WPS Medicare Part A - Quarterly CERT Error Findings Report ~ J5 National Providers~

Transcription

1 WPS Medicare Part A - Quarterly CERT Error Findings Report ~ J5 National Providers~ This report provides details of Comprehensive Error Rate Testing (CERT) errors assessed July 2014 through September 2014 for J5 National providers. The findings below are reported based on the type of error assessed by the CERT Contractor (e.g., insufficient documentation, incorrect coding, etc.). Medically Unnecessary Service or Treatment 61% of total errors Inpatient admission not reasonable and necessary. The beneficiary had benign prostatic hyperplasia (BPH) for six years at least and had previously undergone the transurethral microwave therapy in 2007 to open up his flow. His prostate was enlarged then and now has low flow with outflow symptoms. This procedure is usually done as an outpatient and there were no post procedure complications to justify an inpatient admission. The beneficiary s clinical presentation, prognosis and expected treatment does not support the expectation of the need for hospital care spanning 2 or more midnights. Beneficiary underwent a transurethral resection of the prostate (TURP) and cystoscopy without intra-operative or postoperative complications. The invasive procedure cystoscopy with transurethral resection of the prostate was medically necessary. Inpatient admission not reasonable and necessary. The beneficiary had several episodes of syncope at home and was found to have a pacemaker battery that was at end-of-life. It had been in place for eight years. The procedure was done the following day after arrival in the ER and she was discharged the same day as the procedure. There was only observation the first day and then the procedure was performed with the expected discharge. There was no expectation of two night of care so the admission was not justified. Inpatient admission not reasonable and necessary: pre-procedure hydration may be done as outpatient service; procedure without complication. Disagree with inpatient admission which was not reasonable and necessary. The beneficiary was seen in ER with vertigo. The beneficiary was stable and had no focal deficits. An expectation of at least two midnights was not reasonable. Inpatient admission not reasonable and necessary. The beneficiary had total uterine prolapse and a rectocele she needed repaired. The surgery was a modified colpoclesis with a posterior repair which was performed on 10/2. She did well and had no post-op problems. She was discharged on 10/3. This procedure is usually done as an outpatient with overnight monitoring. There was no expectation for a two night stay and no complications to justify one. The 9/30 date was the preadmission physical but she didn't enter for surgery until 10/2. Inpatient admission is not reasonable and necessary. The beneficiary s clinical presentation, prognosis and expected treatment does not support the expectation of the need for hospital care spanning 2 or more midnights. Beneficiary with dementia, pacemaker for atrial fibrillation, HTN and O2 dependent chronic obstructive pulmonary disease presented after episode of chest pain. Page 1 of 6

2 Upon presentation she was pain free. Troponin level was borderline elevated and stable. Stress test was negative, however not done until two days post presentation, prolonging hospitalization. Inpatient admission not reasonable and necessary: in ER with erythema and drainage left great toe; no fever or leukocytosis; X-ray suggestive but MRI (eventually) negative for osteomyelitis. All could have been provided as outpatient services. Inpatient admission not reasonable and necessary: in ER after fall without injury; issues are chronic. Inpatient admission not reasonable and necessary: in ER due to exacerbation of chronic knee pain; no evidence of infection; stable. All could have been provided as outpatient services Disagree with inpatient admission due to lack of a valid MD admission order. There are valid MD orders for observation written on 10/05, but no valid MD inpatient admission order even after follow-up request. Inpatient admission was not reasonable and necessary. No expectation of a two midnight hospital stay. Beneficiary with dementia admitted for long-term IV antibiotic therapy for urinary tract infection prior to placement in skilled facility. No evidence of urosepsis or renal obstruction upon admission. Other Errors 9% of total errors Deem date of admission is 11/15. Per Pub100-8, 6.5.4, B, The diagnosis determined to be responsible for covered services on the deemed date of admission is the principal diagnosis." Inpatient admission is not reasonable and necessary on 11/14. The beneficiary had routine preoperative evaluations prior to stage II basilic vein superficialization. Inpatient admission was reasonable and necessary on the deemed date 11/15 for post-procedure pain control in this beneficiary with known low pain tolerance and who required IV Dilaudid for several days after the procedure. The physician's intent to admit Beneficiary to inpatient status is documented in the History and Physical. Disagree with inpatient admission, dates of service 11/14 through 11/14. Submitted documentation supports the beneficiary presented to the current facility on 11/13 for planned atrial ablation, which was performed on 11/13. The beneficiary was admitted to observation on 11/13, and post procedure to ICU in an outpatient bed. The beneficiary was discharged home on 11/14. The provider is required to enter the beginning and ending dates of the period included on the inpatient bill. The billed from date submitted on the claim is 11/14 with a through date of 11/14. This is a billing error. Inpatient admission is not reasonable and necessary on 10/11. There is no documentation of inpatient orders dated 10/11. Inpatient admission was deemed medically necessary on 10/12 per physician orders dated 10/12 to commence inpatient stay. Deem date 10/12. Disagree with POA indicator "Y" for (blood loss anemia). Change to "N" as this was a "postoperative acute blood loss anemia" which would not have been present on admission. Present on Admission Reporting Guidelines, codes and should both be coded as Y rather than N. Acute renal failure (584.9) and hyponatremia (276.1 are both stated on 11/25/13 Consults (date of admission) and are both indicated on ER lab values as abnormalities consistent with present on admission status. Page 2 of 6

