Auditors Uncover Billing Errors in Hospitals
A doctor’s Hippocratic oath isn’t good enough for the Centers for Medicare & Medicaid Services (CMS): they need proof that every service a beneficiary receives is medically necessary. This proof comes in the form of diagnostic codes reported on claims, backed by observations documented by the doctor. Coding and documentation that don’t align can cost the doctor and/or his patient, dearly.
Hospitals in Ohio, Kentucky, Indiana, Michigan, Illinois, Minnesota, and Wisconsin found this out the hard way when a Medicare recovery auditor conducted studies to determine whether all covered, paid days associated with long-term acute care confinement equal to the short stay outlier threshold plus up to five days were reasonable, necessary, and appropriate.
Recovery Auditor Review Findings
The auditor reviewed the following Medicare severity-long term care-diagnostic related groups (MS-LTC-DRGs): 064 Intracranial hemorrhage or cerebral infarction w MCC, 177 Respiratory infections & inflammations w MCC, 189 Pulmonary edema & respiratory failure, 193 Simple pneumonia & pleurisy w MCC, 194 Simple pneumonia & pleurisy w CC, 207 Respiratory system diagnosis w ventilator support >96 hours, 208 Respiratory system diagnosis w ventilator support <=96 hours, 689 Kidney & urinary tract infections w MCC, 690 Kidney & urinary tract infections w/o MCC, 870 Septicemia or severe sepsis w MV >96 hours, 871 Septicemia or severe sepsis w/o MV >96 hours w MCC, and 872 Septicemia or severe sepsis w/o MV >96 hours w/o MCC.
In one study, the auditor reviewed 137 claims from 11 providers, covering 11 MS-LTC-DRGs, and adjusted the length of stay (LOS) in 72 audits based on the review of reasonable and necessary stays at the LTAC level of care. In another study, the auditor reviewed 63 claims from six providers covering five MS-LTC-DRGs, and adjusted the LOS in 35 audits, also based on the review of reasonable and necessary stays at the LTAC level of care.
Chances are, the LOS was warranted in every case. It’s too bad the claims lacked the evidence needed in a medical review to support payment.
CMS says, “Ensure that patients receive reasonable and necessary care that is appropriate for the diagnosis and condition of the patient at any time during the stay.” What they mean is that the patient must have a viable reason for being treated as an inpatient.
“The patient 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,” CMS says.
Neither CMS nor their auditors were there; they can’t possibly know what went on in the hospital unless you tell them. And they won’t pay the claim unless you do.
“Documentation must demonstrate a continual progression in care that supports the appropriateness of the setting. A discharge plan should be established at the outset, and its goals should be demonstrably worked toward and achieve as efficiently as the patient’s condition and comorbidities allow, without unjustified, stalled, or repetitive care. A sustained plateau indicates that a lower level of care is more appropriate.”
Do Your Homework
The “LTCH Training Guide,” Chapter 3, Clinical Issues: Coverage, Coding and Medical Review may be of particular interest for the issues discussed in this finding.