By:
Katie White
MBA, MHL, CHC, CCS-P, CCP-P, ACS-PM, LHRM
On November 15, 2011, First Coast Service Options, Inc. (FCSO) issued notice that they will be performing prepayment medical reviews of inpatient hospital claims related to 15 diagnosis related groups (DRGs). FCSO is initiating this prepayment program in an effort to support the Center for Medicare & Medicaid Services' (CMS) goals of reducing the national Medicare paid claims error rate. CMS has an overall error rate reduction goal of 50% for the 2012 year. The November, 2011 published national paid claims error rate is currently at 8.6%, which equates to $28.8 billion in improper payments. FCSO has conducted a comprehensive data analysis and concluded that the Medicare Part A error rate is driven by many higher reimbursing DRG medical necessity denials involving certain surgical procedures and short stay admissions.
The prepayment medical review will be implemented in a staggered approach, beginning January 1, 2012. The prepayment medical review will be up to 100% for the DRGs listed below and heavily impact cardiac procedural admissions and major orthopaedic procedural admissions. Please note that these 15 DRGs encompass many cardiac and orthopaedic surgical procedures. The review of these DRGs will impact both the Part A hospital facility claim and the related Part B surgical professional services claim of the physician performing the procedure.
- 226 Cardiac defibrillator implant w/o cardiac catheter w/MCC
- 227 Cardiac defibrillator implant w/o cardiac catheter w/o MCC
- 242 Permanent cardiac pacemaker implant w/MCC
- 243 Permanent cardiac pacemaker implant w/CC
- 244 Permanent cardiac pacemaker implant w/o CC or MCC
- 245 Automatic cardiac defibrillator (AICD) generator procedures
- 247 Percutaneous cardiovascular procedure w/drug eluting stent w/o MCC
- 251 Percutaneous cardiovascular procedure w/o coronary artery stent w/o MCC
- 253 Other vascular procedures w/CC
- 264 Other circulatory system operating room procedures
- 287 Circulatory disorders except acute myocardial infarction (AMI), w/cardiac catheter w/o MCC
- 458 Spinal fusion except cervical w/spinal curve, malignancy, infection, or 9+ fusions, w/o CC or MCC
- 460 Spinal fusion except cervical w/o MCC
- 470 Major joint replacement or reattachment of lower extremity w/o MCC
- 490 Back and neck procedures except spinal fusion w/CC/MCC or disc device/neurostimulator
Things you can do to prepare for this new program are:
- Review the November 15, 2011 FCSO notice at : www.fcso.com
- Sign up for e-news alerts from FCSO
- Get familiar with the National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) relating to the target DRGs and surgical procedures (New ones were issued for Total Joint Replacements and Spinal Fusions in October, 2011)
- Make sure the documentation in your medical record supports medical necessity per the NCDs and LCDs
- Perform self audits
- Conduct provider education
Act now! Do not wait until you get the 1st medical record review request from FCSO, by then it will be too late.
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Katie White is the President of White Healthcare Consulting, Inc., a Florida based consulting firm specializing in compliance, coding and auditing for various healthcare providers. Ms. White has over 20 years of experience in the healthcare market, holds various certifications and licenses and also is current adjunct faculty at Palm Beach State College in both the AHIMA accredited Health Information Management Program and the Bachelor's in Healthcare Management Program. Contact Katie at 561-373-5209 or whitkath@comcast.net
