Drill Down – What’s In Your DRG Documentation?

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Original story posted on: April 11, 2013

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RAC Region C Connolly posted several complex review-type issues for Inpatient DRGs. One of those DRG issues posted is associated with Injury, Poisoning, and Toxic Effects of Drugs. The MS-DRGs that are targeted are 915, 916, 922 And 923, W/MCC, W/O MCC.

What are the reviewers looking for? The auditor will validate the primary diagnosis, the secondary diagnosis, and procedures affecting or potentially affecting the DRG. These targeted DRGs, along with appropriate diagnostic and procedural codes and the discharge status of the patient as coded on the claim, will be matched to the attending physician description and information contained in the medical record.

So if any one of these elements on the claim doesn’t exactly match the attending’s medical record, rally your team to drill down into the specific MS-DRG, educate the staff, and discuss how to successfully manage the coding of the claim with the clinical content and discharge status of the patient.

Other RAC issues for the week of April 8–12, 2013:

RAC Region A Performant

Physician/Non-Physician Practitioner Claim Types 

  • Doxorubicin Hydrochloride - J12 - Potential incorrect billing occurred for doxorubicin hydrochloride claims billed with an ICD-9-CM code that does not support medical necessity, according to existing Medicare policy, FDA labeling, accepted guidelines, approved compendia, or other Medicare rules and regulations. Payments will be recouped when no additional documentation that supports medical necessity is received from the provider for complex review within the 45-day response period.

Ambulance Claim Types 

  • Ambulance Services Billed with Non-Covered Origin and Destination Modifiers - Jurisdiction 13 - Potential incorrect billing occurred for claims billed with non-covered origin and destination modifier(s). 

RAC Region C Connolly

Carrier

  • Pre-payment Part B Review - Manual Medical Review of Therapy Claims Above the Threshold - In accordance with the American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, prepayment reviews will be conducted on Part B therapy cap for Occupational Therapy (OT). The cap is $1,900 for 2013; the combined cap for Physical Therapy (PT) and Speech-Language Pathology Services (SLP) is also $1,900 for 2013.           
  • Post-payment Part B Review - Manual Medical Review of Therapy Claims Above the Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, post-payment reviews will be conducted on Part B therapy cap for Occupational Therapy (OT). The cap is $1,900 for 2013;  the combined cap for Physical Therapy (PT) and Speech-Language Pathology Services (SLP) is also $1,900 for 2013.           
  • Treatment Frequency: Leuprolide Acetate  - Per its drug label, Leuprolide acetate (for depot suspension) when used in the treatment of prostate cancer, has a treatment interval of every 4 weeks (1 month) for 7.5 mg dosing, 12 weeks (3 months) for 22.5 mg dosing, 16 weeks (4 months) for 30 mg dosing and 24 weeks (6 months) for 45 mg dosing. Per its drug label, Leuprolide acetate implant when used in the treatment of prostate cancer, has a treatment interval of every 52 weeks (1 year) for one 65 mg implant. Paid claims for Leuprolide acetate (J9217, J1950, J9219) with dates of service that are inconsistent with this standard practice, as well as inconsistent compared to the patient/beneficiary’s historic dosing regimen, are deemed suspect and will undergo a complex review to determine if the service was billed/paid, but the drug was not given (billing error, services not rendered) or if the drug service was billed/paid with an incorrect number of HCPCS units. Any corresponding administration codes for the drug service that were not rendered will be recovered along with the drug payment.
  • Treatment Frequency: Leuprolide Acetate  - Per its drug label, Leuprolide acetate (for depot suspension) when used in the treatment of prostate cancer, has a treatment interval of every 4 weeks (1 month) for 7.5 mg dosing, 12 weeks (3 months) for 22.5 mg dosing, 16 weeks (4 months) for 30 mg dosing and 24 weeks (6 months) for 45 mg dosing. Per its drug label, Leuprolide acetate implant when used in the treatment of prostate cancer has a treatment interval of every 52 weeks (1 year) for one 65 mg implant. Paid claims for Leuprolide acetate (J9217, J1950, J9219) with dates of service that are inconsistent with this standard practice, as well as inconsistent compared to the patient/beneficiary’s historic dosing regimen, are deemed suspect and will undergo a complex review to determine if the service was billed/paid, but the drug was not given (billing error, services not rendered) or if the drug service was billed/paid with an incorrect number of HCPCS units. Any corresponding administration codes for the drug service that were not rendered will be recovered along with the drug payment.
  • Treatment Frequency: Eloxatin (J9263 - Injection, oxaliplatin, 0.5 mg) - Per its FDA-approved drug label, Eloxatin (oxaliplatin) Injection has a recommended treatment frequency of one administration every 2 weeks. Paid claims for oxaliplatin injection billing treatments with dates of service inconsistent with this standard practice, as well as inconsistent when compared to the patient's/beneficiary’s historic dosing regimen, are deemed suspect and will be reviewed to determine if the service was billed/paid, but the drug was not given (billing error, services not rendered). Any corresponding administration codes for the drug service that were not rendered will be recovered along with the drug payment.