3 Disagree with POA indicator "N" for diagnosis code (disorder of mineral metabolism; Disorders of Magnesium Metabolism). Labs upon admission reflect condition was present on admission. Revise to "Y". Insufficient Documentation - 13% of total errors Insufficient documentation: the physician's signature on the submitted SNF level of care certification form is not dated; documentation is insufficient to support timely SNF level of care certification. SNF claim for period of service 10/04-10/06. Claim history review confirms Part A enrollment, SNF days remaining, and reported acute qualifying admission. MDS assessment for ARD 10/06 reviewed. Initially submitted documentation included: records from the qualifying hospital admission, unsigned admission/ treatment orders, SNF physician discharge note, nursing records, PT/OT documentation, and the MDS reports. In response to the follow-up request received: physician authenticated electronic orders and SNF level of care certification/recertification form. The certification signatures are not dated; the FAX dates on the form are 7 months after dates of service. The submitted records do not support alternative format for certification as provided for in 42 CFR, section and Procedure, total hip replacement, and thus inpatient admission, not reasonable & necessary: little information about prior conservative treatment; no specific information about X-rays. Procedure & thus inpatient admission not reasonable & necessary: no information about pain's effects on Activities of Daily Living (ADLs) nor about prior conservative treatment; no history and physical; no x-rays; no surgeon's exam. Disagree with inpatient admission for date of service 10/24-10/24 as billed on the CERT claim. There was an MD order for observation, but no valid MD order for inpatient admission was found on the medical record. Disagree with inpatient admission as billed on the CERT claim. There is no valid MD inpatient order or intent to admit. There was no history and physical submitted with the medical record. Inpatient admission not reasonable and necessary: no admit order; History and Physical unsigned. Billed: RVB10 (SNF)(14 units). Missing: a) documentation to support signature validation on Physician Admission Orders, Orders for Oxygen, SNF Recertification, and Therapy Clarification Orders; and b) laboratory test results. Received: a) Admission orders signed but not dated; b) telephone orders for Oxygen but not validated by the physician (Nursing Notes show use of Oxygen), c) PT & OT Clarification Orders missing Physician signature/date at the bottom; d) PT/OT Initial Evaluations, e) PT/OT Therapy progress notes and logs, f) numerous physician orders in the record not dated, g) SNF Initial Certification, signed/dated; h) SNF- Re-Certification signed but not dated, i) records from the inpatient stay; j) SNF Discharge summary, k) Physician progress notes; l) Nursing notes; m) Medications; n) IDT Team Care Plan; and o) hard copy MDS. DRG Wrong Diagnosis Code 13% of total errors Revise DRG to 460 with principal diagnosis code as (Other mechanical complication of other internal orthopedic device, implant, and graft). Code , (Kyphoscoliosis and Scoliosis; other) remains as an additional diagnosis. Beneficiary presented for an elective lumbar re-fusion surgery. Per H&P patient with non-union at L2-3, possibly L3-4 and L4-5 status post previous lumbar Page 3 of 6

