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Please share this article with the therapists at your facility.

With all of the new Medicare requirements for rehabilitative therapy, such as functional limitation reporting, cap amounts applied to hospital outpatient services, and manual medical review of therapy services exceeding the threshold, we thought now would be a good time to address therapy documentation. These Medicare requirements can be found in the Medicare Benefits Policy Manual, chapter 15, section 220.3. Also most Medicare Administrative Contractor shave local coverage determinations for therapy services that include additionald ocumentation requirements.

The Medicare Benefits Policy manual details the minimum documentation requirements for therapy services. They also list documentation elements that are “encouraged” though technically not “required.” But this is a catch 22 –therapy documentation must be sufficient to support the medical necessity of the services provided. The manual states, “It is encouraged but not required that narratives that specifically justify the medical necessity of services beincluded in order to support approval when those services are reviewed.” So, like Medicare, we encourage providers to cover their bases with the amount and type of therapy documentation.

We are not going to re-list all of the documentation elements that Medicare recommends to support therapy services. Most therapists are well aware of the documentation requirements but we recommend providers carefully review the Medicare Benefits Policy Manual and any therapy LCDs for their jurisdiction for complete documentation information. We are going to discuss a few elements we have identified during therapy audits that we believe have potential for improvement. This week we will address documentation in the therapy evaluation, re-evaluation, plan of care and certification.

Evaluation

• Onset date – this is usually documented on the evaluation/certification form though the exact onset date is often hard to pin down. Our recommendation involves chronic conditionsa nd those conditions with an insidious onset. To support medical necessity, we recommend the evaluation answer these questions - If this condition has been going on for a while, why is therapy needed now? Has there been a recent decline in function, increase in pain or stiffness, increase in number of falls, or an exacerbation of the condition,etc.? Is the therapy intended to improve function or prevent further decline? Documentation that clearly addresses these questions helps to support the medical necessity of the therapy services.
• ADLs, ADLs, ADLs – The evaluation will include the patient’s functional deficit with objective measurements, but discussing the patient’s prior function and current limitations in terms of activities of daily living helps to support the medical necessity of the planned therapy. It is great to know the patient has limited mobility or restricted range of motion, but understanding the patient is unable to go grocery shopping or dress themselves is more dramatic and convincing of the need for treatment.

Plan of Care

• ADLs Again – In addition to the objective measures in the goals, linking the goals to improvement in a particular activity of daily living makes the goal more meaningful to the patient and to an outside reviewer.
• The functional impairments identified and expressed in the long term treatment goals must be consistent with those used in the claims-based functional reporting, using non-payable G-codes and severity modifiers.

Re-evaluation

• Continuous assessment of the patient's progress is a component of ongoing therapy services and is not payable as a re-evaluation.
• Re-evaluations are indicated when there are new clinical findings, a significant change in thepatient's condition, or failure to respond to the therapeutic interventionsoutlined in the plan of care.

Certification

• Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. Make sure the signature of the certifying practitioner is dated and be sure to include a copy of the signed certification when submitting records for external review. Medicare may deny services if a signed certification if not available in the medical records submitted for review.
• Let’s discuss timing of the certification -Certifications should be obtained as soon as possible after the plan of care is established or at least within 30 days of the initial treatment. Certifications are acceptable without justification for 30 days after they are due but certifications delayed beyond this time frame should include evidence to justify the delay.Evidence that the provider made immediate and on-going attempts to obtain the certification signature should be included in the record. Note however that delayed certifications are accepted by Medicare unless the contractor has reason to believe that there was no physician involved in the patient’s care, or treatment did not meet the patient’s need (and therefore, the certification was signed inappropriately).

Next week, we will look at daily treatment notes, progress notes, and the discharge summary.

 

CMS has released the April 2013 Medicare Quarterly Provider Compliance Newsletter. As a reminder, this newsletter is an educational product to assist providers in understanding audit findings identified by Contractors such as Medicare Administrative Contractors (MACs), Recovery Auditors (RAs), Comprehensive Error Rate Testing (CERT) contractors and the Office of Inspector General (OIG).

