrella, so I decided to go deeper. I went to the website of NHIC, the Jurisdiction 14 MAC covering the balance of the New England states. Its education schedule ran only to the end of 2011 and included no upcoming sessions on RAC activities. A review of the website for Highmark Medicare Services, which represents the rest of the states in the DCS universe, yielded identical results.
To date I have not received a response to my inquiry to Connolly, but I followed the lead I received from DCS and reviewed the websites of MACs within Region C. I began with Palmetto GBA for West Virginia, Virginia and the Carolinas, and found no upcoming education events. Next I reviewed Cahaba for Tennessee, Alabama, Georgia and (currently) Mississippi, with similar results: no events scheduled for the remainder of 2011. Similarly, Pinnacle for Arkansas and Louisiana and First Coast Service Options for Florida had nothing related to RAC scheduled for the remainder of 2011. Trailblazers, representing the states in the western portion of Region C, showed nothing through January 2012.
Don’t Have to Educate
Yet the Connolly saga didn’t end there. On the heels of my article being published I received a rather enlightening e-mail from a reader in a Trailblazers state. This person has a problematic issue identified by Connolly during a RAC audit of which she cannot get a resolution. In a futile attempt at identifying a solution, she contacted Connolly and was told by a phone representative that they don’t have to educate. I invite this week’s reading audience to reread that last sentence and internalize it.
Now let’s go back to the Fiscal Year 2010 Report to Congress on RAC implementation, which was released in late September. On Page 9 of the report is a summary of the outreach efforts that CMS has undertaken, but this segment mentions nothing about what the individual RACs have done to satisfy the education requirements detailed in the RAC Statement of Work. It’s also worth nothing that the wording in the Report to Congress gives the distinct impression that CMS has completed its outreach efforts, save for occasional updates to their FAQs as they pertain to the RAC program. In this context, a Connolly phone representative stating that they don’t have to educate the provider community should set off alarm bells.
No Outreach in Sight
To review, CMS has completed its outreach efforts, the RACs either have nothing scheduled or have yet to update the education calendars on their websites, and the MACs will get to it all next year (after all, what’s the rush?) Meanwhile, all the provider community is requesting is feedback and guidance – and instead we’re being left needlessly in the dark.
About the Author
Paul Spencer is the compliance officer for Fi-Med Management Inc., a national physician practice financial management company based in Wauwatosa, Wis. Paul has more than 20 years of experience across all facets of healthcare billing, including six years spent with insurance carriers. In his current role with Fi-Med he acts as a physician educator on issues related to E/M level of service and documentation audits by CMS and other outside entities. Paul has carried the CPC and CPC-H credentials from the American Academy of Professional Coders since 1998.
Contact the Author
To comment on this article please go to editor@racmonitor.com
Authority and Responsibility for the Utilization Management (UM) Plan
Another issue posted by a recovery auditor closely resembles targets the Office of Inspector General will focus on in 2012.
Connolly, the Region C RAC, will review whether services provided to patients at inpatient rehabilitation facilities (IRF) are medically necessary, according to an issue approved Nov. 9.
In its 2012 Work Plan, OIG published a new issue examining whether admissions to inpatient rehabilitation facilities are appropriate. “Patients must undergo preadmission screening and evaluation to ensure that they are appropriate candidates for IRF care,” OIG states in its Work Plan.
Connolly plans to evaluate documentation in patient records to ensure patients:
- Need “active and ongoing therapeutic intervention of multiple therapy disciplines,” one of which has to be physical therapy or occupational therapy;
- Require intensive rehabilitation therapy;
- At the time of admission to the IRF must reasonably be expected to “actively participate in an benefit significantly from” the intensive therapy;
- Require supervision by rehabilitation physicians who conduct visits with patients at least three days per week during their stay in the IMF; and
- Needs “intensive and coordinated interdisciplinary approach to providing rehabilitation.”
Also last week, several inpatient issues were posted by DCS Healthcare in RAC Region A and HealthDataInsights in RAC Region D. Connolly also posted three other issues.
Inpatient hospital
|
Name of issue |
Date posted or approved |
Regions/states where it is active |
Description of issue |
Document sources |
|
Medical necessity: Inpatient rehabilitation facility (IRF) patients not meeting medical necessity criteria |
11/9/11 |
RAC Region C |
To be reasonable and necessary, documentation in the patient’s record must demonstrate at the time of admission to IRF that: ·The patient requires active and ongoing therapeutic intervention of multiple therapy disciplines, one of which must be physical or occupational therapy ·The patient must generally require an intensive rehabilitation therapy program, as defined in section 110.2.2 ·The patient must reasonably be expected to actively participate in and benefit significantly from the intensive rehabilitation therapy program that is defined in section 110.2.2 at the time of admission to the IRF ·The patient must require physician supervision by a rehabilitation physician defined as a licensed physician with specialized training and experience in inpatient rehabilitation. The medical supervision requirement means the rehabilitation physician must conduct face-to-face visits with the patient at least three days per week during the patient’s stay in the IRF to assess the patient medically and functionally and modify treatment as needed to maximize the patient’s capacity to benefit from rehabilitation ·The patient must require an intensive and coordinated interdisciplinary approach to providing rehabilitation as defined in section 11.2.5 |
CMS Pub. 100-02 chapter 1; Highmark Part A Bulletins |
|
Medical necessity review – MS-DRG 042 peripheral-cranial nerve and other nervous system procedures without CC-MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 033 ventricular shunt procedures without CC-MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – 710 penis procedures without CC-MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 494 lower extremity-humerus procedures except hip, foot, femur without CC-MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 472 cervical spinal fusion with CC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 853 infectious-parasitic diseases with O.R. procedure with MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 512 shoulder, elbow or forearm procedure, except major joint procedure without CC-MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 580 other skin, subcutaneous tissue and breast procedures with CC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 517 other musculoskeletal system and connective tissue O.R. procedure without CC-MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 983 extensive O.R. procedure unrelated to principal diagnosis without CC-MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 582 mastectomy for malignancy without CC-MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 165 major chest procedure without CC-MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 479 biopsies of musculoskeletal system and connective tissue without CC-MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 418 laparoscopic cholecystectomy without C.D.E. with CC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 328 stomach, esophageal, duodenal procedures without CC-MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 713 transurethral prostatectomy with CC-MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 982 extensive O.R. procedure unrelated to principal diagnosis with CC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 041 peripheral-cranial nerve and other nervous system procedures with CC or peripheral neurostimulator |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 030 spinal procedures without CC-MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 164 major chest procedure with CC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 470 major joint replacement or reattachment of lower extremity without MCC |
11/8/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 155 other ear, nose, mouth, throat diagnosis with CC |
