Is That An Underpayment I See?

on Tuesday, 24 September 2013. All News Items | Recovery Auditor | Documentation | Coding

With the Recovery Auditors looking at so many issues, it is often hard to know where to focus your proactive internal review efforts and education. How about looking for something that might be an underpayment instead of an overpayment for a change? A recent CGI issue offers some food for thought (or for review) and this issue could likely identify potential underpayments.


CGI, the Recovery Auditor for Region B, posted an issue on August 6th to look at DRGs without complications or comorbidities that have a length of stay (LOS) greater than or equal to the geometric mean length of stay (GMLOS). This MS-DRG validation review is to identify if conditions were not coded that would have resulted in an MS-DRG more equal to the intensity of services provided. The reviewers will be validating the principal diagnosis, secondary diagnoses, and procedures that could potentially affect the DRG assignment. If CCs or MCCs were missed, this could result in the discovery of an underpayment by the RAC.


This is also an excellent target for internal or outsourced reviews by the hospital. Compare the length of stay of DRGs without CCs or MCCs to the GMLOS and perform review on those records with an LOS that is equal or greater than the GMLOS. Analyze your findings to determine if you are missing diagnoses or procedures that should be coded as CCs or MCCs. Or is there an issue with not discharging these patients in a timely manner? Is there a particular physician who routinely keeps his/her patients beyond the GMLOS? Are there opportunities for improved documentation or queries to capture secondary or chronic conditions that may be affecting the patient’s treatment requirements and length of stay? If you have a substantial number of such claims, you are bound to learn something from this analysis.


Other news on the RAC front includes a Provider ADR Limit Clarification published on August 5, 2013. The only difference between the documentation requests limits in this clarification and the April 15, 2013 notice is in the limits based on Medicare claim type. The overall maximum number of requests per 45 days remains at 400 and 600 for providers with over $100,000,000 in annual MS-DRG payments. In the April update, Recovery Auditors were allowed to select up to 75% from one claim type. The August clarification now limits that to 70% from one claim type. Claim types include IPPS, OPPS, SNF, IPS, IRF, ASC or physician claims. The remaining 30% can be selected from any or all of the other claim types.


As RAC activity slows down to allow transition to the next Scope of Work, take this lull to determine how to best use your internal and purchased resources to identify your key areas for improvement. With thorough audits, careful analysis, and proper education, in conjunction with Medicare’s changing rules and tightening contractor controls, you might even see an impact.


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 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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