Drill Down: MS-DRG Length of Stay (LOS) Greater or Equal to Geometric Mean Length of Stay (GMLOS)

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Original story posted on: August 23, 2013

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RAC Region B contractor CGI posted an inpatient complex audit issue regarding MS-DRGs without complications and comorbidities or without major complications and comorbidities where the length of stay is equal to or greater than the geometric length of stay. Per CGI, the purpose of this MS-DRG validation is to review DRGs without complication or comorbidity that have a length of stay (LOS) greater than or equal to the geometric mean length of stay (GMLOS). These charts will be reviewed to identify conditions missed that would equate to the intensity of service provided. The reviewer will validate for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG per Medicare guidelines.

Below is an example for MS-DRG 310 - Cardiac Arrhythmia & Conduction Disorders W/O CC/MCC where the LOS is 2.3 days and GMLOS is 2.0 days. This table is located on the Centers for Medicare & Medicaid (CMS) website under Acute Inpatient PPS, FY 2013 IPPS Final Rule Home Page and can be found here: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html

Source: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2013-IPPS-Final-Rule-Home-Page-Items/FY2013-Final-Rule-Tables.html

RAC issues for the week of August 26–August 30, 2013:

RAC Region A Performant

Independent Therapy Provider

  • Home Health Consolidated Billing and Therapy Services - JK - According to the Medicare Benefit Policy Manual, Chapter 7, Section 10.11 (A) (Home Health Services Consolidated Billing), therapy services (physical, occupational, and speech-language pathology) are bundled into the Home Health Prospective Payment System (HH PPS) reimbursement made to the Home Health Agency (HHA), while the patient is under a home health plan of care. Medicare does not make separate payment to the independent therapy provider.

Outpatient Hospital

  • Home Health Consolidated Billing and Therapy Services - JK/JL - According to the Medicare Benefit Policy Manual, Chapter 7, Section 10.11 (A) (Home Health Services Consolidated Billing), therapy services (physical, occupational, and speech-language pathology) are bundled into the Home Health Prospective Payment System (HH PPS) reimbursement made to the Home Health Agency (HHA), while the patient is under a home health plan of care. Medicare does not make separate payment made to the outpatient hospital therapy provider.

Physician/Non-Physician Practitioner

  • Maximum Allowed Units for Part B Drugs and Biologicals - JK - Potential incorrect billing occurred for claims billed in excess of the maximum allowed units for Part B drugs and biologicals, when no additional supporting documentation is received from the provider for complex review within the 45-day response period.

RAC Region B CGI

Inpatient

  • MS-DRGs without CC/MCC and LOS greater than or equal to GMLOS (Medical Necessity Excluded) - The purpose of this MS-DRG validation is to review DRGs without complication or comorbidity that have a length of stay (LOS) greater than or equal to the geometric mean length of stay (GMLOS). These charts will be reviewed to identify conditions missed that would equate to the intensity of service provided. Reviewer will validate for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the MS-DRG were met per Medicare guidelines.

RAC Region D HDI

Inpatient Acute Care Hospital

  • Pre-Payment Review of MS-DRG 392 - 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. DRG Validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate for MS-DRG 392, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRGs.

Professional Services (Physician/Non-Physician Practitioner)

  • Incorrect Billed Drug and Biological HCPCS Code - Providers are required to report appropriate HCPCS codes for the drugs and biologicals administered and billed. Medical documentation will be reviewed to determine that the appropriate HCPCS code was billed. (At this time, Medical Necessity will be excluded from this review.)

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, Medicaid and commercial payors.

Contact the Author

Margaret.Klasa@context4.com

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Margaret Klasa, DC, APN, Bc

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