11/7/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Bone marrow transplant: MS-DRG 014 and 015 (previously DRG 009); medical necessity excluded |
11/7/11 |
RAC Region C |
DRG validation requires that diagnostic and procedural information and beneficiary discharge status, as coded and reported by the hospital on its claims, matches the attending physician description and information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 014 and 015 principal diagnosis, secondary diagnosis and procedures affecting or potentially affecting the DRG. |
ICD-9-CM Addendums and Coding Clinics (2007-2009); ICD-9-CM Vol. 1, 2, 3, coding manuals (2007-2009); CMS Pub. 100-08 chapter 6 |
|
Medical necessity: Disease and disorders of the ear, nose, mouth, throat |
11/7/11 |
RAC Region C |
RACs will review documentation to validate medical necessity of short stay, uncomplicated admissions. Documentation will be reviewed to determine that the services were medically necessary and billed correctly for MS-DRGs 153, 158, 159. RACs also will review documentation to validate MS-DRG 153, 158, 159 requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches the attending physician description and information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG, principal diagnosis, secondary diagnosis and procedures affecting or potentially affecting the DRG. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapters 6, 13; CMS RAC demonstration evaluation report |
|
Medical necessity: postoperative or post-traumatic infections with O.R. procedures without CC/MCC; MS-DRG 858 |
11/4/11 |
RAC Region C |
RACs will review documentation to validate medical necessity of short stay, uncomplicated admissions. Medical documentation will be reviewed to determine that the services were medically necessary and billed correctly for MS-DRG 858. RACs also will review documentation to validate MS-DRG 858 requiring diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches the attending physician description and information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG, principal diagnosis, secondary diagnosis and procedures affecting or potentially affecting the DRG. |
CMS Pub. 100-02 chapter 1; CMS Pub. 100-08 chapter 6; RAC demonstration evaluation report |
|
Medical necessity review – MS-DRG 027 craniotomy and endovascular intracranial procedures without CC-MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 581 other skin, subcutaneous tissue and breast procedures without CC-MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 100 seizures with MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 176 pulmonary embolism without MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 085 nontraumatic stupor and coma, coma less than one hour with MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 432 cirrhosis and alcoholic hepatitis with MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 175 pulmonary embolism with MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 306 cardiac congenital and valvular disorders with MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 201 pneumothorax without CC-MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 061 acute ischemic stroke with use of thrombolytic agent with MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 728 inflammation of the male reproduction system without MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 185 major chest trauma without CC-MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 147 ear, nose, mouth, throat malignancy with CC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 080 nontraumatic stupor and coma with MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 148 ear, nose, mouth, throat malignancy without CC-MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 592 skin ulcers with MCC |
11/4/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
About the Author
Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.
Contact the Author
To comment on this article please go to editor@racmonitor.com
CMS Posts Lists of Providers Who Have Received Revalidation Notices
By Nancy J. Beckley, MB, MBA, CHC
CMS has posted a listing of providers and suppliers that have received enrollment revalidation requests under the Patient Protection and Affordable Care Act provision requiring all enrolled providers and suppliers to revalidate their enrollment information under new screening criteria.
Under Section 6401 (a) of the act, providers that enrolled prior to March 25, 2011 are required to revalidate when so instructed by their CMS contractors. Keep in mind that just because a provider has updated an address on its RAC website in order to ensure prompt delivery of RAC letters, this does not constitute an official notification to CMS of an address change, which must be reported on the appropriate 855 form within the proper timeframe.
The initial round of revalidation requests went out to 89,000 providers and suppliers, according to information provided by CMS representatives during an Oct. 27 provider outreach call. That number since has risen to 105,080 providers and suppliers.
More than 9,000 callers participated in the outreach call, and judging by the few who managed to get in the Q&A queue, they were frustrated by the handling of requests, confused about the notification process and notably perplexed by attempts to utilize the PECOS online system for revalidating enrollment. During the call CMS representatives provided the regulatory basis and citations for the revalidation process, as well as a spirited review of all the planned updates to the PECOS system that will be taking place during the next 12-15 months. Unfortunately, a handout that was promised the day before the phone call was not available, leaving much of the presentation wanting for lack of visuals to support the important nature of the content and the seriousness of the revalidation initiative.
The first wave of providers and suppliers received their notices in a brightly colored envelope intended to attract attention, according to CMS, which also noted that the selection was targeted toward those not currently having a record in the PECOS online system. CMS has provided a sample revalidation letter so that providers can begin to review and assemble documents. While the push is toward the PECOS system, the letter states that enrollment also may take place via the old-fashioned method: the applicable 855 form. Unfortunately, the upgrades designed to make PECOS more user-friendly will be of no benefit to the first wave of those revalidating, as the upgrades are being phased in incrementally.
Providers and suppliers must wait to submit revalidation only after being asked by their MAC to do so – so keep your eye out for the brightly colored envelope and make sure that your PECOS address is up to date. Alternatively, if you are not in PECOS ensure that you have notified CMS appropriately (via the 855) regarding any address changes
During the conference call’s Q&A session two callers unfortunately took a large portion of the allotted time. One provider was trying to explain the difficulties of revalidating a large group practice of radiologists who perform services and assign their numbers at multiple facilities. That provider finally was instructed to get in touch with CMS offline to review the situation. Another caller read a Litany of the Saints venting on her frustration with doing revalidations for her small medical practice – apparently CMS didn’t want to be rude, so officials let her vent away. A few more inquiries were voiced and the Q&A came to a close with more than 400 folks still in the queue. Couldn’t CMS have stayed on the line a bit longer? The agency offered providers an e-mail address to send questions, but within a week of the call CMS had to send out a notice via the MACs indicating that it gave the wrong e-mail address! And since the notice went out via the MACs, there was no guarantee that those on the call received the corrected e-mail address.
As if these missteps weren’t enough, CMS announced that revalidation, originally slated to be completed by March 23, 2013, now has been extended by two years to March 23, 2015. On Nov. 7 Noridian notified its listserve members that revalidation had been extended two years, while the same day NGS notified its listserve members that CMS had not extended revalidation, merely suggesting that it may be appropriate to delay and offering a link to Medlearn Matters article #SE1126 (which indicated that the revalidation cycle had been extended through 2015). No matter whom you believe, if you have a revalidation letter or have been mailed one as per the CMS list, you have from 60 days of the date marked on the letter to process your revalidation. If you are on the list and did not receive a colored envelope in the mail, CMS is instructing you to contract your contractor.
