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
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