FROM: Theodore O. Will, Chief Executive Officer
DATE: Aug 25, 2006
SUBJECT: Hospital Payment Monitoring Program Special Project - Reduction of Payment Errors for DRGS 174 and 182
IPRO CONTACTS:
George Davis, Ph.D., Assistant Director, Data Analysis & Evaluation, Medicare/Federal Health Care Assessment at 516-209-5217
Reduction of Medicare payment errors continues to be a priority for the Centers for Medicare and Medicaid Services (CMS). CMS recently approved IPRO's Medicare 8th Scope of Work (SOW) Hospital Payment Monitoring Program (HPMP) special project to reduce payment errors associated with inappropriate inpatient admissions and incorrect coding/DRG assignment for DRG 174 (GI Hemorrhage with CC) and DRG 182 (Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders age > 17 with CC). Over the past several years, it has become increasingly evident that IPRO and providers must continue to work together to address Medicare payment errors, thus this initiative represents a key effort for IPRO and New York State hospitals.
Project Overview:IPRO has selected a baseline random sample of cases from twenty (20) NYS short-term acute care hospitals to be evaluated, through the traditional case review process, for admission necessity and accuracy of coding/DRG assignment. Ten (10) of these hospitals were selected based on recent disproportionate billing patterns (i.e., high volume of billing to one DRG as compared to another DRG) with regard to DRGs 174 to 182. The remaining ten hospitals represent a control-like group and were selected based on having a more proportionate billing pattern for DRG 174 to DRG 182. Educational interventions, open to all NYS providers, begin this month and are detailed below. Subsequent to improvement opportunities, a re-measurement sample of cases will be selected and reviewed. Project data will then be evaluated. Our goal is to demonstrate and help providers sustain a statistically significant reduction in payment errors from baseline to remeasurement as evidenced by a reduction in payment errors (coding/DRG assignment and appropriateness of admission) related to DRGs 174 and 182.
This month IPRO is offering several opportunities for providers to begin to familiarize themselves with the goals, direction and methodologies integral to the project. The first is through dissemination of a hospital-specific data report on billing patterns for DRGs related to gastrointestinal disorders (i.e., DRGs 174, 175, 182, 183). The report, based on administrative claims data, has already been uploaded to registered Quality Net Exchange users (http://www.qualitynet.org/). This report, created by IPRO, provides information in a format similar to the quarterly PEPPER reports. Differences are addressed in a recorded training webinar. This webinar, found at http://www.ipro.org/gi provides an introduction and overview of the project, as well as guidelines for interpreting and utilizing the IPRO data report mentioned above. Clinical information, including case examples in regard to project-specific admission necessity issues, is also provided. Providers should investigate outlier DRG billing patterns identified in this report through chart review, assessing both the accuracy of coding/DRG assignment, and/or the medical necessity of the admission.
Other IPRO project related resources to be made available over the next several months include a DRG/coding booklet addressing issues related to proper coding/DRG assignment for gastrointestinal disorders and, an online community forum for discussion of project related issues. To keep abreast of the project, please visit http://www.ipro.org/gi. You may also post information, including comments, questions and feedback, by clicking into the "community forum" link on that page.
To assist IPRO in meeting the project goals and objectives, providers need to be actively engaged. At a minimum, a representative from each NYS short-term acute care hospital should download its hospital-specific data report from Qualitynet Exchange and review the content. In addition, it is strongly suggested that providers listen to the recorded training session in order to gain a sufficient level of understanding to contribute to the projects' effectiveness in reducing the New York State payment error rate. This session would be most useful for Administrators, Health Information Management and Utilization Review Directors, Compliance Officers and, Analytic Staff.
We look forward to working together with all of you on this important new HPMP project. Should you have any questions in regard to this memorandum or the Quarterly Data reports, please contact George Davis, Ph.D., Assistant Director, Data Analysis & Evaluation, Medicare/Federal Health Care Assessment at 516-209-5217.