One good piece of information that might have been lost in this call was an update to providers that they need not complete certain new data elements on either the paper or Internet-based PECOS versions of the CMS-855A application under Sections 5 and 6. The handout that was missing in action, appearing below, would have been a great aide in this regard:
Section 5 OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (ORGANIZATONS)
1.“Exact percentage of operational/managerial control this organization has in the provider”
Section 6 OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS)
1.“Exact percentage of control as an Officer this individual has in the provider”
2.“Exact percentage of control as a Director this individual has in the provider”
3.“Exact percentage of management control this individual has in the provider” (under the “W-2 Managing Employee” heading)
4.“Exact percentage of this contracted managing employee’s control in the provider”
5.“Exact percentage of operational/managerial control this individual has in the provider”
In addition, under the "other ownership or control/interest" headings in Sections 5 and 6, the “exact percentage of ownership or control/interest” data element need not be completed if the organization/individual in question does not have any ownership, partnership, mortgage, security or other quantifiable interest in the provider.
For those providers and suppliers that submitted their enrollment applications to CMS on or after March 25, 2011, they will not be required to revalidate under this current initiative. Between now and March 23, 2015 MACs will send out notices on a regular basis to begin the revalidation process for each provider and supplier.
42 CFR 424.515 (d) provides CMS the authority to conduct these off-cycle revalidations, and further information regarding Medicare enrollment and the timelines associated with mandatory reporting of various items can be found in Chapter 10 of the Medicare Program Integrity Manual.
About the Author
Nancy Beckley is the president and CEO of Nancy Beckley & Associates. Nancy is certified in healthcare compliance by the Healthcare Compliance Board, and serves on the Part A and Part B Provider Outreach Education and Advisory Panel for First Coast Services Options (Florida Medicare). She previously served on the CMS Professional Expert Technical Panel for Comprehensive Outpatient Rehabilitation Facilities.
Contact the Author
To comment on this article please go to editor@racmonitor.com
Readmissions 101: Evaluating Patient Returns to the Hospital
CGI Federal, the recovery auditor for RAC Region B, will review documentation for medical necessity and coding requirements for claims with new power wheelchairs, according to an issue approved Oct. 26.
Payments for power wheelchairs have been a target of the Office of Inspector General (OIG). A July 2011 OIG report noted that 61 percent of power wheelchairs provided to beneficiaries in the first half of 2007 “where medically unnecessary or had claims that lacked sufficient documentation to determine medical necessity,” the OIG states. Those claims accounted for $95 million of the $189 million paid for power wheelchairs during that time.
DCS Healthcare, the RAC for Region A, posted a power-wheelchair issue in February and has other wheelchair-related issues on its list. HealthDataInsights, the Region D RAC, posted a power wheelchair issue in April.
Connolly, the Region C RAC, has a wheelchair bundling issues posted.
DCS Healthcare also posted 31 inpatient issues – three for Maryland and 28 for the other states in the region.
For more on the recently posted issues, see below.
Durable medical equipment by supplier
|
Name of issue |
Date posted or approved |
Regions/states where it is active |
Description of issue |
Document sources |
|
New purchased power wheelchairs – groups 1, 2, 3 |
10/26/11 |
RAC Region B |
Power wheelchairs – groups 1, 2, 3 are covered if the equipment is properly coded and meets coverage criteria/ documentation requirements specified in the National Government Services (NGS) LCD L27239, effective Oct. 1, 2006. Medical records will be reviewed for new, purchased PWC–Group 1,2,3 (HCPCS K0813-K0864 with modifiers NU-new equipment and BP-beneficiary elected to purchase item) for appropriate coding, documentation requirements and medical necessity criteria. |
CMS Pub. 100-02, chapter 15; CMS Pub. 100-03, chapter 1; CMS Pub. 100-04, chapter 20; CMS Pub. 100-08, chapter 5; NGS LCD L27239; NGS article A47122; NGS Jurisdiction B Supplier Manual chapters 8, 9, 15, 17; MLN Matters SE1112; MLN Fact Sheet – Power Mobility Devices; NGS toosl and resources, Dear Physician letters |
Inpatient hospital
|
Name of issue |
Date posted or approved |
Regions/states where it is active |
Description of issue |
Document sources |
|
Medical necessity review – MS-DRG 238, major cardiovascular procedures without MCC |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 237, major cardiovascular procedures with MCC |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 460, spinal fusion except cervical without MCC |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 207, respiratory system diagnosis with ventilator support 96+ hours |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 708, major male pelvic procedures without CC-MCC |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 627, thyroid, parathyroid and thyroglossal procedure without CC-MCC |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 419, laparoscopic cholecystectomy without C.D.E. without CC-MCC |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 743, uterine and adnexa procedure for nonmalignancy without CC-MCC |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 621, O.R. procedures for obesity without CC-MCC |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 714, transurethral prostatectomy without CC-MCC |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 490, back and neck procedures except spinal fusion with CC-MCC or disc device/ neurostimulator |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 748, female reproductive system reconstructive procedures |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 038, extracranial procedures with CC |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 484, major joint-limb reattachment procedures of upper extremity without CC-MCC |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 036, carotid artery stent procedure without CC-MCC |
11/2/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 917, poisoning and toxic effects of drugs with MCC |
10/28/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 516, other musculoskeletal system and connective tissue O.R. procedure with CC |
10/28/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 897 alcohol/drug abuse or dependence without rehabilitation therapy without MCC |
10/28/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 813, coagulation disorders |
10/28/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 894, alcohol/drug abuse or dependence, left against medical advice |
10/28/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 082, traumatic stupor and coma, coma greater than one hour with MCC |
10/28/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 054, nervous system neoplasms with MCC |
10/28/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 291, heart failure and shock with MCC; MS-DRG 292, heart failure and shock with CC; MS-DRG 293, heart failure and shock without CC/MCC |
10/27/11 |
Md. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sects. 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; CMS Change Request 3200; Highmark LCD L27548; Admission of less than 24 hours policy; Pepper report; OIG reports A-01-10-0100, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 302, atherosclerosis with MCC, and MS-DRG 303, atherosclerosis without MCC |
10/27/11 |
Md. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sects. 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; CMS Change Request 3200; Highmark LCD L27548; Admission of less than 24 hours policy; Pepper report; OIG reports A-01-10-0100, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 516, other musculoskeletal system and connective tissue O.R. procedure with CC |
10/27/11 |
Md. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sects. 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; CMS Change Request 3200; Highmark LCD L27548; Admission of less than 24 hours policy; Pepper report; OIG reports A-01-10-0100, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 200, pneumothorax with CC |
10/27/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 307, cardiac congenital and valvular disorders without MCC |
10/27/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 187, pleural effusion with CC |
10/27/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 186, pleural effusion with MCC |
10/27/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 184, major chest trauma with CC |
10/27/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
|
Medical necessity review – MS-DRG 081, nontraumatic stupor and coma without MCC |
10/27/11 |
Conn., Del., D.C., Maine, Mass., N.H., N.J., N.Y., Pa., R.I., Vt. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sect. 1886(d) of the Social Security Act; CMS Pub. 100-08 chapters 6, 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Medicare inpatient fact sheet; Pepper report; OIG reports A-01-10-0100, OAI-09-88-00880, A-03-00-00007, OAI-05-88-00730 |
About the Author
Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.
