April 23, 2013

Drill Down – Check Your Present on Admission (POA) Indicator

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RAC Region B CGI posted a Complex type review issue for April 8, 2013, Inpatient Issue: Circulatory Disorders Except Acute Myocardial Infarction w/Cardiac Cath MS-DRG 286 and 287 (Medical Necessity Excluded).

This particular issue discusses the lack of the Present on Admission Indicators (POA) required by CMS for every diagnosis on an inpatient acute care hospital claim effective since October 1, 2007.

Source CMS – http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/wPOAFactSheet.pdf

This issue addresses the fact that diagnostic and procedure information, along with the POA and discharge status of the patient on the claim, must match the attending physician description recorded in the patient’s medical record. Further, the reviewer will target the principal diagnosis, secondary diagnosis, and procedures that affect the MS-DRG and ensure they are within the Medicare guidelines.

Other RAC issues for the week of April 22–26, 2013:

RAC Region A Performant

Community Mental Health Center Claim Types 

  • Partial Hospitalization Programs (PHP) - Partial hospitalization services must meet Medicare’s benefit requirements, must be reasonable and necessary, and reasonably expected to improve or maintain the individual’s condition and functional level and prevent relapse or hospitalization. It is not enough that a patient qualify under the benefit category unless the documentation supports the need for the active, intensive treatments provided by the program of services.

DME Supplier Claim Types

  • Blood Glucose Monitors with Integrated Voice Synthesizer - DME - Jurisdiction A - Potential incorrect billing occurred when claims for voice synthesized blood glucose monitors were billed without an indication supporting medical necessity as described in the NHIC Local Coverage Determination (LCD) L11530 and related article (A33614)

Hospice Claim Types 

  • Hospice Care, Extensive Length of Stay - Jurisdiction A - The potential for overpayment exists when hospice care rendered contiguously beyond a 20-month period lacks medical necessity and it is determined that the condition has improved and/or the beneficiary is no longer considered terminally ill.

Inpatient Hospital Claim Types – MS-DRGs

  • Medical Necessity Review (MNR) for MS-DRG 682 Renal Failure w/MCC, MS-DRG 683 Renal Failure w/CC, and 684 Renal Failure w/o CC/MCC 
  • Medical Necessity Review (MNR) for MS-DRG 193 Simple Pneumonia and Pleurisy w/MCC, MS-DRG 194 Simple Pneumonia and Pleurisy w/CC, and MS-DRG 195 Simple Pneumonia and Pleurisy w/o CC/MCC

Outpatient Hospital Claim Types 

  • Partial Hospitalization Programs (PHP) - Partial hospitalization services must meet Medicare’s benefit requirements, must be reasonable and necessary, and reasonably expected to improve or maintain the individual’s condition and functional level and prevent relapse or hospitalization. It is not enough that a patient qualify under the benefit category unless the documentation supports the need for the active, intensive treatments provided by the program of services. 

Physician/Non-physician PractitionerClaim Types

  • Octreotide Maximum Units - J13 - Potential incorrect billing occurred for claims billed for dosing amounts not supported in the octreotide FDA approved prescribing information, when no additional documentation is received from the provider for complex review within the 45-day response period.
  • Octreotide Maximum Units - J12 - Potential incorrect billing occurred for claims billed for dosing amounts not supported in the octreotide FDA-approved prescribing information, when no additional, supporting documentation is received from the provider for complex review within the 45-day response period.

Home Health Agency (TOB 34x), Outpatient Hospital, Outpatient Rehabilitation Facility, Part B Skilled Nursing Facility, Private Practice, Rehabilitation Agency (Comprehensive Outpatient Rehabilitation Facility) Claim Types

  • Post-payment Review - Manual Medical Review of Outpatient Therapy Claims Above the $3,700 Threshold - The Balanced Budget Act of 1997 enacted financial limitations on outpatient physical therapy, occupational therapy, and speech-language pathology services in certain settings. Exceptions to the limits were enacted by the Deficit Reduction Act, and have been extended by legislation several times. Claims for services at or above $3700 will require a complex medical review process where the beneficiary therapy services have exceeded the threshold for the year.

 

RAC Region B CGI

Inpatient Claim Types – MS-DRGs 

  • Allergic Reactions MS-DRG 915 and 916 (Medical Necessity)
  • Circulatory Disorders Except Acute Myocardial Infarction w/Cardiac Cath MS-DRG 286 and 287 (Medical Necessity Excluded)
  • Diseases and Disorders of the Circulatory System MDC 5 MS-DRG 302-307 (Medical Necessity Excluded)
  • Disorders of Biliary Tract MS-DRG 444, 445, and 446 (Medical Necessity)
  • Endocrine Disorders MS-DRGs 643, 644, and 645 (Medical Necessity)
  • Fractures of Hip and Pelvis MS-DRG 535 and 536 (Medical Necessity)
  • Minor Skin Disorders MS-DRG 606 and 607 (Medical Necessity).
  • Peripheral/Cranial Nerve and Other Nervous System Procedures with MCC (Medical Necessity Excluded)
  • Seizures MS-DRG 100 and 101 (Medical Necessity)