This edition of the newsletter addressed several findings related to the review of Inpatient hospital claims. Specifically, findings are provided for review of the following MS-DRGs:

• Neoplasm Surgery (MS-DRGs 826, 827, 828, 829, 830, 834, 835 and 836)
• Pancreas, Liver & Shunt Procedures (MS-DRGs 405, 406 and 407)
• Medical Necessity for respiratory neoplasms with a complication or co-morbidity (CC) (MS-DRG 181),
• Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders with MCC (MS-DRG 391); and
• Acute Inpatient Hospitalization – Signs and Symptoms without MCC (MS-DRG 948)

 

Examples of review findings include:

• Incorrect selection of the Principal Diagnosis, reminding providers that “the circumstances of inpatient admission always govern the selection of principal diagnosis” and “is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
• High percentage of coding errors, reminding providers that “DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary’s medical record.”
• Medically unnecessary inpatient hospitalizations, reminding providers that:

1. “Medicare pays for inpatient hospital services that are medically necessary for the setting billed. The Medicare Benefit Policy Manual, Chapter 1, Section 10, states that the physician or other practitioner responsible for a patient’s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient.”
2. “The Medicare Integrity Program Manual, Chapter 6, Section 6.5.2.A, states that inpatient care is required only if the patient’s medical condition, safety or health would be significantly and directly threatened if care were provided in a less intense setting.”

 

The following table is being provided to help you identify which MACs and RAs have currently targeted the MS-DRGs from this newsletter. A review of the specific examples and findings can afford you the proactive opportunity to ensure your records are coded accurately and that the hospitalizations were medically necessary.

On March 13, 2013, CMS released a Ruling and a Proposed Rule that changes Medicare’s existing policy and allows payment of all Part B hospital services that were furnished and would have been reasonable and necessary if the patient had been treated as an outpatient, rather than admitted as an inpatient, except for those services specifically requiring an outpatient status. CMS also released Change Request 8185 with billing instructions for Part B rebilling to be implemented July 1, 2013 and discussed the Part B rebilling rules on the April 2 Hospital Open Door Forum call. But even with all this information, there are parts of the new rules that remain somewhat confusing. We thought we would address some questions to hopefully clear some of the confusion. Note that more information is expected from CMS soon and we will do our best to keep you up to date.

What services go on the Part B outpatient claim (13x type of bill) and what services go on the Part B inpatient claim (12x type of bill)?

Outpatient services that were bundled into the Part A inpatient claim under the 3-day payment window rule can be separately billed on an outpatient claim (13x TOB) if the inpatient admission is determined to be not reasonable and necessary. Therefore services that were provided before the inpatient order was written would be on the 13x claim.

Part B services that were provided after the patient was admitted (after the admission order was written) would be eligible to be billed on the Part B inpatient claim (TOB 12x). Services that require an outpatient status, such as ER services and observation services, would not be provided after the inpatient admission order was written, so these types of services are not allowed on the 12x claim.

 

When can claims for Part B rebilling be submitted?

The Ruling was effective March 13, 2013 but Medicare has to work out the details of claims submission and allow the processing contractors time to put changes in place to accept the claims. Medicare published CR 8185 with billing instructions, but this CR will not be implemented until July 1, 2013. CMS has promised interim billing instructions to be released soon. Once these interim instructions are released, Part B rebilling claims can be submitted.The interim billing instructions are now available at http://www.cms.gov/Center/Provider-Type/Hospital/Other-Content-Types/Quick-Reference-CMS-1455-R.pdf

 

Which previously denied claims are eligible for rebilling?