Contact the Author
To comment on this article please go to editor@racmonitor.com
Lately I have seen a great deal of discussion concerning whether extrapolation, when used to determine overpayment amounts, is of benefit or detriment to any healthcare organization.
The alternative, from the payer’s perspective, is to conduct a 100 percent audit. What does that mean? It means that instead of using a random sample and gauging what likely would have happened if all claims were reviewed, all claims are, in fact, reviewed. That sounds like an overwhelming task, and it is. Imagine this: you have a practice that has filed 10,000 claims during the last year, and each claim represents an average of 2.2 claim lines (meaning that in a 100 percent audit, the payer would have to review 22,000 individual procedures to determine if those 10,000 claims were paid appropriately).
The Payer Perspective
Let’s say that an auditor can handle five claim lines per hour (not for coding, but for the purpose of the audit). That equals 4,400 hours of work, or the equivalent of just more than one year’s worth of effort by a full-time equivalent employee. Obviously, an auditor would want the audit completed long before that, so let’s say that they budgeted three months for completion. That would require eight full-time reviewers. Let’s say that each reviewer earns $45,000 per year, and now we are talking about the payer investing $360,000 to conduct an audit that may end up returning significantly less than that on the initial investment.
The Provider Perspective
Let’s look at this from the provider’s perspective. At first glance it seems like a better deal for the provider and a worse deal for the payer. In fact, on many occasions I have advised a practice to go for a 100 percent review because I knew (based on workload) that a payer instead would opt out for a real-time assessment – meaning it would estimate overpayments only on audited claims. But what happens if a payer does agree, which has happened in the past? Think about the workload involved for the provider, having to pull and make copies of the documentation required to support 10,000 claims. This includes basic charts, post-operative notes, lab and imaging studies, prescriptions, etc. This can be an overwhelming task. So why would a provider ever decide to go this route? It’s a good question and it deserves a thoughtful answer, so let’s take a look at what I call the “audit ROI.”
The Audit ROI
First I want to comment on whether extrapolation is ever appropriate. There are two opposing schools of thought on this. In the “world according to Frank,” extrapolation, if used properly, is a very appropriate and often very effective method for inferring an outcome for a larger set of data. It is often the only option available, particularly when studying an entire universe of data is impractical. Consider, for example, political polling. Let’s say there are two candidates running against each other in an election and I want to know which is likely to win; suppose this is a national election, so it involves the entire voting population of the United States, or about 207 million people. Now, we could just go out and try to survey all 207 million registered voters, but for obvious reasons that would be impractical. Even if you tried to do this, you always would end up missing someone somewhere, or some people would not give you an honest response. In any event, you might get very close, but could never achieve 100 percent certainty. Another option, however, is to poll a random sample of the voting population and then estimate, using their responses, how the entire voting population would vote. This is extrapolation.
Sample Error
One of the main issues that arise when conducting an extrapolation analysis is the idea of sample error, which is a bit more than we can address in this article. In general, however, this means that for every sample I take representing a certain group of people, the overall ratio of how many of them would vote for a certain candidate would vary – so instead of predicting an actual value, I need to predict a range, accounting for that potential variation. For these types of cases, the smaller the sample size, the larger the potential error. For example, if I was satisfied with a 5 percent margin of error – meaning that if I estimated that 50 percent of the population would vote for a certain candidate, it would yield a range of 45 to 55 percent – I would need to survey 783 likely voters. If I wanted to keep the sample error down to 3 percent, I would need to survey 2,178 likely voters. If I wanted to keep sample error to 1 percent, I would need to survey 19,620 likely voters. The ROI is determined by weighing the cost of the sample (or audit, in our case) to the criticality of the outcome (overpayment amounts).
The Probe Audit
So, if given the option, how can a practice determine which route to take? One way is to perform your own probe audit. Pull a random sample of claims (say, 30) and conduct your own review to determine what the damage would be if you were to be subject to an outside audit. If it’s a huge amount, you may not have a lot to lose in a 100 percent review. If it is a smaller amount (or financially survivable), extrapolation is likely your best bet. In either case, you already will have determined the range in which the overpayment estimate should fall, giving you the ability to assess the accuracy of a payer’s audit.
The Essential Issue
One very critical point to remember here, and I can’t emphasize this enough: how accurate an extrapolation audit turns out to be is almost completely dependent on how random a sample was. If the sample is not random, then all bets are off. Remember, extrapolation amplifies the degree of error within a sample – so in our example here, if an estimate for a sample is off by $10 per claim, multiply this by 10,000 claims and it means that someone just made a $100,000 mistake (and in my experience this type of mistake rarely, if ever, happens in favor of the provider).
You must ensure that samples are statistically valid random samples, and if you don’t know how to determine this, get help from someone who does. Remember, your financial survival may depend on it.
About the Author
Frank Cohen is the senior analyst for The Frank Cohen Group, LLC. He is a healthcare consultant who specializes in data mining, applied statistics, practice analytics, decision support and process improvement. Mr. Cohen is a member of the RACMonitorEnews editorial board and makes frequent appearances on Monitor Monday podcasts.
Contact the Author
To comment on this article please send to editor@racmonitor.com
Since the beginning of the permanent Recovery Audit Contractor program, the four RACcontractors have been mandated to perform provider outreach to “notify provider communities of the recovery auditor’s purpose and direction,” according to the RAC Statement of Work (SOW), which was updated in September.
