Administrative Memos

200111

FROM: Theodore O. Will, Chief Executive Officer
DATE: Jun 27, 2001
SUBJECT: Hospital - Specific Medicare Case Review Report for Calendar Years (CYS) 1998, 1999 and 2000
IPRO CONTACTS:

Kathy Terry, Ph.D., Sr. Director of Data Analysis & Evaluation, Medicare/ Federal Health Care Assessment, Extension 261 and Alice Vallar, Sr. Director, Medicare/ Federal Health Care Assessment, Extension 423

As you are aware, IPRO performs case review of medical records in both the Medicare Payment Error Prevention Program (PEPP) and the Mandatory Review Program. The review process includes (but is not limited to) an evaluation of the documentation for medical necessity (including the appropriateness of the inpatient admission), quality of care, and coding accuracy and appropriateness. Medical records may be reviewed for any or all of the above reasons, depending on case selection criteria and case review guidelines.

In an effort to assist hospitals in identifying the volume of Medicare cases reviewed, the outcomes, and the source of fiscal denial for the reviews, IPRO has compiled and attached your hospital's CY 1998, 1999, and 2000 case review reports. These reports detail denials for admission and DRG/coding reviews and provide comparisons to your peer group and New York State (NYS) aggregated hospitals. In the following reports, review category detail is provided for admission denials and DRG coding changes. For example, you may find that 80% of your admission denied cases were due to "Category A01: the medical condition does not seem to require hospital level of care"; alternatively, 90% of DRG/coding denial cases may have been due to "Category D01: Principal diagnosis not present at admission". In addition to the review categories provided, for coding denials we have also provided the top five (5) denied DRGs to assist hospitals in "drilling-down" to their particular coding issues.

These reports reflect reviews that were complete at the time of report generation; thus reviews may still be underway for additional cases within the calendar years reported. Furthermore, these reports include cases selected for either Medicare Mandatory Review or as part of IPRO's PEPP initiatives, therefore denied cases from exempt hospitals/units are not included.

Recommendations:

• Review the hospital data provided to identify admission and/or coding denial trends across calendar years.
• Review the category outcomes provided to identify problem areas within your facility in need of additional hospital action.
• Consider concurrent review of medical records to evaluate chart documentation of both medical necessity and coding appropriateness.
• Examine medical record documentation processes in light of your hospital-specific findings.
• Incorporate the above activities/findings into your hospital's voluntary compliance plan.

Should you have any additional questions in regard to this report, please feel free to contact Dr. Kathy Terry (data questions) or Alice Vallar (Case Review questions).