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CMS Identifies Recovery Auditor Findings

 |  By jcarroll@hcpro.com  
   May 31, 2012

 

For the first time since it began publishing a quarterly Medicare compliance newsletter, the Centers for Medicare & Medicaid Services has released CERT findings on problematic billing errors.

Unlike all of the preceding releases, the April issue of the Medicare Quarterly Provider Compliance Newsletter, CMS's seventh issue, contains comprehensive error rate testing (CERT) findings in addition to recovery auditor findings.

Find the strengths of your organization and develop a strategic marketing plan that promotes strong service lines to new and existing patients. According to Donna Wilson, RHIA, CCS, CCDS, senior director at Compliance Concepts in Wexford, PA., the inclusion of this new information should prove beneficial to providers.

"Including CERT findings is an added bonus to this priceless resource tool from Medicare," she said. "Providers should consider adding these issues to their internal compliance monitoring. Governmental auditing agencies use CERT, RAC, PEPPER, and OIG studies to detect suspicious billing practices."

 

As has been the case, these documents are provided in order to propagate information on understanding claims submission problems while also providing guidance on avoiding such errors and improper billing activities moving forward. As auditing bodies continue to grow and evolve, the addition of CERT findings only makes sense.

In the report, CMS identified the following findings. affected provider types are in parentheses:

CERT findings

  • Three-day qualifying hospital stay for skilled nursing facility stays (Inpatient hospitals, SNFs)
  • Inpatient hospital consultations (Inpatient hospitals)

Recovery audit findings

  • Cholecystectomy-incorrect secondary diagnosis (Inpatient hospitals)
  • Kidney and urinary tract disorder - incorrect principal diagnosis (Inpatient hospitals)
  • Transient ischemic attack - services rendered in a medically unnecessary setting (Inpatient hospitals)
  • Craniotomy and endovascular intracranial procedures (Inpatient hospitals)
  • Small and large bowel procedures (Inpatient hospitals)
  • Spinal fusion (Inpatient hospitals)

One finding providers should take note of is the three-day qualifying hospital stay required for skilled nursing facilities, according to William Malm, ND, RN, CMAS, senior data projects manager at Craneware.

"It is unclear what CMS will do with this information in the longer term.  In 2011, CMS conducted a number of conference calls on the impact of observation at facilities and part of that discussion was on the three-day inpatient requirement for SNF admission for a covered stay," he said.

"CMS indicated that they were aware of the concern and would monitor it, and we now have CERTs stating this is an issue and that physicians are trying to admit to ensure covered stays for SNFs.  Clearly the regulation is a challenge to patients and facilities. We would hope that CMS would review this and amend the process for SNF admission to include the most appropriate settings including observation."

As a result, providers should take a closer look at their records, says Malm.

"Providers should take a look at each record in which there was a discharge to a SNF and the transfer should be reviewed by at least two people—perhaps a coder and someone from internal audits, quality review or a physician advisor—to make sure it is compliant."

James Carroll is associate editor for the HCPro Revenue Cycle Institute.

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