The SOW details how the RACs submit a baseline provider outreach plan to CMS. CMS uses the plan as a starting point for discussion, which presumably would lead to a more detailed plan that should include “potential outreach efforts to associations, providers, Medicare contractors and any other applicable Medicare stakeholders.”
Hunch Break
On a hunch (the hunch being that provider outreach has come to a grinding halt), I decided to look into the efforts of the contractors in this area. As of this writing, I still am awaiting a definitive answer from DCS, the Region A RAC, and Connolly, the Region C RAC. The reason for this is that, unlike their counterparts in Regions B and D, DCS and Connolly do not list their past or future outreach sessions on their websites. It would seem, from all current appearances, that my hunch is correct.
CGI, the Region B RAC, does have its schedule of all conducted outreach sessions on its dedicated RAC website. The last provider outreach session held by CGI occurred on March 24 of this year in Illinois. Being from Wisconsin, I was interested in particular by the fact that in my state, only three such sessions have ever taken place. To add insult to the injury of ignorance, none of these sessions was aimed directly at facilities or physicians.
HDI, the Region D RAC, doesn’t make its list of outreach meetings easy to find, but after some fancy clicking of links I came across this page on its website. As it indicates, the last outreach session for Region D providers occurred in September 2009.
To get a mental picture of what this outreach vacuum means for the provider community, it helps to compare the schedules of these two contractors with the number of approved issues added by each RAC during this same period when outreach education didn’t occur. In Region D, 336 of 386 approved issues have been added since HDI’s last provider outreach session was held. In Region B, 53 new issues have been added since March 24, with 43 of these issues being complex.
RACs and the SOW
While many larger organizations have taken to discussing RAC issues on their own as groups in search of enlightenment, it would appear that the RACs are violating their work order. In the SOW, the RACs are tasked with submitting monthly progress reports to CMS outlining all work accomplished during the previous month. These reports are supposed to include details about upcoming provider outreach efforts, but perhaps CMS is so busy dissecting some appalling appeal statistics that they have been skimming over this requirement.
When the RAC in charge of the most densely populated state in the country has produced 87 percent of its approved issues list without presenting outreach to providers in its region, I would argue that this is indicative of a problem.
Hospitals at this point know the ins and outs of the program, but I continue to encounter physician groups across the country that have only passing knowledge of the RAC program. Many that I encounter have no knowledge of RACs at all.
CMS asks a lot from the provider community with regard to compliance. Perhaps the time has arrived for physicians to request that CMS return the favor with a little shared knowledge.
About the Author
Paul Spencer is the Compliance Officer for Fi-Med Management, Inc., a national physician practice financial management company based in Wauwatosa, WI. Paul has over 20 years of experience across all facets of healthcare billing, including 6 years spent with insurance carriers. In his current role with Fi-Med, he acts as a physician educator on issues related to E/M level of service and documentation audits by CMS and other outside entities. Paul has carried the CPC and CPC-H credentials from the American Academy of Professional Coders since 1998.
Contact the Author
To comment on this article please go to editor@racmonitor.com
Improving the Provider Experience Through Analytic Technology
Impact of an Untimely Hospice Face-to-Face Encounter: An Update
By Amy K. Fehn, Esq. and Jennifer Colagiovanni, Esq.
A hospice provider's failure to comply with the timing requirements for the newly mandated face-to-face encounter may lead to claim denials in future audits.
Hospice providers are advised to take heed of the recent MLN Matters article issued by the Centers for Medicare & Medicaid Services (CMS) addressing claims processing issues when the required face-to-face encounter does not occur in a timely fashion.
To be eligible for the Medicare hospice benefit, a beneficiary is required to be certified by a physician as terminally ill. This certification must be issued in writing and must be on file prior to claim submission.
The Medicare Benefit Policy Manual requires specific elements to be part of a hospice certification or recertification, including: a) a statement that an individual's medical prognosis includes a life expectancy of six months or less if the terminal illness runs its normal course; b) specific clinical findings and other documentation supporting the life expectancy of six months or less; c) the physician's signature; and d) a brief narrative of the clinical findings supporting a life expectancy of six months or less.
Face-to-Face Encounters
Section 3132(b) of the Patient Protection and Affordable Care Act of 2010 (PPACA) added the requirement that a hospice physician or nurse practitioner conduct a face-to-face encounter with each hospice patient prior to the beginning of the 180-day recertification (i.e. the third benefit period) and prior to the start of each subsequent benefit period. Effective Jan. 1, 2011, the required face-to-face encounter must occur no more than 30 calendar days prior to the start of each benefit period.
Specifically, the recertification form must include a written attestation by the hospice physician or nurse practitioner who performed the face-to-face encounter. In cases in which the encounter is performed by a nurse practitioner, the attestation must indicate that the clinical findings of the encounter visit were provided to the certifying physician. The attestation, along with an accompanying dated signature, is required to be a separate and distinct section of the recertification form.
If all the above requirements are met, the beneficiary will be eligible for the Medicare hospice benefit. CMS recently released MLN Matters (MM7478) and Change Request 7478, which advise hospice providers of the repercussions of failing to meet the face-to-face requirements within the required time frames. Such a failing will cause the beneficiary to no longer be classified as terminally ill, and without this designation, the beneficiary will no longer be eligible for the hospice benefit.
If a beneficiary is ineligible for the hospice benefit due to lack of status, the hospice must discharge the patient from the Medicare hospice benefit. However, the hospice can readmit the patient to the hospice benefit if the patient later receives the face-to-face encounter and meets other eligibility requirements.
Potential Future Audit Reviews
In cases in which a patient is discharged from hospice care due solely to a face-to-face encounter failing to occur in a timely fashion, CMS expects the hospice to continue to service the patient at its own expense until the face-to-face encounter requirement has been met. By doing so, the hospice will be able to reestablish Medicare eligibility more swiftly.
This assertion by CMS suggests a potential focus for future audit reviews because hospice beneficiaries with delayed face-to-face documentation could have a lapse in coverage, which would be considered an overpayment to the hospice provider. Because of the new requirement under the PPACA's Section 6402, hospice providers have an affirmative duty to report and return any such overpayments.
The likelihood of such audits seems probable based on the scrutiny with which CMS audit contractors currently view hospice providers in regard to other requirements such as certification, level of care and six-month prognosis. The RACs also have taken aim at certain hospice-related issues on their current approved issues lists. For instance, HealthDataInsights, the RAC for Region D, has approved review of hospice-related services - specifically, services related to hospice terminal diagnosis provided during hospice period, which are included in the hospice payment and are not separately payable.