Home Health Claim Types

  • Invalid HIPPS Code - Providers are billing with Health Insurance Prospective Payment System (HIPPS) codes that are invalid or no longer in use.    
  • Invalid Treatment Authorization Code - Providers are billing with Treatment Authorization Codes (Claim-OASIS Matching Key) that are of an invalid length or contain invalid characters.
  • Validation of Early Episode Timing - Early episode home health claims not appropriately adjusted by Medicare will be validated and recoded.

 

Inpatient Claim Types 

  • Medical Necessity Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast, MS-DRGs 592, 593, 594, 595, 596, 597, 598, 599, 600, 601 w/CC, w/MCC, without CC/MCC - RACs will review documentation to validate the medical necessity of short-stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRGs 592, 593, 594, 595, 596, 597, 598, 599, 600, and 601. RACs WILL ALSO REVIEW documentation for DRG Validation for MS-DRGs 592, 593, 594, 595, 596, 597, 598, 599, 600, and 601, requiring 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, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
  • Diseases and Disorders of the Ears, Nose, Mouth and Throat, MS-DRGs 146, 147, 148, 149, 150, 151, 152, 154, 155, and 156 w/CC, w/MCC, without CC/MCC - RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRGs 146, 147, 148, 149, 150, 151, 152, 154, 155, and 156. RACs WILL ALSO REVIEW [ST1] documentation for DRG Validation for MS-DRGs 146, 147, 148, 149, 150, 151, 152, 154, 155, and 156, requiring 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, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. 
  • Medical Necessity: Diseases And Disorders of The Ear, Nose, Mouth and Throat- MS-DRG 157 with MCC - RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRG 157. RACs WILL ALSO REVIEW [ST2] documentation for DRG Validation for MS-DRG 157, requiring 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, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
  • Medical Necessity: Injury, Poisoning and Toxic Effects of Drugs MS-DRGs 915, 916, 922 And 923, W/MCC, W/O MCC - RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRGs 915, 916, 922 and 923. RACs WILL ALSO REVIEW documentation for DRG Validation for MS DRGs 915, 916, 922 and 923, requiring 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, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
  • Medical Necessity: Diseases and Disorders of The Digestive System, MS-DRGs 326, 327 And 328, W/MCC, W/CC, W/O CC/MCC - RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRGs 326, 327and 328. RACs WILL ALSO REVIEW documentation for DRG Validation for MS DRGs 326, 327 and 328, requiring 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, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.   
  • Medical Necessity: Diseases and Disorders of The Hepatobillary System And Pancreas, MS-DRGs 432 And 433, W/MCC, W/CC - RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRGs 432 and 433. RACs WILL ALSO REVIEW documentation for DRG Validation for MS DRGs 432 and 433, requiring 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, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.  
  • Medical Necessity: Diseases And Disorders of The Nervous System, MS-DRGs 052, 053, 054, 055, 078, 079, 085, 098 And 099, W/CC/MCC, W/O CC/MCC, W/MCC, W/CC - RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRGs 052, 053, 054, 055, 078, 079, 085, 098 And 099. RACs WILL ALSO REVIEW documentation for DRG Validation for MS DRGs, 052, 053, 054, 055, 078, 079, 085, 098 And 099, requiring 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, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG. 

