INDEPENDENT VERIFICATION AND CODING VALIDATION (IV & V) FOR APR-DRG. Effective September 1, 2014

Transcription

1 INDEPENDENT VERIFICATION AND CODING VALIDATION (IV & V) FOR APR-DRG Effective September 1, 2014

2 Who are we? eqhealth has a 16 year partnership with Mississippi Division of Medicaid (DOM) as the Utilization Management and Quality Improvement Organization APR/DRG Independent Verification and Coding Validation is a new review type eqhealth Solutions will be performing on behalf of DOM beginning September 1,

3 What is Independent Verification and Coding Validation? Verification of the accuracy of the APR-DRG assignment used for reimbursement of inpatient services provided to beneficiaries based on DOM s requirements for billing eqhealth will assess whether documentation in the medical record substantiates the billed APR-DRG assignment through confirmation of the variables upon which the APR/DRG assignment was made: Principal, secondary diagnoses, codes, and present on admission (POA) indicators Procedural codes Discharge status codes Date of service (admit and discharge dates) Patient age and sex Newborn gram weight (ICD-9-CM code) Other State specific billing requirements, e.g., Observation stay billed as an inpatient stay Lack of physician order for acute inpatient level of care 3

4 Who performs Independent Verification and Coding Validation review at eqhealth? The eqhealth Solutions Independent Verification and Coding Validation review team is made up of: Registered Health Information Administrators (RHIA) Certified Coding Specialists (CCS) and Physicians 4

5 How do I know if a record has been selected for coding validation review? On a monthly basis eqhealth selects a random sample from hospital inpatient paid claims based on discharge date All requests for records or notices of decisions are sent to the hospital The notice at right is an example of the notice hospitals will receive when records have been selected for review IMPORTANT: The due date to submit records to eqhealth is in the top right corner of the notice 5

6 Notification that a record is selected for review eqhealth inserts the total number of randomly requested records here The specific records requested are listed here 6

7 Inventory Tracking Sheet and Checklist Included with Notification An Inventory Tracking Sheet and Medical Record Completeness Checklist for each requested record will be sent with the notification Important: The bar code is a unique identifier with routing technology which keeps records safe Complete the tracking checklist for each record requested and securely attach to the requested record before submitting record to eqhealth The attestation at the bottom of the tracking checklist must be completed and signed; this is your verification that the sample is complete 7

8 Tips Recap Check and validate the completeness of the record, and attach unique bar coded tracking checklist to the corresponding record before returning to eqhealth eqhealth prefers that records are sent via fax with the unique bar coded tracking checklist as the fax cover sheet; please don t send other cover sheets If records are being mailed in boxes containing multiple medical records include a packing list detailing the contents of the box Submit the requested records to eqhealth prior to the due date on the notice 8

9 What happens if eqhealth does not receive the requested record? eqhealth will send a second request to the hospital for the records 9

10 What does eqhealth do once a record is received? eqhealth first determines if the medical record is complete and whether review can be performed 10

11 What happens if eqhealth absolutely cannot complete the review? eqhealth will notify the hospital with a Review Not Performed notice The types of reasons why eqhealth would not be able to complete the review are: The medical record documentation indicates the claim was submitted or paid under the incorrect hospital provider number The medical record documentation indicates that the claim was submitted for the incorrect Medicaid beneficiary The billed date of admission does not match the date recorded in the medical record. 11

12 What happens if eqhealth absolutely cannot complete the review? The types of reasons why eqhealth would not be able to complete the review are (cont d): The billed date of discharge does not match the date recorded in the medical record. The billed discharge status does not match the information in the medical record The hospital has informed eqhealth that there is no record of inpatient hospitalization for the requested dates of service and beneficiary The physician s order admits the patient to an outpatient status. There is no physician s order found in the medical record to indicate that the patient s status was changed to acute level of care. This appears to be an outpatient case that was billed as an inpatient admission The physician s order admits the patient to observation status. There is no physician s order found in the medical record to indicate that the patient s status was changed to acute level of care. This appears to be an outpatient observation care-setting case that was billed as an inpatient hospitalization There is no physician s order found in the medical record to indicate that the patient was admitted as an inpatient. This appears to be an outpatient (observation) case that was billed as an inpatient admission. 12

13 What happens if eqhealth does not have enough information to complete the review? eqhealth will request additional information needed to complete the review. Q. What is the time frame to respond to a request for additional information notice? Within 15 calendar days of the date of the notice What happens if the response to the request for additional information is not sent? Or is late? eqhealth will notify the hospital with a Review Not Performed notice 13

14 How can I respond to the Review Not Performed Notice? eqhealth notices will include an adjustment/void request form, submit the completed form to DOM and include eqhealth s notice to correct the error. Select either the Adjustment or Void option Include the Transaction Control Number (TCN) and the Remittance Advice date in Month/Date/Year format 14

15 Tips Recap Time Sensitive: Submit the medical record on or before the 30th calendar day of the date of the Notice of Medical Records Selected for Coding Validation If additional information is needed be sure to send the information on or before the 15th calendar day of the Request for Additional Information notice Errors: Respond to Review Not Performed notices by using attached form to request either an adjustment or a void for the TCN 15

16 What does eqhealth do next? eqhealth reviews the record for completeness and validates the billed codes and POA indicator Records that are complete and correctly coded in accordance with national coding guidelines and compliant with Division of Medicaid specific policies for reimbursement are deemed satisfied. The hospital will receive a Notice of APR/DRG Satisfied 16