The Need for Policies and Procedures
Hospice providers are advised to develop and maintain effective policies and systems to ensure that face-to-face encounters are conducted in a timely fashion and documented appropriately. It is important to educate clinicians, coding and billing staff, and referring providers about the applicable time frames and documentation requirements connected to these encounters. Failure to have such policies in place could lead to future claim denials and place providers at risk of overpayment liability. These risks can be minimized by reviewing and understanding the recent guidance issued by CMS and its contractors.
Hospice providers also must be cognizant of the requirement to report and return any known overpayments, including those related to failure to perform face-to-face encounters in a timely fashion.
About the Authors
Jennifer Colagiovanni is an attorney at Wachler & Associates, P.C. Ms. Colagiovanni graduated with Distinction from the University of Michigan and Cum Laude from Wayne State University Law School. She is a member of the State Bar of Michigan Health Care Law Section.
Amy K. Fehnis a partner at Wachler & Associates, P.C. Ms. Fehn is a former registered nurse who has been counseling healthcare providers for the past eleven years on regulatory and compliance matters and frequently defends providers in RAC and other Medicare audits.
Contact the Authors
To comment on this article please go to editor@racmonitor.com
LINKS:
MLN Matters MM7478: https://www.cms.gov/MLNMattersArticles/downloads/MM7478.pdf
Change Request 7478: https://www.cms.gov/MLNMattersArticles/downloads/MM7478.pdf
More...
The two recovery auditors that posted issues last week listed a slew of medical necessity reviews.
DCS Healthcare Services, the Region A RAC, posted four issues for Part A providers in Maryland about surgical cardiovascular procedures, renal and urinary tract disorders, infections and musculoskeletal disorders.
HealthDataInsights, the Region D RAC, posted 26 issues for short-term acute care hospitals ranging from allergic reactions with major complications and comorbidities to alcohol/drug abuse or dependence with rehabilitation therapy.
For more, see the chart below.
Part A
|
Name of issue |
Date posted or approved |
Regions/states where it is active |
Description of issue |
Document sources |
|
Medical necessity review – Surgical cardiovascular procedures, MS-DRGs 246-254, 263-265 |
10/26/11 |
Md. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sections 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Pepper Report; OIG reports A-01-10-01000, A-03-00-00007, OIA-05-88-00730; Change request 3200; Admission of less than 24 hours policy – Maryland |
|
Medical necessity review – Renal and urinary tract disorders |
10/26/11 |
Md. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Sections 1886(d) and 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapter 1; CMS Pub. 100-04 chapter 3; Highmark LCD L27548; Pepper Report; OIG reports A-01-10-01000, A-03-00-00007, OIA-05-88-00730; Change request 3200; Admission of less than 24 hours policy – Maryland |
|
Acute inpatient hospitalizations – infections, MS-DRGs 094-096, 177-179, 488-489, 539-541, 602-603, 689-690, 856-858, 862-869, 871-872, 977 |
10/26/11 |
Md. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Section 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapters 1, 6; Change request 3200; Admission of less than 24 hours policy – Maryland |
|
Acute inpatient hospitalization – musculoskeletal disorders |
10/26/11 |
Md. |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
Section 1814(b)(3) of the Social Security Act; CMS Pub. 100-08 chapter 13; CMS Pub. 100-02 chapters 1, 6; Change request 3200; Admission of less than 24 hours policy – Maryland |
Inpatient hospital
|
Name of issue |
Date posted or approved |
Regions/states where it is active |
Description of issue |
Document sources |
|
Acute inpatient hospitalization – malignancy of hepatobiliary system or pancreas with CC (DRG 436) |
10/6/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – allergic reactions with MCC (DRG 915) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – complications of treatment with CC (DRG 920) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – traumatic injury with MCC (DRG 913) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – allergic reactions without MCC (DRG 916) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – other factors influencing health status |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – poisoning and toxic effects of drugs with MCC (DRG 917) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – signs and symptoms with MCC (DRG 947) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – other injury, poisoning and toxic effect diagnosis with MCC (DRG 922) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – other injury, poisoning and toxic effect diagnosis without MCC (DRG 923) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – alcohol/drug abuse or dependence without rehabilitation therapy without MCC (DRG 897) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – disorders of pancreas except malignancy with CC (DRG 439) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – lymphoma and non-acute leukemia with MCC (DRG 840) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – malignancy of hepatobiliary system or pancreas without CC/MCC (DRG 437) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – disorders of pancreas except malignancy with MCC (DRG 438) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – other myeloproliferative disease or poorly differentiated neoplasm diagnosis without CC/MCC (DRG 845) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – alcohol/drug abuse or dependence with rehabilitation therapy (DRG 895) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – alcohol/drug abuse or dependence without rehabilitation therapy with MCC (DRG 896) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – acute adjustment reaction and psychosocial dysfunction (DRG 880) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – disorders of personality and impulse control (DRG 883) |
10/13/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – other multiple significant trauma with MCC (DRG 963) |
10/14/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – other multiple significant trauma with CC (DRG 964) |
10/14/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – other myeloproliferative disease or poorly differentiated neoplastic diagnosis with CC (DRG 844) |
10/14/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – chemotherapy without acute leukemia as secondary diagnosis with MCC (DRG 846) |
10/14/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – disorders of liver except malignancy, cirrhosis, alcoholic hepatitis with MCC (DRG 441) |
10/14/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
|
Acute inpatient hospitalization – traumatic stupor and coma, coma less than one hour with CC (DRG 086) |
10/19/11 |
RAC Region D |
Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation will be reviewed to determine that services were medically necessary. |
CMS Pub. 100-02 chapters 1, 6; CMS Pub. 100-08 chapter 6 |
About the Author
Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.
Contact the Author
To comment on this article please go to editor@racmonitor.com
An issue posted for complex review by the Region C recovery auditor (RAC) Connolly is similar to one in the Office of Inspector General (OIG) Work Plan for 2012.
The issue relates to multi-dose vials of Herceptin (Trastuzumab), which contain 440mg of the drug. Outpatient hospitals should bill only the doses of the drug administered to the patient, not any drug waste, Connolly noted.
The OIG issue does not specify provider type but does say the multi-use vials "are not subject to payment for discarded amounts of a drug or biological," the 2012 Work Plan stated.
The other issues Connolly posted Oct. 13 were automated reviews involving outpatient claims billed during inpatient stays, payments for noncovered mammography screenings or diagnostics and Bevacizumab injections for noncovered diagnoses.