 

  • Medical Necessity: Diseases and Disorders of The Female Reproductive System, MS-DRGs 746, 748 And 749, W/CC/MCC - RACs will review documentation to validate the medical necessity of short stay, uncomplicated admissions. Medicare only pays for inpatient hospital services that are medically necessary for the setting billed and that are coded correctly. Medical documentation will be reviewed to determine that the services were medically necessary and were billed correctly for MS-DRGs 746, 748 and 749. RACs WILL ALSO REVIEW documentation for DRG Validation for MS DRGs, 746, 748 and 749, requiring 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, principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the DRG.
  • CMS Pre-Pay Demonstration: MS-DRG Short Stay Reviews, MSD-DRG 377, 378 AND 379, W/MCC, W/CC W/O CC/MCC - The Recovery Audit Prepayment Review Demonstration will allow Medicare Recovery Auditors to review claims before they are paid to ensure that the provider complied with all Medicare payment rules. The demonstration has been approved with the following limitations: • CMS approves all issues for review; and • The issues reviewed have a high Comprehensive Error Rate Testing (CERT) rate. The demonstration will begin initially with short-stay inpatient hospital claims in the seven Health Care Fraud Prevention and Enforcement Action Team (HEAT) states (Florida, California, Michigan, Texas, New York, Louisiana, and Illinois) and one state in each of the four Recovery Audit jurisdictions with the highest number of inpatient stays (Pennsylvania, Ohio, North Carolina, and Missouri). Initial claims selected for review will be those billed with the top Medicare Severity Diagnosis Related Groups (MS-DRGs) on the CERT report. The first edit that Fiscal Intermediaries (FIs)/ Part A and Part B Medicare Administrative Contractors (A/B MACs) shall install is for claims that meet the following criteria: • Billed with MS-DRGs 377, 378 AND 379, GI Hemorrhage, W/MCC, W/CC, W/O CC/MCC; • Length of stay is two days or less; • From providers who practice in the applicable demonstration state(s) only. RACs WILL ALSO REVIEW documentation for DRG Validation requiring 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. Auditors will review claims for principal diagnosis, secondary diagnosis, and procedures affecting or potentially affecting the focused MS-DRGs.      

Outpatient Hospital Claim Types

  • Pre-payment Review - Manual Medical Review of Therapy Claims Above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, prepayment reviews will be conducted on outpatient hospital claims reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.
  • Post-payment Review - Manual Medical Review of Therapy Claims Above the $3,700 Threshold - In accordance with The American Taxpayer Relief Act of 2012 (ATRA) signed into law by President Obama on January 2, 2013, post-payment reviews will be conducted on outpatient hospitals claims reaching the $3,700 threshold for PT and SLP services combined and/or $3,700 for OT services.   
  • Treatment Frequency: Leuprolide Acetate (for depot suspension) - Per the drug label, Leuprolide acetate (for depot suspension), has a treatment interval of every 12 weeks for 22.5 mg dosing, 16 weeks for 30 mg dosing, and 24 weeks for 45 mg dosing. Paid claims for Leuprolide acetate (for depot suspension) with dates of service that are inconsistent with this standard practice, as well as inconsistent compared to the patient/beneficiary’s historic dosing regimen, are deemed suspect and will undergo a complex review to determine if the service was billed/paid, but the drug was not given (billing error, services not rendered). Any corresponding administration codes for the drug service that were not rendered will be recovered along with the drug payment. 

SNF Claim Types

  • Units in Excess of PPS Assessment Maximum - Medicare assigns standard scheduled payment periods for SNF assessments. Overpayment occurs when additional units in excess of assessment maximums are billed.    

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 is this all caps?

 [ST2]See above

Margaret Klasa, DC, APN, Bc

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