Cahaba GBA Prepayment Reviews Update July 2012

on Monday, 16 July 2012. All News Items | MAC Reviews

Special Review Projects

Cahaba GBA continues to add more DRGs to a CMS-approved special project to intensify pre-pay review of high-dollar inpatient claims. This month Cahaba is adding two DRGs to this project based on high error rates identified within medical review and their impact to the overall CERT error rate. Reviews focusing on the medical necessity for acute inpatient hospitalization will increase from 25-30% to 100% for the following DRGs:

  • DRG 287-Circulatory Disorders Except Acute Myocardial Infarction, with Cardiac Catheterization without Major Complication/Comorbidity {MCC}, and
  • DRG 312- Syncope and Collapse

In addition to the usual inpatient and observation definitions and guidance included in these announcements to assist providers in the selection of the appropriate care setting, there are some interesting key points in this latest announcement concerning the use of observation services. The articles states:

  • If the admission is based on a symptom, (suggesting a diagnosis that must be ruled out, e.g., chest pain, back pain, abdominal pain, TIA symptoms) or if there is an unusually prolonged recovery period after an outpatient procedure (e.g., pain management issues, cardiopulmonary concerns, urinary retention), use Observation Services.
  • Using outpatient observation as an alternative to inpatient admission will allow you time to determine if admission is necessary, reduce denials for unnecessary admissions and ensure that some payment is received for services rendered.

As a reminder, the other four DRGs selected for participation in this special project are:

  • DRG – 552 – Back Pain
  • DRG – 313 – Chest Pain
  • DRG – 392 – Esophagitis
  • DRG – 247 – Percutaneous Cardiovascular Procedure with Drug-Eluting Stent without MCC

The most egregious providers driving the errors for the DRG prepay special project quarterly will receive educational letters.

All the Documentation articles, Probe Review announcements and Results Notifications can be found on the Part A What’s New page of the Cahaba GBA website at

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