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January Edition of the Medicare Compliance Newsletter

Published on 

Monday, February 4, 2013

 | Quality 
 | Recovery Auditor 

CMS’s Medicare Learning Network publishes quarterly Medicare Compliance Newsletters to address the findings from reviews by Medicare contractors such as MACs, RAs (formerly RACs), ZPICs, CERT and the OIG. The January 2013 edition addresses several findings related to review of inpatient hospital claims.

Lack of Medical Necessity for Inpatient Admission always seems to be a big topic and this quarter is no exception. Three different DRGs are discussed with examples of services that should have been provided in a lower level of care setting. Patients did not meet criteria for an inpatient admission for the following DRGs for the reasons noted.

  • MS-DRG 491, Back & Neck Procedures excluding Spinal Fusion
  • Patient did not experience any intraoperative or post-op complications; and
  • Recovery phase was within expectations for this procedure.
  • MS-DRG 312, Syncope and Collapse
  • Signs and symptoms documented were not significant or severe enough to warrant the need for medical care at the intensity of an inpatient admission.
  • Evaluation and treatment could have been rendered as observation services
  • The medical record does not establish the need for acute care hospitalization at an inpatient level.
  • MS-DRG 516, Other musculoskeletal system & connective tissue operating room (O.R.) procedures with complicating conditions (CC).
  • Elective, scheduled, non emergent kyphoplasties for compression fractures in patients with pre-operative medical clearance and a low probability of complications can be performed at an outpatient level of care.

Also, Coding Errors were found for Other OR Procedures for Injuries (DRGs 907, 908, and 909). In the examples given, a procedure or acute injury from a prior admission was coded as occurring during or being the cause of the current admission. Coders should only code procedures performed during the current inpatient admission. Subsequent encounters require the use of an orthopedic after care code.

Refer to the Compliance Newsletter to see the specific examples and the complete discussions.

Article Author: Debbie Rubio, BS MT (ASCP)
Debbie Rubio, BS MT (ASCP), was 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.

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.