KEPRO’s CASE REVIEW CONNECTIONS Acute Care Edition

on Tuesday, 13 June 2017. All News Items | Case Management | Quality | Coding | Billing

Spring 2017 BFCC-QIO Newsletter

While we are just seven days from the June 21st Summer Solstice, let’s enjoy the last few days of spring by reviewing highlights from KEPRO’s Spring 2017 CASE REVIEW CONNECTIONS Acute Care Edition newsletter. For those reading this not familiar with KEPRO, they are the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC QIO) for Areas 2, 3 and 4 in the country.

Medical Director’s Corner: Hospital Discharge Appeals

The Medical Director’s Corner this quarter highlights appeals. Appeals is one of the highest volume reviews they perform. Specific to the acute care hospital are the hospital discharge appeals. Per the newsletter, KEPRO uses Physician Reviewers from the same state where the beneficiary is receiving care and they look for medical stability and a safe discharge disposition. It is important to note that when documentation is incomplete or poor and the Physician Reviewer cannot determine if the patient can be safely discharged, KEPRO indicates they will always find in favor of the patient.

New Process for Medical Records Submitted to KEPRO for Appeals

Beginning this summer, KEPRO will be implementing a new medical record request form to be used for all appeal reviews. They will be adding a bar code to all appeal medical record fax requests sent to healthcare providers and Medicare Advantage health plans directly correlating to the case ID associated with each appeal.

Hospital Discharge Appeals

KEPRO instructs that when a beneficiary in the acute setting wishes to file an appeal, the hospital is responsible for sending medical records in a timely manner and the record need to include the following:

  • Documentation clearly showing the beneficiary has a safe discharge in place; and
  • Current and updated case management or social services notes.

If KEPRO is unable to determine if there is a safe discharge, they may close the appeal and the beneficiary will remain in your hospital until clear documentation is provided.

Higher Weighted Diagnosis-Related Group (HWDRG) Reviews

Hospitals can submit requests for HWDRG assignments directly to their Medicare Administrative Contractor (MAC) for processing and payment. All such requests granted by the MAC are subsequently selected by CMS for BFCC-QIO review on a post-payment basis. BFCC-QIOs review the record for medical necessity, quality, and DRG validation.

In this edition of CASE REVIEW CONNECTIONS, KEPRO reminds you to submit the entire medical record related to the claim including physician’s orders and medication administration records. They go on to note that if the HWDRG is due to a combined claim related to the Three-Day Payment window the outpatient record should also be submitted.

Short Stay Reviews

KEPRO reminds the reader to submit all medical records at the same time to include orders and Medication Administration Records (MARs) noting that this documentation if often missing. Also discussed is the new short stay review methodology that was implemented April 1, 2017. In addition to information provided in this newsletter more can be learned about the changes in a related MMP article at http://www.mmplusinc.com/news-articles/item/april-2017-process-change-for-short-stay-record-requests.

Acute Care FAQs

Finally, this edition of the Case Review Connections, provides answers to questions about the short stay review process. Specifically, the time frames for KEPRO scheduling one-on-one educational sessions and the time frame for a final determinations after an education session.

MMP encourages you to read the newsletter in its entirety.

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-four years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth 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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