The ruling applies to claims denied after March 13, 2013, claims with pending appeals, and claims denied prior to March 13th that are still within the appeals timeframe. On the latter point, if claims were within the appeals timeframe as of March 13th, do they remain eligible for rebilling even when they are beyond the appeals timeframe? As providers wait on billing instructions from CMS, claims that were still eligible for appeal as of March 13th will have their appeals timeframe expire. But in listening to the Hospital Open Door Forum, CMS’s comments seem to indicate that these claims would remain eligible for rebilling until the 180 days post denial date. CMS even indicated that denials from November 8, 2012, which is 125 days prior to March 13th (120 appeals timeframe plus 5 mailing days) would be eligible for rebilling under this rule until May 7, 2013 (180 days from 11/8/12). This means that providers would not have to appeal previously denied claims to maintain their billing rights under the Ruling. This gives CMS some time to develop billing instructions without impacting providers’ rebilling opportunities.

 

Can rehabilitative therapy services be included on a Part B inpatient claim?

Under current regulations, outpatient therapy services (PT, OT, and SLP services) are included in the list of “Part B only” services and may be billed on a Part B inpatient, 12x type of bill. Billing of therapy services will also be allowed under the Ruling. But, in the proposed rule for Part B rebilling, Medicare notes such “therapy” services are defined in section 1833 (a) (8) of the Act as outpatient services. Since “services specifically requiring an outpatient status” are not allowed to be billed on an inpatient claim under the proposed rule, rehabilitative therapy services (physical therapy, occupational therapy, and speech language pathology services) cannot be billed on the Part B inpatient claim once the proposed rule is finalized. So any therapy services that are provided to the patient after he/she is admitted will not be billable, unless Medicare further modifies the policy.

 

 

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It has been just over three years since the Affordable Care Act (ACA) was signed into law on March 23, 2010. This slide provided by the Kaiser Family Foundation Health Tracking Polls, polled people on their view of the health reform bill based on what they know about it. As you can see, there are very mixed views.

To test what you know about the health reform law you can go to the Kaiser Health Reform quiz at this link: http://healthreform.kff.org/quizzes/health-reform-quiz.aspx

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On March 13, 2013, CMS released a ruling (Ruling 1455-R) with a HUGE impact for hospitals. This ruling is in light of the numerous recent appeal decisions by Administrative Law Judges (ALJs) and the Medicare Appeals Council to allow payment for Part B services when an inpatient admission is determined to not be medically necessary. This interim ruling is effective immediately and remains in effect until the corresponding proposed CMS rule entitled, "Medicare Program; Part B Billing in Hospitals" is finalized. Note that there are differences in the requirements of the ruling versus the proposed rule. This article discusses the currently effective Ruling only.

The Ruling allows hospitals to bill and receive payment for all reasonable and necessary Part B services provided to a hospital inpatient when a Medicare review contractor denies the Part A inpatient admission as not reasonable and necessary.

On Friday, March 22, 2013, CMS released Transmittal 1203 (CR 8185) which details the claims requirements for Part B rebilling. Although this transmittal is effective March 13, 2013, the implementation date is not until July 1, 2013. Therefore, hospitals cannot bill under the instructions of CR 8185 until July 2013. Further instructions from Medicare regarding billing in the interim are expected to be released soon. As indicated in our Extra newsletter yesterday, if you have a denied claim that has not been appealed and is approaching the end of the appeal timeframe, you should appeal the claim now in order to reserve your right to request a dismissal and bill under Part B once the billing instructions are released.

The key points from the Ruling are: 