RAC Region C Connolly

Inpatient Hospital Claim Types – MS-DRGs

  • Medical Necessity: Alcohol/Drug Use And Alcohol/Drug-Induced Organic Mental Disorders, MS-DRGs 894, 895, 896 AND 897, W MCC W/O MCC
  • Medical Necessity: WOUND DEBRIDEMENTS FOR INJURIES[ST1] , MS-DRGs 901, 902 AND 903 W MCC, W CC, W/O CC/MCC
  • Medical Necessity: THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES, MS-DRGs 625, 626 AND 627 W MCC, W CC W/O CC/MCC 
  • Medical Necessity: SIGNS & SYMPTOMS, MS-DRGs 947 AND 948 W MCC, W/O MCC
  • Medical Necessity: Diseases And Disorders Of The Musculoskeletal System And Connective Tissue, MS-DRGs 453, 454, 477 AND 478, W MCC, W CC   
  • Medical Necessity: UPPER LIMB & TOE AMPUTATION FOR CIRC SYSTEM DISORDERS, MS-DRGs 255, 256 AND 257 W MCC, W CC, W/O CC, W/O MCC   
  • Medical Necessity: BACK & NECK PROC EXC SPINAL FUSION W CC/MCC OR DISC DEVICE/NEUROSTIM MS-DRG 490   
  • Medical Necessity: COAGULATION DISORDERS MS-DRG 813   
  • Medical Necessity: OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC MS-DRG 425    
  • Medical Necessity: PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W MCC MS-DRG 040      
  • Medical Necessity: HAND PROCEDURES FOR INJURIES MS-DRG 906
  • Medical Necessity: KNEE PROCEDURES W PDX OF INFECTION W MCC, W CC, MS-DRG 485 AND 486
  • Medical Necessity: MAJOR BLADDER PROCEDURES W CC MS-DRG 654  
  • Medical Necessity: LYMPHOMA & LEUKEMIA W MAJOR O.R. PROCEDURE W MCC MS-DRG 820
  • Medical Necessity: O.R. PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS MS-DRG 876
  • Medical Necessity: Mental Diseases and Disorders, MS-DRG 881, 882, 883 AND 884    
  • Medical Necessity: WND DEBRID & SKN GRFT EXC HAND, FOR MUSCULO-CONN TISS DIS, MS-DRG 463, 464 AND 465 W MCC. WCC, W/O MCC/CC   
  • Medical Necessity: Diseases And Disorders Of The Skin, Subcutaneous Tissue And Breast, MS-DRG 573, 574, 575, 576, 582 AND 583, W MCC, W CC, W/O CC/MCC
  • Medical Necessity: SKIN GRAFTS & WOUND DEBRID FOR ENDOC, NUTRIT & METAB DIS, MS-DRG 622, 623 And 624, W MCC, W CC, W/O CC/MCC - C001892013 Inpatient Hospital    
  • Medical Necessity: UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY, 736, 737 AND 738 W MCC, W CC W/O CC/MCC   
  • Medical Necessity: LOCAL EXCISION & REMOVAL INT FIX DEVICES EXC HIP & FEMUR MS-DRG 496 W CC   
  • Medical Necessity: Diseases and Disorders of the Respiratory System - MS-DRG 201 without CC/MCC    
  • Transient Ischemia, MS DRG 069    
  • Vagina, Cervix, and Vulva Procedures without CC/MCC: MS-DRG 747   
  • Medical Necessity: Diseases And Disorders Of The Nervous System, MS-DRGs 024, 025, 026, 027, 028, 029, 030, 031, 032, AND 034, W/MCC, W/CC, W/O CC/MCC
  • Medical Necessity: Diseases And Disorders Of The Nervous System, MS-DRGs 035, 036, 037, 038 AND 039, W/MCC, W/CC, W/O CC/MCC   
  • Medical Necessity: Diseases And Disorders Of The Nervous System, MS-DRGs 064, 065, 066, 067, 082, 083 AND 084, W/MCC, W/CC, W/O CC/MCC  
  • Medical Necessity: Diseases And Disorders Of The Ear, Nose, Mouth And Throat, MS-DRGs 129 And 130, With CC/MCC, W/O CC/MCC 
  • Medical Necessity: MAJOR CHEST PROCEDURES MS-DRGs 163, 164 AND 165, W/MCC, W/CC, W/O CC/MCC
  • Medical Necessity: Diseases And Disorders Of The Respiratory System, MS-DRGs 175, 176, 189 AND 208, W/MCC, W/O MCC
  • Medical Necessity: CARDIAC VALVE & OTH MAJ CARDIOTHORACIC PROC, MS-DRGs 220 AND 221 W/O CARD CATH W CC, W/O CC/MCC
  • Medical Necessity: MS-DRG 237

