MAC Prepayment Reviews – April 2013 Updates

on Tuesday, 16 April 2013. All News Items | MAC Reviews

Highlight: Documentation Requirements for Spinal Fusions

Several Medicare contractors have reviewed DRG 460 and found deficiencies in documentation. Be sure your hospital understands the expected documentation required to support the indications for spinal fusion. If your hospital were audited, what would your error rate be?

This month Novitas published the results of a service-wide post pay probe review for DRG 460, Spinal Fusion Except Cervical without Major Complication/Co-Morbidity. The average dollar error rate for the Novitas Jurisdiction 12 states was 73%, with denial rates ranging from 50-90% (we note an error on the report for the District of Columbia error rate, so we excluded this from our calculations). A review of this DRG by Cahaba GBA completed last October demonstrated an overall claim error rate of 64% with 88% of the denials resulting from the lack of documentation of the appropriate indications for the spinal fusion.

The Novitas article identified the reasons for denial as:

  • physician documentation of conservative measures tried prior to surgery was not submitted,
  • x-ray or detailed description of disease process was not provided, and
  • documentation not submitted.

 

The Cahaba Findings article included a list of the documentation specifics required to support the diagnosis and indications for spinal fusion. Those include:

  • Pre-procedure radiologic findings or mention of the radiology report result in the medical record
  • Failed conservative measures/treatment prior to surgery
  • Documentation of duration of pain and/or impairment of function
  • Physical exam documenting the functional pathology
  • Documentation of instability if applicable

First Coast, the Jurisdiction 9 Medicare Administrative Contractor has also reviewed DRG 460 and has a Local Coverage Determination for Lumbar Spinal Fusion for Instability and Degenerative Disc Conditions. Note that DRG 460 is also a PEPPER target. You can compare your hospital’s percentages against other hospitals in your MAC region and the nation by reviewing your PEPPER report. If you are above or below the median range, you should consider auditing the records to verify patient status assignment, correct coding and complete documentation.

Part A MAC Cahaba GBA, Jurisdiction 10
No Cahaba Announcements or Findings this month
 
Part A MAC Novitas Solutions, Jurisdiction 12
Review Findings

Date

States

Claim Type

Type of Review

Service Code

Service Description

Charge Denial Rate

Reason for Review / Findings

Status

4/8/2013

DE, DC, MD, NJ, PA

IPPS

service wide post pay probe review

DRG 244

Permanent Cardiac Pacemaker without Complications or Comorbid Conditions.

57%

inpatient admission not warranted; documentation not submitted

data analysis to monitor utilization; additional review as indicated

4/8/2013

DE, DC, MD, NJ, PA

IPPS

service wide post pay probe review

DRG 460

Spinal Fusion Except Cervical without Major Complication/Co-Morbidity

73%

documentation of conservative measures tried prior to surgery not submitted; X-ray or detailed description of disease process not provided; documentation not submitted

data analysis to monitor utilization; additional review as indicated

3/25/2013

DE, DC, MD, NJ, PA

IPPS

service wide pre pay probe review

DRG 149

Dysequilibrium

61%

inpatient admission not warranted; documentation missing or not submitted

data analysis to monitor utilization; additional review as indicated

3/18/2013

DE, DC, MD, NJ, PA

IPPS

service wide pre pay probe review

DRG 515

Other Musculoskeletal System and Connective Tissue Operating Room Procedure with Major Complications and Comorbidities (MCC)

6%

inpatient admission not warranted; documentation not submitted

a re-probe of post pay claims will be initiated

3/18/2013

PA

OP

service wide pre pay probe review

HCPCS C2616

Brachytherapy source, non-stranded, yttrium-90, per source

71%

Off-Label Use without providing peer reviewed medical literature; no covered diagnosis; missing Humanitarian Device Exemption (HDE) #

data analysis to monitor utilization; additional review as indicated

 
Part A MAC Palmetto GBA, Jurisdiction 11
Review Findings

Date

States

Claim Type

Type of Review

Service Code

Service Description

Charge Denial Rate

Reason for Review / Findings

Status

3/25/2013

NC, SC, VA and WV

inpatient

service-specific prepayment probe review

ICD-9 Procedure Code 38.18

Endarterectomy of Lower Limb Arteries

7-18%

Not medically necessary; missing documentation, orders, or signatures; no response to ADR

discontinued

3/20/2013

VA, WV

outpatient

service-specific prepay targeted medical review

TOB 13X and Revenue Code 54X

ambulance services

82%

Not medically necessary; missing documentation, orders, or signatures; no response to ADR

service-specific targeted reviews to resume in 30-60 days

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. .

 

;

green-iconWe are an environmentally conscious company, dedicated to living “green” both at work and as individuals.

Location

home-icon
1900 Twentieth Avenue South
Suite 220
Birmingham, AL 35209

Connect

phone
205-941-1105
phone
800-592-9639
email
This email address is being protected from spambots. You need JavaScript enabled to view it.

 

 mhms