For durable medical equipment (DME) suppliers, one issue was posted about inappropriate billing of spring-powered devices. For ambulance and transport services, Connolly posted one issue about billing claims during inpatient stays.
See below for more detail.
Outpatient Hospital
|
Name of issue |
Date posted or approved |
Regions/states where it is active |
Description of issue |
Document sources |
|
Outpatient claims billed within a PPS inpatient admission |
10/13/11 |
RAC Region C |
The reimbursement of outpatient services within a PPS Hospital stay is considered a duplicate payment in the Medicare Claims Processing Manual. This reimbursement would be an overpayment for services that were previously processed and paid. |
CMS Pub. 100-04 chapters 1, 3, 18 |
|
Inappropriate screening/ diagnostic mammography payments |
10/13/11 |
RAC Region C |
Local coverage determination policy has indicated specific conditions or diagnoses that are covered for screening (77057, G0202) and diagnostic (77051, 77055, 77056, G0204, G0206) mammography services. Outpatient claims have been identified where the first-listed and/or other diagnosis codes do not match to the covered diagnosis codes in the LCD policies. |
CMS Pub. 100-04 chapter 18; national coverage determination NCD 220.4; TrailBlazer LCD L26764; First Coast LCDs L29328, L29329; Palmetto LCD L31785; Pinnacle Guide for Coding/Billing for Diagnostic and Screening Mammography; First Coast Guide on Diagnostic and Screening Mammography |
|
Multi-dose vial waste: Trastuzumab (Herceptin), J9355 |
10/13/11 |
RAC Region C |
Per its package label, Trastuzumab/Herceptin (J9355: INJECTION, TRASTUZUMAB, 10 MG) is supplied from the manufacturer in a 440mg multi-dose vial. Providers should be billing only units of J9355 associated with the amount of the drug administered to the patient. Drug waste is not paid and should not be billed for drugs supplied in multi-dose vials. |
CMS Pub. 100-04 chapter 17; CDC FAQs regarding safe practices for medical injections; MLN Matters articles MM5718, MM6323, MM5520; CMS Q&A answer ID 8523; Trastuzumab/Herceptin full prescribing information; U.S. BLA Supplement: Herceptin |
|
Bevacizumab - noncovered diagnosis |
10/13/11 |
RAC Region C |
Local coverage determination policy has indicated specific conditions or diagnoses that are covered for Bevacizumab injections. Bevacizumab outpatient claims have been identified where the first-listed and/or other diagnosis codes do not match to the covered diagnosis codes in the LCD policies. |
Cahaba LCD L29992; Avastin treatment information for healthcare professionals; TrailBlazer LCD L26746 |
DME
|
Name of issue |
Date posted or approved |
Regions/states where it is active |
Description of issue |
Document sources |
|
Inappropriate billing of spring-powered device (A4258) |
10/13/11 |
DME suppliers who bill CIGNA (RAC Region C) |
More than one spring-powered device (A4258) per six months is not considered medically necessary. |
CIGNA LCD L11520, CGS LCD L11520 |
Ambulance
|
Name of issue |
Date posted or approved |
Regions/states where it is active |
Description of issue |
Document sources |
|
Ambulance/ transport services provided during an inpatient hospitalization |
10/13/11 |
RAC Region C |
Ambulance transports provided by hospital-based ambulance suppliers to beneficiaries who are in an inpatient stay are the responsibility of the inpatient hospital provider with the exception of transports on the day of admission, day of discharge and during a leave of absence from the inpatient facility. |
CMS Pub. 100-02 chapter 10; CMS Pub. 100-04 chapters 3, 15; Electronic Code of Federal Regulations Title 42, part 410, subpart B; OIG report A-01-04-00513; CMS Transmittal 668 from Sept. 2, 2005; Social Security Act section 1862 |
About the Author
Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.
Contact the Author
To comment on this article please go to editor@racmonitor.com
While the RACs were quiet last week, the Office of Inspector General (OIG) posted its own audit targets to keep providers busy.
The OIG's 2012 Work Plan, released Oct. 5, gives providers insight into areas where the OIG sees potential for problems and where providers might need to bolster their compliance programs.
Here are some of the highlights from the Work Plan:
- Home health has five new issues, including "questionable billing characteristics of home health services" that might reveal potential fraud. The issue was posted at almost the same time that the Senate Finance Committee published a report alleging evidence of fraud in home health therapy services at three of the four biggest home health companies.
- For hospitals, six of the 23 issues are new. One new issue examines the appropriateness of admissions to inpatient rehabilitation facilities and another investigates critical access hospitals' size, services and distance from other hospitals.
- OIG posted eight issues for nursing homes, of which three are new. For Medicare- and Medicaid-certified nursing homes, auditors will review whether the facilities' compliance plans incorporate OIG compliance program guidance and whether the plans are part of "day-to-day operations," the Work Plan stated.
- Hospices have just two issues. The one new issue - hospice marketing practices and financial relationships with nursing facilities - follows a Medicare Payment Advisory Commission (MedPAC) note that "hospices and nursing facilities may be involved in inappropriate enrollment and compensation," the Work Plan notes.
- Four of the fourteen issues are new for medical and equipment supplies providers. The new issues include effectiveness of edits to prevent payments to multiple suppliers of home blood-glucose testing supplies, questionable billing for Medicare diabetic testing supplies, support surface pricing and collection of surety bonds for overpayments made to suppliers of durable medical equipment.
OIG posted several issues for physicians under the "other providers and suppliers" section, including new issues such as incident-to services, use of modifiers during the global period and high cumulative Part B payments.
About the Author
Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation's leading independent authority on home healthcare business, regulation and reimbursement.
Contact the Author
To comment on this article please go to editor@racmonitor.com
RAC Focuses on Pain Management Providers at Various Audit Levels
For more on the OIG's 2012 Work Plan, Please Click Here
On Wednesday, Oct. 5 the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released its work plan for the 2012 fiscal year. As with past versions of this tried-and-true compliance roadmap, there were some issues that returned for an encore and some issues that are appearing for the first time.
To begin, we will look at the repeat issues. The OIG continues to examine "error-prone providers," which are physicians who have had at least one identified CERT error for four consecutive years. Much like the RACs, the OIG will continue to look at the financial effects of place-of-service errors on physician claims as well as E/M services in the global period.