• The ruling applies to
• Inpatient denials on or after the date of this ruling (March 13, 2013),
• Prior inpatient denials still within the appeal timeframe or
• Prior inpatient denials with an appeal pending.
• The ruling does not apply to
• Prior inpatient denials if the timeframe to appeal has expired, or
• Inpatient admissions determined by the hospital to not be medically necessary, such as during UR or other internal review.
• Hospital may submit a Part B inpatient claim for all reasonable and necessary Part B services that would have been payable if the patient had been treated as an outpatient –
• It is not limited to “Part B only” services described in Medicare Benefit Policy Manual, Chapter 6, Section 10. Prior to this ruling, a hospital could only bill selected services on a 12x type of bill when an inpatient admission was not allowed. These services are referred to as “Part B only” services, are listed in the policy manual referenced above, and include mostly laboratory tests and imaging studies. They did not include therapeutic services such as drug administrations, surgery, or therapeutic coronary or peripheral interventions. Under the Ruling, these types of services will be allowed to be billed on the Part B inpatient claim if the Part A stay was denied as not medically necessary by a Medicare contractor.
• Outpatient services that require an outpatient status, such as outpatient visits, ER services, and observation services may not be submitted on the Part B inpatient claim. These types of services may occur immediately prior to the inpatient admission and can be billed on an outpatient claim (see next bullet point regarding the 3-day window). Only Part B services occurring during the inpatient admission (i.e. after an inpatient admission order) would be included on the Part B Inpatient claim.
• Reasonable and necessary outpatient services provided during the 3-day payment window prior to inpatient admission may be billed separately on an outpatient claim if the inpatient admission is denied as not medically necessary. This ruling allows billing of this outpatient claim beyond the usual timely filing restrictions in accordance with the time frames listed below.
• The hospital may not have simultaneous requests for both Part A and Part B payment:
• The hospital must withdraw any Part A appeals in order to submit Part B claims for the same services.
• The hospital may not initiate a Part A appeal after submitting a Part B claim for the same services.
• The Part B billing may occur past normal timely filing limitations as long as it is:
• Within 180 days from the date of receipt of an appeal dismissal notice or,
• Within 180 days from the date of receipt of a final denial decision or,
• Within 180 days from the from the date of receipt of the initial or revised determination on the Part A inpatient claim (that is, the date of the remittance advice).

(Note the date of receipt of an initial or revised determination, or an appeal decision or dismissal notice is presumed to be 5 days after the date of such notice or decision, unless there is evidence to the contrary.)

• For the Part B claims billed under this Ruling, the beneficiary's patient status remains inpatient as of the time of inpatient admission and is not changed to outpatient.
• The Part A to Part B Rebilling Demonstration is being terminated. CMS will inform participating hospitals that the Part A to Part B Rebilling Demonstration is being terminated and will provide the necessary instructions.
• The ruling clarifies Medicare appeals adjudicators’ scope of review. Administrative Law Judges (ALJs) may no longer award payment for Part B services when the Part A claim is denied. According to the Office of Medicare Hearings and Appeals (OMHA), “The Ruling explains that adjudicators may only consider the originally billed Part A inpatient admission denial. Adjudicators may not consider potential coverage under Part B because hospitals are solely responsible for determining whether to bill for services under Part A or Part B, and submitting the appropriate claims.”
• Beneficiaries will be responsible for their usual Part B financial obligations under the ruling. Part A copayments or the difference must be refunded to the patient if the Part A amount is greater than the Part B amount.

For more information, see the CMS Ruling and the MLN Matters Article MM8185 concerning Part B Inpatient Billing in Hospitals.

 

 

 

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I remember from my first year as a compliance officer, a hospital representative lecturing at a national compliance conference explained how her facility made unintentional errors in the assignment of Medicare patients’ discharge statuses that were interpreted by the government as fraudulent activity. Now she could have presented a skewed interpretation and I am, in no way, questioning the government’s conclusion of any of the cases below. I am just acknowledging that sometimes, different parties have differing interpretations of how certain activities are classified.

The Health Care Fraud and Abuse Control Program 2012 Annual Report, a collaboration between the Department of Health and Human Services and the Department of Justice, highlights the successes of the government’s program to identify, prosecute, and prevent healthcare fraud and abuse. Below is a summary of the issues that resulted in settlements by hospitals to resolve claims and allegations under the False Claim Act (FCA).

 

1. Two settlements (almost $25M) relating to inflated fees for services that resulted in inappropriate Medicare “outlier” payments. The report states that both hospitals manipulated their charge structures to make it appear as though their treatment of certain patients was unusually costly, when in fact it was not.
2. Four settlements (over $31M) resulting from medically unnecessary inpatient admissions for patients that could have been treated as hospital outpatients. These cases include patients receiving Gamma Knife stereotactic radiotherapy and patients having kyphoplasty, a minimally-invasive procedure used to treat certain spinal fractures, or other surgical procedures that could have been performed on an outpatient basis.
3. Four settlements (approximately $6.7M) for a variety of other issues including:
4. Medically unnecessary and dangerous endovascular procedures
5. Surgical services performed in an Ambulatory Surgery Center (ASC), but billed as hospital outpatient surgeries
6. The drug Lupron® billed with the wrong HCPCS code (note also that even after becoming aware of the issue, these hospitals never self-disclosed or attempted to pay back monies received in error)
7. Improper physician recruitment arrangements.