4 fusion. Plan was exploration of the fusion at L2-S1 with revision of fusion. Per operative report... non-union was present between L2-5. I proceeded to take down the nonunion. Per ICD-9-CM Guidelines for Hospitals, Section II, AHA Coding Clinic, Second Quarter 2013 Page: 22, and available documentation code is a more appropriate principal diagnosis. Disagree with DRG 455. Add diagnosis code , (Other mechanical complication of other internal orthopedic device, implant, and graft) changing the DRG to 454. Per ICD-9-CM Official coding Guidelines and available medical record documentation, beneficiary, (per operative report)...the left screw had a broken tip suggesting that there was continued motion through it and a pseudoarthrosis present." The screw was replaced during surgery. Disagree with DRG 470. Add diagnosis code for acute diastolic heart failure (428.31) as a diagnosis code changing the DRG to 469. Per ICD-9-CM Official Coding Guidelines for Hospitals and available medical record documentation, beneficiary was diagnosed by physician (see Medicine discharge note) with acute congestive heart failure probable diastolic. Disagree with code , (joint effusion - lower leg) and DRG of 983. Per ICD-9-CM and Official Coding Guidelines, Section II. Selection of Principal Diagnosis the more appropriate principal diagnosis code is sinoatrial node dysfunction, (427.81). Following observation stay for knee pain, beneficiary began to experience changes in EKG. Change of status order (admit) written for dysrhythmias and pacemaker was inserted on 8/23. Focus of treatment for inpatient stay was the arrhythmia as the more acute condition as noted in physician admission note that beneficiary had recurrent falls. Acute conditions are always sequenced before chronic conditions, Section A. B. 10. Acute and Chronic Conditions, Official ICD-9-CM General Guidelines for Hospitals. POA indicators correct as submitted. Discharge disposition changes to 62, rehabilitation. DRG Wrong Procedure Code 13% of total errors Disagree with facility coded DRG 455. Revise to 473 by removing procedure code (lumbar fusion anterior/posterior approach). No operative report or other indication within the record of such procedure. Agree with POA indicators and discharge status. Per CERT Physician, agree with procedure, anterior cervical fusion, and inpatient admission reasonable; both were reasonable and necessary. The beneficiary had progressive neck and upper extremity pain with an abnormal upper extremity neurologic exam. There was significant stenosis per imaging; likely amenable only to surgery. Disagree with facility coded DRG 491. Revise DRG to 490 by adding procedure code (Insertion or Replacement of Interspinous Process Device). Per operative report interlaminar spacer devices were placed at L3-4 and L4-5. Per AHA Coding Clinic, Fourth Quarter 2007 Page: 116, and Coding Manual Volume 3, procedure code is an appropriate assignment. Disagree with facility coded DRG 254. Revise DRG to 221 with principal procedure code as 39.73, (Endovascular Implantation of Graft in Thoracic Aorta). Remove procedure codes 39.50, 39.90, and as these are not supported in the operative report. Per procedure report a Gore Tag Thoracic Endoprosthesis was advanced into the thoracic aorta, the graft was successfully deployed, it was post dilated using a trilobed balloon, and the Arteriotomy site was closed. Procedure code is a more appropriate code assignment. Page 4 of 6

