July
29, 2013
DRILL
DOWN - July 2013 Pre-Payment Review for MS-DRGs
As part of the Pre-payment
Demonstration Project for Medicare, the July 2013 target for RAC contractors
will be MS-DRGs 391-392 which addresses Digestive Disorders such as
esophagitis, gastroenteritis as well as other miscellaneous digestive
disorders. RAC contractors should be posting these review issues to their
websites soon.
As mentioned in my previous
pre-payment article (Drill
Down - Pre-Payment Reviews and Short Stays: http://www.racmonitor.com/rac-enews/1429-pre-payment-reviews-and-short-stays.html), pre-payment reviews are complex
review types and will require the provider to submit documentation before a
payment or denial is made. The RAC will be looking for 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.
Pre-payment Audit Workflow
·
ADRs will come from
the FI/MAC
·
Providers will have
30 days to send documentation
·
Recovery Auditors
will review and communicate payment determination to FI/MAC
–
Providers will
receive determination within 45 days
–
RAC will also send
detailed review results letter
·
Providers may appeal
the denial
–
Same appeal rights as
other denials
RAC issues for the
week of July 29 – August 2, 2013:
No
issues were posted by RAC contractors.
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