1. Pneumonia and sepsis. RACs trawl for cases where the hospital billed for pneumonia as the principal diagnosis but the patient also had sepsis. If the patient had sepsis at admission, the rule is that the hospital must code for sepsis as the principal diagnosis, which pays less than pneumonia. “It’s pretty easy for RACs to data-mine for this,” Ms. Bowden says. If they detect the ICD-9 code for sepsis as a secondary diagnosis, they request the patient’s record to determine whether sepsis should be the principal diagnosis. “Hospitals have been appealing this when sepsis has been documented as suspected or likely and not confirmed by blood cultures, but they have not been winning,” she adds.
2. Comorbid conditions. Hundreds of DRG pairs allow for a higher payment when a “complicated or comorbid conditions” are present. If only one such condition qualifies the case for the higher DRG in the pair, all the RAC has to do is disqualify it and the reimbursement falls to the low paying DRG level, which is substantially less. “We see many of these cases,” Ms. Bowden says. RACs love them because “if they can kick that condition off, they can make it a lower-paying case,” she says.
3. Ventilator cases. RACs have recouped a lot of money on ventilator cases where the hospital billed for continuous ventilator care lasting more than 96 hours but actual time on the ventilator was less than that. This groups to a lower paying DRG. The RAC simply has to ask for the patient’s chart, find the respiratory flow sheets and look for start and finish times. After being zinged many times for this, “hospitals are now much more vigilant about making sure the 96-hour limit is reached,” Ms. Bowden says.
4. Excisional debridement. Coding for debridement is limited to cutting away dead tissue. It cannot be used when the cutting is part of another procedure. For example, the surgeon may perform an excisional debridement when draining an abscess, but when billing for the incision and drainage of the abscess, he cannot claim debridement as well. by sniffing around a little, it is easy for the RAC to detect billing for both codes at once and examine the case. Because they are so straightforward, “these cases are harder to argue on appeal,” Ms. Bowden says.
5. Short hospital stays. Claims that are billed as inpatient full admissions have to meet medical necessity. Otherwise they have to be billed as observation or outpatient levels of care, which pay much less. Physicians are often not aware of the difference and the mistaken determinations cannot be changed once the patient is discharged. To find mistakes, RACs zero in on short stay (1-3 day) admissions that involve chest pain, congestive heart failure or short stay procedures. If the hospital doesn’t appeal and win, it will not get any reimbursement for the short stay admission except for ancillary services and only if billed within the Medicare filing limit. However, Ms. Bowden says Medicare’s inpatient definition allows a hospital leeway to argue the clinical merits of the case. As a result, these cases are fairly easy to win on appeal, but the hospital must often wait for the level of the administrative law judge to overturn the denial.
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