 

You can read the full report on the OIG website at HCFAC Report.

Over the years the American Health Information Management Association (AHIMA) has provided guidance on when and how to query for additional health record documentation in a compliant manner. They have recently published a new practice brief on “Guidelines for Achieving a Compliant Query Process” that augments and where applicable, supersedes prior AHIMA guidance on queries. MMP, Inc. encourages coders and clinical documentation specialists to read the AHIMA article for complete guidance and some excellent examples of compliant and non-compliant queries.

Key Points about Queries

The AHIMA article defines the purpose of a query as follows: “The desired outcome from a query is an update of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment.”

• Queries should be used to clarify documentation in the medical record for accurate code assignment, such as when
• Information is ambiguous, incomplete, or conflicting,
• Clinical indicators are not related to a specific condition,
• Clinical indicators to support a documented diagnosis are missing, or
• Greater specificity is needed.
• All queries must be accompanied by the relevant clinical indicator(s) that justify the need for the query. These indicators should be derived from the specific patient’s current episode of care and may contain elements from any part of the current medical record.
• Verbal queries should contain the same information and be in the same format as written queries.
• Queries should not indicate the impact on reimbursement or provider profiles.
• Queries should not be leading. A leading query is one that is
• Not supported by clinical indicators in the medical record and/or
• Directs or “leads” a provider to a specific diagnosis or procedure.

Query Formats

Although open-ended queries are preferred, “yes/no” queries and multiple choice queries are acceptable under certain circumstances.

Yes/no queries:

• Are appropriate for example in
• determining if a documented condition was present on admission (POA),
• substantiating a diagnosis that is already present in the medical record,
• establishing a cause and effect relationship, or
• resolving conflicting documentation.
• Should include additional options besides “yes” and “no” such as “clinically undetermined”, “other”, and “not clinically significant”.
• Should not be used to document a condition/diagnosis that is not already documented in the medical record, i.e. a new diagnosis based on clinical indicators.

Multiple choice queries:

• Are appropriate for example to document greater specificity.
• Should include clinically significant and reasonable options as supported by the clinical indicators.
• Should include additional options such as such as “clinically undetermined”, “other”, and “not clinically significant”.
• Should allow the addition of free text by the provider.

Note: It is acceptable to include a new diagnosis as an option in a multiple choice list if supported by the clinical indicators, since other options including “other” and free text are also available.

Handling Missing Clinical Indicators

Is a query appropriate when a diagnosis is documented that does not appear to be supported by clinical indicators or should this type of conflict be addressed through the facility’s escalation policy? This is something your hospital will have to decide how to handle. CMS recommends that all facilities have an escalation policy that may include referral to a physician advisor, chief medical officer, or other administrative personnel. Even if you use queries in some of these situations, escalation will be needed for more complex situations, for unanswered queries and to address any concerns regarding queries. An example of a query from the brief that addresses documented conditions without clinical indicators is:

QUERY: “Please review the laboratory section of the present record to confirm your discharge diagnosis of hypernatremia. Laboratory findings indicate a serum sodium of 120 mmol/L.”

Should the Query Be Part of Your Medical Record?

Your facility should have internal policies that address query retention and whether the query is to be a part of the patient’s permanent medical record or stored as a separate business document. Either way, remember that the medical record should include the clinical rationale for all diagnoses. Also, capturing the content of the query and the provider’s response supports the sequence of events so that documentation does not appear out of context.

