Drill Down – What’s In Your DRG Documentation?
April 16, 2013
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.
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).
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) is $1,900 for 2013, and 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) is $1,900 for 2013, and 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 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 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-DRG's 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-DRG’S 915,
916, 922 and 923. RACs WILL ALSO REVIEW documentation for DRG Validation for MS
DRG’S 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-DRG'S 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-DRG’S 326,
327and 328. RACs WILL ALSO REVIEW documentation for DRG Validation for MS DRG’S
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-DRG'S 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-DRG’S 432
and 433. RACs WILL ALSO REVIEW documentation for DRG Validation for MS DRG’S
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-DRG'S 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-DRG’S 052, 053, 054, 055,
078, 079, 085, 098 And 099. RACs WILL ALSO REVIEW documentation for DRG
Validation for MS DRG’S, 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-DRG'S 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-DRG’S 746,
748 and 749. RACs WILL ALSO REVIEW documentation for DRG Validation for MS
DRG’S, 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-DRG'S 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, postpayment 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.
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