UR Alert Newsletter

UR Alert is a bi-monthly newsletter created for physicians to assist in reducing inpatient admission necessity denials. To be notified of new issues as they become available, please subscribe to our announcement list.

Current Issue

#9: Readmissions in the News - (PDF)
In this issue: Readmissions in the news: An excerpt from The Commonwealth Fund's Quality Matters, and CMS readmission PEPPER target area changes: An excerpt from the PEPPER users guide.

Previous Issues

#8: Top Denied DRGs for failure to meet CMS inpatient admission necessity criteria - (PDF) IPRO reviews select inpatient prospective payment system (PPS) medical records for inpatient admission necessity as well as DRG/coding accuracy. On a bi monthly basis we provide denied DRGs along with case examples of unnecessary inpatient remissions. In this issue: Top Denied DRGs for failure to meet CMS inpatient admission necessity
#7: Present on Admission: New Data Reporting Requirement - (PDF) In this issue: Accurate and complete physician documentation has always been essential to providing optimum care to the patient and allowing for correct coding and reimbursement. In this issue: Present on Admission: New Data Reporting Requirement.
#6: DRG 174 (Gastro Intestinal Hemorrhage with CC) and DRG 182 (Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders age > 17 with CC) - (PDF)
In this issue: Hospital Payment Monitoring Program (HPMP) project to reduce payment errors in Medicare claims data in New York State (NYS) hospitals. One purpose of the project is to assist hospitals in reducing inappropriate admissions for DRG 174 (GI Hemorrhage with Complication Comorbidity CC) and DRG 182 (Esophagitis, Gastroenteritis and Miscellaneous Digestive Disorders age >17 with CC).

#5: DRG 463: Signs and Symptoms with Complications/Comorbidities (PDF)
Determining when a sign and symptom or definitive diagnosis should be coded can be challenging. The varying rules for coding a symptom versus coding a definitive diagnosis should be applied. In this issue: Examples of cases, reviewed by IPRO that were originally billed by the provider to DRG 463.

#4: DRG 034: Other Disorders of Nervous System with CC (PDF)
DRG 034, Other Disorders of Nervous System with CC, encompasses a wide array of neurological diagnoses involving both the central as well a peripheral nervous system, congenital as well as acquired. There are about 2000 DRG 034 Medicare inpatient discharges each year with a portion of these admissions denied. In this issue: Examples of cases, reviewed by IPRO, that were originally billed by the provider to DRG 034.

#3: DRG 012: Degenerative Nervous System Disorders (PDF)
DRG 012, Degenerative Nervous System Disorders, includes a number of chronic progressive conditions such as Alzheimer's disease and Parkinson's disease. While these conditions can result in significant medical issues and require extensive treatment, frequently the issues are chronic and do not require acute inpatient hospitalization. In this issue: Examples of cases, reviewed by IPRO, that were originally billed by the provider to DRG 012.

#2: DRG 243: Medical Back Problems result in high inpatient admission necessity denials - (PDF)
DRG 243 - medical back problems includes a number of diagnoses that can at times require acute inpatient care but frequently the patient can be treated as an out-patient. In this issue: Examples of patients who were discharged with DRG 243; however, review of the medical record did not support the need for admission.

#1: UR Alert - Introductory Issue - (PDF)
Hospitals have requested additional information from IPRO to assist in the reduction of payment errors associated with admission necessity denials. In this issue: Insight into the reasons for the high denial rate and case examples for clarity.