 

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The HCPCS codes for the drug medroxyprogesterone acetate changed at the beginning of this year. Medroxyprogesterone acetate is known by the brand names of Depo-Provera, Provera, Prempro, Depo-Provera Contraceptive, Cycrin, Lunelle, Premphase, Amen, depo-subQ provera 104, Curretab, Premphase 14/14.

The “old” codes (for dates of services prior to January 1, 2013) were:

• J1051 – Injection, medroxyprogesterone acetate, 50 mg*
• J1055 - Injection, medroxyprogesterone acetate for contraceptive use, 150 mg*

For dates of service on and after January 1, 2013, the following code replaces the above codes:

• J1050, Injection, medroxyprogesterone acetate, 1 mg

 

As a result of this code change, Alabama Medicaid is requiring the use of a modifier to distinguish between use of the drug for contraceptive use and other (non-contraceptive) uses. Modifier FP is used to indicate the injection of the drug for contraceptive use and modifier U1 indicates non-contraceptive use. The Medicaid Alert also lists the following restrictions for usage.

 

Contraceptive Use Restrictions (J1050-FP)

• Limited to female recipients 10-55 years of age
• Dosage of 104 – 150 mg per injection
• Allowed once every 70 days
• Claim must include a contraceptive management diagnosis code

 

Non-contraceptive Use Restrictions (J1050-U1)

• Covered for recipients of all ages
• Limited to 1000 mg per injection
• Claim must not include a contraceptive management diagnosis code

 

Providers should report the drug units based on the new “per 1 mg” description – for example 150 mg would be billed with 150 units, 500 mg with 500 units. Alabama Medicaid reimburses J1050 at $ 0.20 per unit (per mg). Claims for J1050 billed without a modifier will be denied by Alabama Medicaid. See the link above for complete information.

 

This week we would like to acknowledge Cardiac Rehab Week. Cardiac Rehabilitation Week was initiated by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) to focus national attention on cardiac rehabilitation’s contribution to the improvement of the health and physical performance of individuals at risk for heart disease and/or those individuals diagnosed with heart disease or dysfunction. MMP, Inc. expresses our appreciation to the dedicated individuals who work with patients, physicians, and other health care providers to make us all “heart healthier”. And to assist cardiac rehab providers, we offer the following guidance on Medicare coverage of Cardiac Rehabilitation services.

Make sure the cardiac rehabilitation services you are providing meet all of Medicare’s requirements in order to ensure appropriate reimbursement. Palmetto GBA, the Part A MAC for Jurisdiction 11, has conducted service specific complex reviews of cardiac rehab services in South Carolina, North Carolina, Virginia, and West Virginia. In the last round of reviews, denial rates, although continuing to decrease, were still between 48 – 64%.

In addition to lack of timely submission of medical records and services not documented, the findings demonstrated the following denial reasons:

1. Cardiac Rehab Not Warranted for Diagnosis - Medicare covers cardiac rehabilitation items and services for patients who have experienced one or more of the following:
2. An acute myocardial infarction within the preceding 12 months; or
3. A coronary artery bypass surgery; or
4. Current stable angina pectoris; or
5. Heart valve repair or replacement; or
6. Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
7. A heart or heart-lung transplant.
8. Cardiac Rehab Session Did Not Include the Required Services - Cardiac rehabilitation programs must include the following components:
9. Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
10. Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
11. Psychosocial assessment;
12. Outcomes assessment; and
13. An individualized treatment plan detailing how components are utilized for each patient.
14. Physician Must Be Readily Available - All settings must have a physician immediately available and accessible for medical consultations and emergencies at all time items and services are being furnished under the program. This provision is satisfied if the physician meets the requirements for the direct supervision for hospital outpatient therapeutic services.

Also, providers need to be aware of the frequency limitations for Cardiac Rehab services. Cardiac Rehab services are limited to a maximum of two 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor.

More information concerning Cardiac Rehab and Medicare coverage and billing requirements can be found at:

• Medicare Benefits Policy Manual, Chapter 15, Section 232
• Medicare Claims Processing Manual, Chapter 32, Section 140
• MLN Matters Article MM6850

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.