CMS under its Medical Review Policy holds its contractors such as the Medicare Administrative Contractors responsible for insuring the payment of provider claims accurately with the primary mission of reducing provider billing errors. The primary goal is to pay the claims correctly the first time around. MACs review clinical documentation to prevent improper payments and choose claims for review based on many factors such as the service specific improper payment rate, data analysis and billing patterns of the provider.

In 2014 CMS began a program that combined a review of a sample of claims with education to help reduce errors in the claims submission process. CMS called this medical review strategy, Probe and Educate. Rather than focus upon all providers using a “widespread” approach to medical review, CMS is now further improving this strategy by moving from a broad Probe and Educate program to a more targeted one (Targeted Probe and Educate) by focusing upon providers with aberrant coding and billing patterns. The MACs identify providers with potential billing patterns through advanced data analytics and data mining from historic claims. Under the TPE program, MACs will select claims for services that pose the greatest financial risk to the Medicare Trust fund and/or those that have a high national error rate. Within these identified areas, the MACs will identify and focus upon review of claims from providers with the highest claims error rates or billing practices that significantly out from their peers. Let’s look and closely examine how the Medical Review improvement process.

CDI Specialists May Be Contributing to Targeted Probe and Educate Exposure

CDI specialists may be contributing to TPE scrutiny through our regular duties and responsibilities in clarifying diagnoses without even recognizing it. Remember that MACs as part of its expansive Medical Review program is charged with identifying and “probing” high risk areas that pose a threat to properly paying provider claims for services rendered. A well-known high-risk area is coding and billing of high weighted MS-DRGs as consistently identified in the OIG’s ongoing Hospital Compliance Reviews. High weighted MS-DRGs include those with one Major MCC such as:

• DRG 871- Septicemia or Severe Sepsis w/o MV> 96 Hours with MCC
• DRG 177- Respiratory Infection and Inflammation with MCC
• DRG 291- Heart Failure and Shock with MCC
• DRG 539- Osteomyelitis with MCC
• DRG 64- Intracranial Hemorrhage or Cerebral Infarction with MCC
• DRG 867- Other Infectious and Parasitic Disease Diagnoses with MCC
• DRG 682- Renal Failure with MCC

These are just a few of many DRGs that are under intense third-party payer scrutiny for potential overdocumentation and overcoding. The question CDI specialists needs to be asking and concerned for is how many DRGs coded and billed contain only one MCC. What is your facility’s CC/MCC capture rate and what is the proportion of billed DRGs that contain only one CC or MCC since a high number of billed cases will invite outside regulatory scrutiny? While I fully support the notion of clinical documentation improvement and optimization of DRGs, the CDI community must not operate within a vacuum, operate with their blinders on, and not remain cognizant of the compliance dangers and increased scrutiny we may pose our hospitals to when querying for additional targeted diagnoses. Simply put, achieving of well publicized Key Performance Indicators including CC/MCC capture rate, number of DRGs shifted to higher weighted DRGs, query response rate and case-mix increase must be qualified with the validity of the outcomes we generate beyond additional reimbursement. What is the calculated compliance ratio we expose our facilities to calculated by computing the dollar amount of claims that may be subject to outside third-party payer review compared to the total dollar number of claims billed in any given time. This compliance ratio should be calculated monthly and reported as one of the defined metrics followed and monitored by CDI leadership and hospital administration.

CDI- Necessity of Total Picture Viewpoint

CDI specialists focusing upon the total picture in conducting and carrying out assigned duties and responsibilities will materially reduce the unnecessary costly avoidable compliance risk we subject our facilities through strikingly aberrant patterns of coding and billing. The best approach to minimizing the risk of aberrant patterns of billing is to incorporate a holistic approach to clinical documentation improvement, fulfilling the need for achieving solid complete documentation that communicates fully informed coordinated care right from the start beginning in the Emergency Department, following the patient through admission, progression of care and culminating in discharge. How do we accomplish this? First, we must begin to expand our breadth and depth of knowledge in standards and principles of documentation that can be shared with our physicians in an action oriented way. Stay tuned for my next blog on the approach CDI should be taking to acquire this knowledge.

Resource

CMS Medical Review & Education

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/