 


 

  • Medical Necessity: CARDIAC CONGENITAL & VALVULAR DISORDERS, MS-DRGs 306 AND 307, W/MCC, W/O MCC
  • Medical Necessity: Disease And Disorders Of The Digestive System, MS-DRGs 330, 331, 333, 339 AND 340, W/CC, W/O CC/MCC     
  • Medical Necessity: Disease And Disorders Of The Hepatobiliary System And Pancreas, MS-DRGs 406, 407, 415 AND 416, W/CC, W/O CC/MCC               
  • Medical Necessity: Diseases And Disorders Of The Musculoskeletal System And Connective Tissue, MS-DRGs 455, 457, 458, 460, 468, 471, 472, 473, 475 AND 476, W/CC, W/MCC, W/O CC/MCC
  • Medical Necessity: Diseases And Disorders Of The Musculoskeletal System And Connective Tissue, MS-DRGs 481, 482, 483 AND 484, W/CC, W CC/MCC, W/O CC/MCC
  • Medical Necessity: PELVIC EVISCERATION, RAD HYSTERECTOMY & RAD VULVECTOMY, MS-DRGs 734 AND 735 W CC/MCC, W/O CC/MCC  
  • Medical Necessity: Abortion with D&C, Aspiration Curettage or Hysterectomy MS-DRG 770
  • Medical Necessity: POSTPARTUM & POST ABORTION DIAGNOSES W/O O.R. PROCEDURE, MS-DRG 776     
  • Medical Necessity: SPLENECTOMY, MS-DRG 800 AND 801, W/CC, W/O CC/MCC     
  • Medical Necessity: Myeloproliferative Diseases And Disorders And Poorly Differentiated Neoplasms, MS-DRGs 821, 822, 824, 825, 827, 828, 829, 830, 835 AND 836
  • Medical Necessity: Mental Diseases And Disorders, MS-DRGs 880, 885, 886 AND 887    
  • Medical Necessity: MAJOR HEMATOL/IMMUN DIAG EXC SICKLE CELL CRISIS & COAGUL, MS-DRGs 808, 809. AND 810, W/ MCC, W/CC, W/O CC/MCC  
  • Medical Necessity: SKIN GRAFTS FOR INJURIES, MS-DRGs 904 AND 905 W CC/MCC, W/O CC/MCC
  • Medical Necessity: TRAUMATIC INJURY, MS-DRGs 913 AND 914, W MCC, W/O MCC    
  • Medical Necessity: FULL THICKNESS BURN W SKIN GRAFT OR INHAL INJ, 928 AND 929, W CC/MCC, W/O CC/MCC
  • Medical Necessity: NON-EXTENSIVE BURNS, MS-DRG 935
  • Medical Necessity: O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES, MS-DRGs 939, 940 AND 941, W/ MCC, W/CC, W/O CC/MCC 
  • Medical Necessity: Factors Influencing Health Status And Other Contacts With Health Services, MS-DRGs 945, 946, 949, 950 AND 951, W/CC/MCC, W/MCC, W/O CC/MCC 
  • Medical Necessity: OTHER MULTIPLE SIGNIFICANT TRAUMA, MS-DRGs 964 AND 965, W/CC, W/O CC/MCC               
  • Medical Necessity: HIV W MAJOR RELATED CONDITION, MS-DRGs 974, 975 AND 976, W/ MCC, W/CC, W/O CC/MCC     
  • Medical Necessity: EXTENSIVE O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS, MS-DRGs 981, 982 AND 983, W/ MCC, W/CC, W/O CC/MCC         
  • Hip And Femur Procedures Except Major Joint, MS-DRG 482, W/O CC/MCC
  • Major Joint And Limb Reattachment Procedures Of Upper Extremity, MS-DRG 484 W/O CC/MCC

Outpatient Hospital Claim Types

  • Incorrect Billing of Per Day Observation Services - Outpatient observation claims are being incorrectly billed with per day E&M observation CPT codes as hourly codes.

RAC Region D HDI

Inpatient Hospital Claim Types – Pre-payment MS-DRGs

  • Pre-Payment Review of MS-DRG 377
  • Pre-Payment Review of MS-DRG 378
  • Pre-Payment Review of MS-DRG 379

About the Author

Dr. Margaret Klasa is the medical director for Context4 Healthcare. She is responsible for the company’s business knowledge discovery unit for medical context as it relates to the daily development of data products and software for medical claims editing and coding with an emphasis on clinical and regulatory guidelines for Medicare and Medicaid and commercial payers.

Contact the Author

Margaret.Klasa@context4.com

To comment on this article please go to editor@racmonitor.com


 [ST1]Why are some of these in all caps? Should they all be consistent?

Margaret Klasa, DC, APN, Bc

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