MAC Prepayment Reviews – March 2013 Updates

on Tuesday, 19 March 2013. All News Items | MAC Reviews

All of the Recovery Auditors and most of the Medicare Administrative Contractors have at one time or another reviewed DRG 552, Medical Back Problems without MC or MCC, for medical necessity. At a recent speaking engagement, the Cahaba GBA Medical Director indicated that attention on this DRG was coming around again and as recently as the end of January, CGS, the Jurisdiction 15 MAC, announced a complex medical review for DRG 552. Findings published by Cahaba in November 2012 as part of the CERT Special Project Targeted Reviews revealed error rates of 59 – 71% for DRG 552. Earlier information from the Florida Hospital Association also showed error rates around 71%. The main issue is the medical necessity of the inpatient admission. Per the Cahaba article:

“Review of the documentation submitted indicated that the patients did not meet medical necessity for inpatient admission. The patients care could have been appropriately rendered at a lower level. Per the Medicare Program Integrity Manual, Chapter 6, Section 6.5.2, ‘The beneficiary must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis.’”

Note that DRG 552 is also a PEPPER target. You can compare your hospital’s percentages against other hospitals in your MAC Jurisdiction, your state 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 and coding are correct.

Part A MAC Cahaba GBA, Jurisdiction 10

Review Announcements and Findings

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

Error/Denial Rate

Reason for Review / Findings

Status

3/11/2013

DC, MD, NJ, PA

IPPS

service wide post pay probe review

DRG 251

Percutaneous Cardiovascular Procedure without Coronary Artery Stent without Major Complication/Co-morbidity (MCC.)

72%

inpatient admission not warranted; documentation; not submitted

data analysis to monitor utilization; additional review as indicated

3/11/2013

DE, DC, MD, NJ, PA

IPPS

service wide post pay probe review

DRG 303

Atherosclerosis without Major Complications/Co-morbidities (MCC.)

84%

inpatient admission not warranted; documentation; not submitted

data analysis to monitor utilization; additional review as indicated

3/11/2013

DE, DC, MD, NJ, PA

IPPS

service wide pre pay probe review

DRG 153

Otitis Media and Upper Respiratory Infection without Major Complication/Co-morbidity (MCC.)

68%

inpatient admission not warranted; documentation; not submitted

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

Error/Denial Rate

Reason for Review / Findings

Status

2/28/2013

SC, VA

outpatient

service specific complex reviews

CPT 93797

Top of Form

cardiac rehabilitation without continuous ECG

Bottom of Form

32-89%

cardiac rehab services did not include the required services; not warranted for diagnosis; physician must be readily available; services not documented; phase 3 CR not covered

discontinued

2/21/2013

NC, SC, VA and WV

inpatient

Top of Form

service-specific prepayment probe review

Bottom of Form

ICD-9 Diagnosis Codes 680.0 - 682.9, and 684 – 686.9

Cellulitis Procedure (sic) Codes

6-13%

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

discontinued

2/21/2013

NC, SC, VA and WV

inpatient

Top of Form

service-specific prepayment probe review

Bottom of Form

DRG 377

Top of Form

Gastrointestinal Hemorrhage with Major Complications or Comorbidities

Bottom of Form

4-7%

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

discontinued

2/21/2013

NC, SC, VA and WV

inpatient

Top of Form

service-specific prepayment probe review

Bottom of Form

DRG 378

Top of Form

Gastrointestinal Hemorrhage with Complications or Comorbidities

Bottom of Form

2-10%

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

discontinued

2/21/2013

NC, SC, VA and WV

inpatient

Top of Form

service-specific prepayment probe review

Bottom of Form

DRG 811

Top of Form

Red Blood Cell Disorders with Major Complications or Comorbities

Bottom of Form

4-9%

Not medically necessary; missing orders; no response to ADR; documentation did not support dates billed

discontinued

2/21/2013

NC, SC, VA and WV

inpatient

Top of Form

service-specific prepayment probe review

Bottom of Form

Top of Form

primary Diagnosis Code 286.9

Bottom of Form

Top of Form

Other and Unspecified Coagulation Defects

Bottom of Form

17-26%

DRG code change; not medically necessary; no response to ADR

discontinued

2/21/2013

NC, SC, VA and WV

inpatient

Top of Form

service-specific prepayment probe review

Bottom of Form

Top of Form

Procedure Code 33.27

Bottom of Form

Top of Form

Closed Endoscopic Biopsy of Lung

Bottom of Form

3-6%

Not medically necessary; missing signature; no response to ADR; documentation did not support dates billed

discontinued

2/21/2013

NC, SC, VA and WV

inpatient

Top of Form

service-specific prepayment probe review

Bottom of Form

Top of Form

Procedure Codes 31.1, 31.21, and 31.29

Bottom of Form

Top of Form

Tracheostomy Procedure Codes

Bottom of Form

3-17%

Not medically necessary; missing orders; no response to ADR; documentation did not support dates billed

discontinued

2/20/2013

NC, SC, VA and WV

inpatient

Top of Form

service-specific prepayment probe review

Bottom of Form

Top of Form

Procedure Code 86.22

Bottom of Form

Top of Form

Excisional Debridement of Wound, Infection, or Burn

Bottom of Form

2-8%

Not medically necessary; missing documentation, orders, or signatures; no response to ADR; documentation did not support dates billed; DRG code change

discontinued

2/20/2013

NC

outpatient

service specific complex reviews

CPT 93797

Top of Form

cardiac rehabilitation without continuous ECG

Bottom of Form

42-44%

cardiac rehab services did not include the required services; not warranted for diagnosis; physician must be readily available; services not documented

discontinued

2/19/2013

NC, SC, VA and WV

inpatient

Top of Form

service-specific prepayment probe review

Bottom of Form

Top of Form

Procedure Code 96.72

Bottom of Form

Top of Form

Continuous Invasive Mechanical Ventilation for 96 Consecutive Hours or More

Bottom of Form

0.2-24%

Not medically necessary; missing documentation, orders, or signatures; no response to ADR; documentation did not support dates billed

discontinued

2/18/2013

VA, WV

outpatient

service specific complex reviews

CPT 93798

Top of Form

cardiac rehabilitation with continuous ECG

Bottom of Form

39% and 51%

cardiac rehab services did not include the required services; not warranted for diagnosis; physician must be readily available; services not documented

discontinued

2/13/2013

WV

outpatient

service specific complex reviews

CPT 93797

Top of Form

cardiac rehabilitation without continuous ECG

Bottom of Form

67%

cardiac rehab services did not include the required services; not warranted for diagnosis

discontinued

2/12/2013

SC, VA and WV

13X

Pre-payment service-specific targeted review

Rev code 54X

Ambulance services

11.5-63.6%

beneficiary signature requirements not met; transport not medically necessary; records not submitted timely

discontinued

 

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. .

 

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