17 What happens if eqhealth disagrees with APR/DRG? eqhealth will notify the hospital there is the potential of an APR/DRG Change Potential is the key word, as this allows the hospital an opportunity to submit additional information for review The notice gives detailed comparison of what was billed by the hospital and eqhealth s findings Specific information regarding the reason for eqhealth s results are also provided 17

18 What happens if eqhealth disagrees with APR/DRG coding used in billing? Time Sensitive: Opportunity to submit additional information is offered The hospital may seek input from the attending physician Deadline for submitting additional information is on or before the 20th calendar day of the date of the notice If you need assistance submitting additional information call eqhealth at (local) or

19 If I receive a Potential APR/DRG Change Notice, what happens after the 20 th calendar day? eqhealth proceeds with the review process and makes a decision based on available information When additional information is submitted the information is considered during review When the billed diagnoses, POA indicator, and procedures are supported by the information the hospital will receive a Notice of APR/DRG Satisfied, OR If the additional information does not change the potential change outcome, eqhealth will send the hospital a Notice of APR/DRG Change There are several key features of this notice to review 19

20 Notice of APR/DRG Change Key Feature #1 If you (hospital representative) agree with the APR/DRG change simply complete the Adjustment Request Form and return to DOM. The address and fax number is on the form 20

21 Notice of APR/DRG Change Complete the form and submit it and a new claim to DOM to accept the APR/DRG change Include the Transaction Control Number (TCN) and the Remittance Advice date in Month/Date/Year format Attach corrected claim form 21

22 Tips Recap eqhealth will send a Notice of Potential APR/DRG Change when coding is not validated Opportunities to submit additional information on or before the 20th calendar day of the date of the Notice of Potential APR/DRG Change. After 20 days eqhealth will proceed with decision Hospital can accept eqhealth decision or may ask for a reconsideration 22

23 Notice of APR/DRG Change Key Feature #2 If you disagree with the APR/DRG change you may request a reconsideration by eqhealth 23

24 How can a hospital request a reconsideration of the APR/DRG change? A reconsideration or second look can be requested by following the instructions in the Change Notice shown at right, here are keys to remember: Reconsideration request must be received by eqhealth on or before the 30th calendar day from the date of the Change Notice If the request is submitted beyond the 30 calendar day timeframe; include information that may justify the untimely submission. eqhealth will determine whether there is good cause for the late submission If you have additional information to support the hospital billed APR/DRG assignment please send the information along with reconsideration request. HELPFUL TIP The attending physician may be a good resource for additional clinical information. Regardless, eqhealth will send you an acknowledgment of receipt of the reconsideration request and will remind hospitals they have 10 calendar days from the date of receipt of the reconsideration request to submit any additional relevant information A reconsideration is completed by a different eqhealth reviewer 24

25 If the request for reconsideration is not received on or before the 30 th day what happens? An untimely reconsideration request notice is sent to the requestor 25

26 If the request for reconsideration is received on or before the 30 th day what happens? A notice is sent to the hospital acknowledging receipt of the reconsideration request The request is placed on hold for 10 calendar days to allow the hospital representative an opportunity to submit additional information After 10 days the reconsideration is sent to a different eqhealth reviewer for a second look eqhealth makes review decisions as soon as possible but will complete APR/DRG reconsideration on or before the 30 th day following receipt of the request for reconsideration A reconsideration outcome notification is sent to the hospital 26

27 Reconsideration Outcome - Reversed This outcome means that eqhealth is reversing the initial outcome decision and has validated coding during the reconsideration review the APR/DRG assignment billed by the hospital 27

28 Reconsideration Outcome Upheld or Modified This outcome means that eqhealth is affirming or upholding the original outcome decision or is modifying the original decision A detailed explanation of the findings is provided 28

29 Reconsideration Outcome Upheld or Modified Complete the form to accept the reconsideration outcome and submit with a new claim form to DOM Include the Transaction Control Number (TCN) and the Remittance Advice date in Month/Date/Year format 29

30 Reconsideration Outcome Upheld or Modified and Appeal Rights If you are dissatisfied with the outcome of the reconsideration, you have appeal rights Appeals are conducted by Division of Medicaid (DOM) Request for appeal must be received by DOM on or before the 30th calendar day from the date of the eqhealth Reconsideration Outcome notice Instructions to request an appeal are contained in the Reconsideration Outcome Notice 30

31 Tips Recap Time Sensitive: Reconsiderations must be requested on or before the 30 th calendar day of the APR/DRG Change Notice The hospital representative can submit additional information at the time of the reconsideration request, OR On or before the 10th calendar day following the reconsideration request receipt date 31

32 Tips Recap Time Sensitive eqhealth will send a receipt notice when a reconsideration request is received An outcome notice is also sent when the reconsideration is completed Reconsiderations are completed as soon as possible but no later than on or before the 30th calendar day 32

33 Overall Tips Recap Time Sensitive: Read all notices carefully and pay particular attention to due dates, and instructions. Timeliness is critical Quality check: Check records before shipping, enclose checklists and detailed inventories Training: If additional training or assistance is needed contact us at: , , or This presentation is available for download or viewing by visiting our website; ms.eqhs.org 33

34 Questions and Answers 34

35 Thank You For Attending 35