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• RAC audits reveal that coding errors and lack of sufficient clinical documentation to support medical necessity are the highest areas of recoupment activity
– Renal and urinary tract disorders– Surgical cardiovascular procedures– Acute inpatient admission neurological disorders– Outpatient services billed as inpatient
• Section 6402 of PPACA (42 USC Section 1320a-7k(d)) creates an affirmative obligation on a provider to return an “overpayment” within 60 days of its “identification”
• CMS issued Transmittal 299 (Change Request 3444) on September 10, 2004, implementing new section 50.3 in Chapter 1 of the Medicare Claims Processing Manual– Describes when and how a hospital may change a patient’s status from
inpatient to outpatient
– “The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital;”
– Establishes the necessity for Admission Review to be completed before patient discharge
• Section 1879(a) of the Social Security Act (Limitation on Liability) provides where:
“(1) a determination is made that… payment may not be made under part A or part B of this title for any expenses incurred for items or services furnished an individual by a provider of services …, and (2) both such individual and such provider of services…did not know, and could not reasonably have been expected to know, that payment would not be made for such items or services under such part A or part B, then to the extent permitted by this title, payment shall…be made…as though the coverage denial…had not occurred.”
“that a provider that furnishes services that are not reasonable and necessary is considered to have known that the services were not covered if it is clear that the provider could have been expected to have known that the services were excluded from coverage on the basis of notification of PRO screening criteria specific to the condition of the beneficiary for whom the furnished services are at issue or its knowledge of what are considered acceptable standards of practice by the local medical community.”
• The only way the provider could not be expected to know that payment for services would be denied was if it conducted an Admission Review process to certify medical necessity for ALL beneficiaries.
Notice: This query is an attempt to gather more information for accurate and specific coding. No particular response is expected or desired. We may add an addendum to your discharge summary depending on your response to this query. You should review this addendum carefully before signing the discharge summary. If there is a discrepancy, please contact the coding supervisor.
Dr ________________:Patient with acute viral gastroenteritis was treated with fluids, dehydration documented on admission orders.Was the patient treated for dehydration? Sincerely, Coding Department
In review of the record of your patient listed above, it was documented in the Progress Notes three days post admission that the patient had a catheter-associated UTI. There was not adequate information to determine if this was POA. I marked it YES for POA – if you disagree please document in the Progress Notes and sign and date.