A Chance to be Proactive Instead of Reactive

on Monday, 23 June 2014. All News Items | Patient Status | Outpatient Services | MAC Reviews | Documentation

Proper Documentation of Inpatient Order and Critical Care Services

Hospitals are seeing some relief from Medicare medical reviews due to the RAC moratorium and the Probe and Educate program. But this does not mean that you should not pay attention to proper documentation requirements for both inpatient and outpatient services. In fact, this decreased activity allows hospitals some extra time to focus on proactive improvements. This month I will address one outpatient issue and one inpatient issue that are often the focus of medical reviews.

Since the Medicare Administrative Contractors (MACs) are continuing with the Probe and Educate reviews, medical review activity on their websites is minimal to mostly none. I was surprised to find the results of widespread targeted reviews for several DRGs posted on Cahaba’s website on May 23, 2014. We thought all such reviews had been discontinued during the Probe and Educate period. We have reached out to Cahaba to determine if these review results are from the Probe and Educate review, from a prior timeframe, or if there is another explanation.

Specificity of Inpatient Admission Order

In addition to the standard medical necessity findings, the Cahaba DRG reviews identified that some of the records submitted did not have physician orders that clearly indicated an inpatient admission versus outpatient admission. The 2014 IPPS update codified that an inpatient admission order documented in the patient’s medical record is required as a condition of payment for a Medicare inpatient admission. The specific requirements for inpatient orders can be found in the January 30thCMS document on inpatient admission order and certification. Generally, the order must specify admission for inpatient services. The wording of the order should be such that an outside reviewer could clearly determine the intention to admit the patient as an inpatient. Only in extremely rare circumstances, when the intent for inpatient admission can be clearly derived from the medical record, will a CMS reviewer accept a claim as an inpatient admission when the order is missing, illegible, or ambiguous.

Critical Care Services

A frequent focus of Medicare reviews for outpatient services is critical care services. A February 2014 Cahaba article explains the requirements for appropriate billing of critical care CPT codes 99291 and 99292.

  • Critical care is the direct delivery of care by a physician or hospital staff to a patient with a critical illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition.
  • Critical care is based on time. Documentation must include the amount of time the physician or hospital staff spent providing critical care to the patient.
  • CPT code 99291 is for 30-74 minutes of critical care. Critical care lasting less than 30 minutes is not separately billable. Each additional 30 minutes beyond 74 minutes is reported with CPT code 99292.
  • Documentation must support that the physician and/or hospital staff were engaged in active face to face critical care of a critically ill or critically injured patient.
  • Per the Correct Coding Initiative (CCI) manual, the time devoted to performing cardiopulmonary resuscitation (CPT code 92950) should not be included in critical care E&M service time.

Cahaba is also reviewing Part B (physician) billing of critical care services. See the findings and comments for this review at Part B Critical Care Review.

So use your time wisely and determine if these or other documentation issues at your facility need to be improved.

MAC Medical Review Announcements/Findings for this month.

Cahaba J10 Pre-Payment and Post-Payment Reviews

DateStatesClaim TypeType of ReviewService CodeService DescriptionCharge Denial RateReason for Review / FindingsStatus
5/23/2014 AL, GA, TN 11X widespread probe review DRG 069 Transient Ischemia AL 100% GA 93% TN 99% care could have been provided at lower level of care; physician order did not clearly indicate inpatient admission vs outpatient services Last Results: Dec 2013: 95-96% continuing prepay review
5/23/2014 AL, GA, TN 11X widespread probe review DRG 190, 191, 192 Chronic Obstructive Pulmonary Disease AL 100% GA 93% TN 83% care could have been provided at lower level of care; physician order did not clearly indicate inpatient admission vs outpatient services Last Results: Dec 2013: 65-89% continuing prepay review
5/23/2014 AL, GA, TN 11X widespread probe review DRG 470 Major Joint Replacement or Reattachment of Lower Extremity without MCC AL 52% GA 36% TN 60% care could have been provided at lower level of care; physician order did not clearly indicate inpatient admission vs outpatient services Last Results: Dec 2013: 27-37% continuing prepay review
5/23/2014 AL, GA, TN 11X widespread probe review DRG 641 Nutritional and Miscellaneous Metabolic Disorders without MCC AL 99% GA 77% TN 92% care could have been provided at lower level of care; physician order did not clearly indicate inpatient admission vs outpatient services Last Results: Dec 2013: 86-93% continuing prepay review

 

Palmetto GBA Pre-Payment and Post-Payment Reviews

No Current Review Announcements or Findings

 

Novitas JH Pre-Payment and Post-Payment Reviews

No Current Review Announcements or Findings

 

Novitas JL Pre-Payment and Post-Payment Reviews

No Current Review Announcements or Findings

   

First Coast JN Pre-Payment and Post-Payment Reviews

No Current Review Announcements or Findings

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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