5 Service Incorrectly Coded - 4% of total errors Billed CPT 85025: blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count. Documentation submitted includes physician progress note that documents intent for CBC with noting intent for differential. Lab results were submitted for CBC with differential. Documentation supports code change from CPT to 85027: Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count). Billed CPT (Urinalysis with automated microscopy) for 10/14/2013. Submitted treating physician's order is for "Urinalysis" that did not include microscopy even though one was performed. Supports code change from CPT to CPT (Urinalysis; automated without microscopy). SNF claim for period of service 11/07-11/13 submitted with HIPPS Code CC110 (Clinically Complex; ADL 6-10; no signs depression) for (6) units of service. Submitted documentation included: Nurse practitioner (NP) SNF level of care certification /recertification statement(s), admission and treatment orders; SNF history and physical and physician/npp notes; nursing records; PT/OT documentation; and the MDS report. The MDS from repository was RUG d at RMB (Rehabilitation Medium: requiring Rehabilitation Therapy, 150 minutes/ week minimum, 5 days any combination of 3 rehab disciples, ADL 6-10) and hierarchical non-therapy RUG (CC1). Per the provider response letter, the clinically complex indicators, MDS items M1040E (surgical wound) and M1200F (surgical wound care) were coded in error. The wound from total knee replacement surgery described as "edges well approximated with Steri-strips in place." Correction of items results in QC module recalculation of Hierarchical non-therapy RUG to PC1 (Reduced Physical Function), however MDS validated therapy RUG (RMB) remains most beneficial to the provider per case-mix maximization and reported 325 /total rehab minutes with OT 3 days/160 minutes and PT 3 days/165 minutes are supported by review. Up-code billed HIPPS to RMB10 (6) UOS. Invasive Procedure Not Medically Necessary - % of total errors Discharge with facility coded DRG 478. Revise DRG to 552 with procedure codes (percutaneous vertebral augmentation), (bone biopsy NEC) and (lumbar spine xray) removed from the coding sequence. Procedure codes 81.66, 77.49, and are not reasonable and necessary. Disagree with facility coded DRG 455. Revise DRG to 552 with removal of spinal fusion and its related procedure codes 81.07, 81.06, 80.51, 41.31, 81.62, and from the coding sequence. Inpatient admission was reasonable and necessary. Spinal fusion was not medically necessary. Procedure codes (Lumbar and lumbosacral fusion of the anterior column, posterior technique) and 80.51(excision intervertebral disc) are not reasonable and necessary. The Beneficiary s clinical presentation, prognosis and expected treatment does support the expectation of the need for hospital care spanning 2 or more midnights. The Beneficiary had postoperative pain control issues requiring physician to adjust pain medication regimen several times. Invasive procedure, Lumbar Fusion and Excision of IV Disc, was not medically necessary as there is no documentation of Beneficiary having failed conservative therapy. Page 5 of 6

6 Wrong Discharge Status Code - % of total errors Disagree with facility discharge status 04 (intermediate care). Revise to 03 (SNF). This was verified via the claims history. No Documentation was Received - % of total errors Missing physician order/plan to order, documentation to support the need for Clostridium Difficile toxin and lab result for billed. Initial submission includes statement, in part the date of service you have requested is called a reference account and the person did not come to our facility. Received no response to follow-up call for documentation. Based on CERT error findings for this quarter, below are educational resources that can assist your facility in avoiding these issues. CMS Resources Acute Inpatient PPS web page - Payment/AcuteInpatientPPS/ Determining Medical Necessity and Appropriateness of Admission - CMS IOM, Publication , Chapter 6, Section a Inpatient Rehabilitation PPS CMS IOM, Publication , Chapter 3, section 140 Inpatient Rehabilitation Facility Services CMS IOM, Publication , Chapter 1, section 110 Recertification for Extended Care Services/ Delayed Certifications and Recertification CMS IOM, Publication Chapter 4, section Medical Review of Certification and Recertification of Residents in SNFs CMS IOM, Publication , Chapter 6, section 6.3 Provider Signature Requirements - CMS Internet-Only Manual(IOM), Publication , Chapter 3, Section Requirements for Ordering and Following Orders for Diagnostic Tests CMS IOM, Publication , Chapter 15, Section 80.6 WPS Medicare Web Page Resources CERT Identified Errors Medical Review Provider Specialties/Services Note: Review results are based on Medicare regulations in place at the time services were rendered. Medicare providers are responsible for compliance with all current applicable Medicare coverage, coding and billing regulations upon claim submission. Page 6 of 6