Coding Trends for E/M Services
Some of the other issues, when considering some of the shifts going on across the healthcare landscape, require some context to digest. The OIG will continue to study coding trends for E/M services. In 2009, $32 billion was spent by Medicare on E/M services, and during the last five years there has been a significant increase in the utilization of CPT codes 99214 and 99215 for established patient encounters. Looking at these numbers alone would be eye-opening, but the work plan also touches on inappropriate payments as they apply to EMR documentation practices.
The work plan actually spelled it out fairly bluntly by making reference to "the increased frequency of medical records with identical documentation across services." For some time I have been introducing into the public sphere my ideas as they pertain to the dangers of widespread EMR documentation. As a blunt reminder, you can have the best history and examination record ever documented, but medical necessity needs to be the driver of level of service. A bug bite is a bug bite, and a complete 14-point review of systems, along with documenting that the patient is married and smokes, doesn't change that fact. The OIG now appears to agree with me.
If you are a chiropractor, or if you bill for sleep studies, that heat you feel on the back of your neck is the sun's rays hitting the magnifying glass the OIG is holding over your head. The work plan calls for reviewing whether chiropractic claims for active treatment actually are being cleverly disguised as maintenance therapy.
There have been some MAC probes of chiropractic claims, most notably by Palmetto GBA in California and Nevada. These probes have focused on documentation as it relates to billing. The OIG plan seems to go a step further. For sleep testing the OIG will be looking at whether services billed are reasonable and necessary.
With the expansion of non-physician practitioners, the OIG also has decided to take a closer look at incident-to services. As a person who has a sub-specialty in practice analytics, I can report that abuses in this area are becoming easy to catch from an audit standpoint, especially when the doctor employs a physician assistant and subsequently reports more than 24 hours of services on one calendar day. As a subtle reminder, we do not live on Mars, and until we do one day still equals 24 hours (and I have yet to meet the physician in the modern age whose office doubles as his or her personal boarding house).
Physicians Opting Out
I'd like to end with a big issue upon which to ponder. For the first time the OIG is going to look at the impact of physicians who opt out of the Medicare program. The task is twofold, first looking at whether certain geographic areas have higher rates of physicians leaving the program and secondly seeking to ensure that doctors who opt out aren't submitting claims to Medicare for payment.
I've been following trends in the realm of concierge/membership medicine, which currently is drawing physicians away from the traditional physician reimbursement model. The public chatter about this topic sounds similar to an occasionally conspicuous drip from a faucet in an adjoining room of a house.
If the OIG is looking into this for the first time, it is obvious that the drip is becoming progressively more annoying. In the past year a government report estimated that less than 1,000 physicians nationwide operate under this model, but that figure has been determined to be hugely underestimated. No one, however, disputes that we have a primary care shortage in this country.
It is clear that this work plan issue represents the OIG's first recognition that even one primary-care physician abandoning the indentured servitude of insurance participation clearly may have long-term consequences for healthcare delivery. If I'm right, we're in for a lot of saber-rattling and clenched fists about this topic in the very near future.
About the Author
Paul Spencer is the Compliance Officer for Fi-Med Management, Inc., a national physician practice financial management company based in Wauwatosa, WI. Paul has over 20 years of experience across all facets of healthcare billing, including 6 years spent with insurance carriers. In his current role with Fi-Med, he acts as a physician educator on issues related to E/M level of service and documentation audits by CMS and other outside entities. Paul has carried the CPC and CPC-H credentials from the American Academy of Professional Coders since 1998.
Contact the Author
To comment on this article please go to editor@racmonitor.com
OIG Will Continue Data Mining: Highlights of the OIG Work Plan for 2012
Connect with Us
Top Stories
Advisors
Editorial Board
-
Allen Jost, PhDAlvin Gore, MD, CHCQM and Cathi Charlberg, LVN, CHCQMAmanda Gilliland, RN, BSNAndrew B. Wachler, Esq.Andrew H. Hughes, MD and Charles Locke, MD, CHCQM-PHYADVAndrew Wachler and Kaitlin NucciAndrew Wachler, Esq., and Sarah Hillegonds, Esq.Angela Phillips, PTBarbara Vandegrift, RN, BSN, MABecky Rodrian, CPC, CEMC, CBCS, MBSBrian T. LandryChristina Panos, RHIA, CTRChristopher Halleman, DOChristopher J. Laney, Esq.Chuck BuckDaniel Zirkman, MDDavid A. McKenzie, CAEDavid M. Glaser, Esq.Denise Nash, MD, CCS, CIMDheeraj Mahajan, MD, FACPDuane Abbey, PhD, CFPEdward Roche, PhD, JDElizabeth C. Dunbar, MD, MBA, FACEP, CHCQM-PHYADVEllen Fink-Samnick MSW, ACSW, LCSW, CCM, CRPErica E. Remer, MD, FACEP, CCDSErin Diesel Roumayah, Esq.Frank D. Cohen, MPA, MBBGlenn Krauss, RHIA, BBA, CCS, CCS-P, CPUR, CCDS, C-CDI, PCS, FCS, C-CDAMGloryanne Bryant, RHIA, RHIT, CCS, CCDSGreg FordHolly Louie, RN, CHBMEJ. Paul Spencer, CPC, COCJanelle Ali-Dinar, PhDJeffrey D. Lehrman DPM, FASPS, MAPWCAJessica Forster, Esq.John K. Hall, MD, JD, MBA, FCLM, FRCPCJuliet B. Ugarte Hopkins, MD, CHCQM-PHYADVKathleen K. Borchard, BSN, RN-ACMKathy Seward, MD, CHCQM-PHYADVKim T. Charland, BA, RHIT, CCSKnicole C. Emanuel Esq.Kristi Pollard, RHIT, CCS, CPC, CIRCC, AHIMA-approved ICD-10-CM/PCS trainerLaurie M. Johnson, MS, RHIA, FAHIMA AHIMA Approved ICD-10-CM/PCS TrainerLeslie Marsh, RN, BS, MSN, MBALori O’Hara, MA, CCC-SLPMark SpiveyMarvin D Mitchell, RN, BSN, MBAMary Beth Pace, RN, BSN, MBA, ACM, CMACMary Inman, Esq. and Max Voldman, Esq.Matthew AlbrightMaureen Testoni Esq,Max Voldman, Esq.Melinda Battaile, MD, FHM, MMCI, CHCQM-PHYADV, CCDSMichael A. Salvatore, MD, FACPMichael Rosen, Esq.Nancy J. Beckley, MB, MBA, CHCNena Scott, MSEd, RHIA, CCS, CCS-P, CCDS
