UR Alert October/November 2006

IN THIS ISSUE

Welcome
Case Examples
Share and follow-up

Welcome

Welcome to the first electronic issue of UR Alert, IPRO's newsbrief created for physicians to assist in reducing inpatient admission necessity denials. Please forward this electronic newsbrief on to your physicians. We look forward to their direct enrollment. If you wish to receive future free electronic editions of UR Alert, it is easy to opt in. To subscribe to this newsletter, visit http://lists.ipro.us/read/all_forums/subscribe?name=hpmp-ur-alert.

Hospitals have requested additional information from IPRO to assist in the reduction of payment errors associated with admission necessity denials. To that end, we present this bi-monthly electronic newsbrief that is created for physicians, which will focus on de-identified case examples of IPRO Medicare admission necessity denials.

Analysis of admission necessity denials has found that the current Medicare admission denial rate for New York State (NYS) is at 4.3%. Looking further into these denials, we find that there are select DRGs with greater denials than others. Specifically, DRG 429: Organic Disturbances and Mental Retardation has 25% of all cases reviewed resulting in an admission denial. The following provides insight into the reasons for the high denial rate and, includes case examples for clarity.

The need for admission as an inpatient must be decided based on the patients presenting complaints, the severity of the signs/symptoms and, the inability to safely and effectively provide the needed medical services in an alternate setting. If there is no identified medical necessity for inpatient admission, the admission will be denied as not medically necessary. An admission for social reasons would not be considered medically necessary. In situations where it is unclear whether inpatient care is needed, a Medicare patient may be admitted to observation status for reasonable and necessary outpatient observation services that span rarely more than 48 hours 100-02 Medicare Benefit Policy Transmittal 42, December 16, 2005.

If the initial evaluation indicates that ongoing acute inpatient care is required, the patient is at that time admitted as an inpatient. More information about the use of Medicare observation may be found in a recent CMS Medlearn Matter article http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM4259.pdf.

The following redacted examples of actual cases reviewed by IPRO help to illustrate inappropriate admissions relating to DRG 429-Organic Disturbances and Mental Retardation.

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CASE EXAMPLES

Case Example 1:

An 80-year-old woman was brought to the emergency department (ED) with complaints of being agitated and abusive with her home attendant. The patient had a history of ischemic dementia.

The patient had been recently discharged with the same diagnosis. On the day she came to the emergency department, the patient had a new home attendant who called the health agency who called EMS. The patient was admitted and eventually discharged with DRG 429.

Comment: Review of the record demonstrated no acute medical issues and the referral to the ED was the result of a breakdown in the home care situation. The admission was denied.

Case Example 2:

A 73-year-old woman came to the ED with a change in mental status. Based on the information provided by the family, the patient was having episodes of confusion with inability to care for herself over the last several months. She had been discharged from the hospital within the past 3 days for similar complaints. A complete evaluation at that time including a CT of the head was negative. On evaluation, there were no acute issues identified. Admission orders were for regular diet, aricept was added to her medications and, social service evaluation was obtained. She was sent to a nursing home on day 3.

The patient was in the hospital for 3 days. The discharge diagnosis was 294.8 with a DRG of 492.

Comment: This patient was felt by the family to no longer be manageable at home and needed ongoing nonskilled care. There were no acute medical issues. The admission was thus denied.

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Share and Follow-up:

Please feel free to share this newsbrief as appropriate. In addition, be sure to review the discharges and subsequent Medicare billings for DRG 429 to ensure that similar instances of inappropriate Medicare billings are not occurring within your facility.

To subscribe to UR Alert, visit http://lists.ipro.us/read/all_forums/subscribe?name=hpmp-ur-alert. The newsbrief will be emailed to your account in December and every other month thereafter, once you subscribe.

HPMP Compliance Workbook: http://providers.ipro.org/index/hpmp-compliance-workbook

JENY: Medicare Payment Error & Case Review Initiatives forum: http://jeny.ipro.org/forumdisplay.php?f=34

This material was prepared by IPRO, the Medicare Quality Improvement Organization for New York State, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-NY-TSK3B-UR-06-01

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