Administrative Memos

200101

FROM: Theodore O. Will, Chief Executive Officer
DATE: Feb 06, 2001
SUBJECT: PEPP Hospital-Specific Short Stay Report Calendar Years (CY) 1999 and 2000 Follow-Up (Case Listings)
IPRO CONTACTS:

Kathy Terry, Ph.D., Director, Data Analysis, Ext. 261 and Paula Monetti, Sr. Director, Medicare/Federal Program Integrity, Ext. 261

In December 2000, IPRO distributed PEPP Administrative Memorandum #2000-14 with hospital-specific short stay data reports for calendar years (CY) 1999 and 2000. These reports identified the New York State (NYS), hospital peer group and hospital-specific short stay percentages for each year as well as high percentage short stay DRG's associated with those stays.

Several hospitals have since contacted us requesting case listings so that they might review a sample of cases. Based on these requests and our commitment to support hospital payment error process improvement initiatives, we have produced a hospital-specific random sample case listing of short stays for those DRGs that were above both peer group and NYS proportions. The Selection Methodology is included as Attachment I. Your hospital-specific case listing is included as Attachment II.

These case listings will enable you to select and review sample cases in order to identify hospital-specific issues that might have led to a higher percentage of short stay admissions. Some utilization, coding and documentation areas you may explore include:

Admission necessity - could the services have been safely and effectively provided in an outpatient setting?
Medical record documentation - was there sufficient physician documentation in the medical record to support an inpatient stay?
Premature discharge - was the patient stable at discharge?
DRG appropriateness - was the documentation in the medical record sufficient to support the assigned DRG?

IPRO has provided hospitals with a variety of references and tools to supplement ongoing auditing and monitoring activities. Below are some examples of such materials that may be useful in your review of short stay admissions:

PEPP Compliance Workbook

Using Audits for Compliance Monitoring (Tab 4): approaches and techniques for developing, conducting, and evaluating initial and subsequent coding and claims audits;
Utilization Management for Compliance (Tab 5): ideas for identifying risk areas related to medically unnecessary admissions and billing issues (pp. 60-62);
Documentation for Compliance(Tab 6):insights into the importance of documentation in the healthcare setting and the responsibility of providing adequate medical record documentation (also see Tab S);
Instructions for Audit Process in Using Audit Tool for Admission Review(Appendix Tab L): guidelines for developing an audit process and tool for admission review that can be used to evaluate the appropriateness of admissions, procedures, readmissions, and transfers (see p. 137 for audit tool);
Instructions for Audit Process in Using Audit Tool for Coding (Appendix Tab M):guidelines for developing an audit process and tool for coding review to evaluate simple/complex coding errors that impact DRG assignments (see p.142 for coding tool); and
Inpatient Documentation Prompter Card (Appendix Tab S): supplements a hospital's standard medical record documentation process (see p.169).

A Resource Guide for Planning and Implementing Payment Error Prevention Program (PEPP) ActivitiesSections on PEPP Projects and Information for Coders present educational aides and tools that can be adapted for hospital use for internal education programs geared to coders, physicians, utilization department staff, as well as other hospital staff involved in PEPP compliance activities. Section on Information for Physicians provides a general guide about the effect physician documentation of clinical information has on ICD-9-CM procedure codes and DRGs. Poster-sized inpatient documentation prompters for prominent display as medical staff reference.

Videos"Payment Error Prevention Program (PEPP)" and "What Physicians Need to Know": PEPP Overview and the importance of physician documentation.

We hope you find the case listing and resource information useful. Through this collaborative effort we can work together to support the educational and interventional goals of PEPP. Should you have any questions in regard to this memorandum, please feel free to contact Paula Monetti or Dr. Kathy Terry.