Cahaba GBA Medical Review Update October 2010

on Thursday, 28 October 2010. All News Items

Upcoming Reviews

Inpatient - Cahaba GBA will soon be conducting a widespread probe review of DRG 064, Intracranial Hemorrhage or Cerebral Infarction with MCC, for bill type 11X. This will be a full claim review and claims will be reviewed for medical necessity, such as compliance with CMS guidelines, contractor LCDs, correct billing and coding.

Outpatient – Based on the outcome of a probe review, a pre-pay targeted review will be initiated for Foot Care, CPT 11055-11057, 11719-11721 and G0127, for type of bill 13X. See summary of the results of the probe review below.

Inpatient Probe Review Results

Cahaba GBA, the Part A MAC for Alabama, Georgia, and Tennessee, recently completed three widespread probe reviews for Inpatient Short-term Hospitals, type of bill 11X. The reviews were for:

  • DRG 690 Kidney and Urinary Tract Infections without MCC (Tennessee only),
  • DRG 641 Nutritional and Miscellaneous Metabolic Disorders without MCC, and
  • Diagnosis Code 428.23 Acute on Chronic Systolic Heart Failure

Based on the outcome of these reviews, no further action will be taken at this time, although Cahaba will continue to monitor utilization through data analysis to determine if further reviews will be necessary in the future. Cahaba used McKesson InterQual criteria for the medical review decisions and reminds providers that documentation should validate that Severity of Illness and Intensity of Service criteria are met. The findings for all 3 reviews are basically the same. Issues include:

  1. Discharge disposition errors
  2. Incomplete medical records, specifically missing physician signatures from pertinent documents. The attending physician must sign any document dictated by a physician “extender.”
  3. The principal diagnosis and all MCCs / CCs should appear in the first nine fields on the UB.
  4. Documentation should include Case Management, UR, and Social Services notes in order to evaluate adequacy of discharge planning and appropriate discharge disposition.
  5. Leading queries are not appropriate. CMS has approved “AHIMA Practice Brief for Effective Queries” as a guideline for this issue.
  6. Coding errors regarding: abnormal test results whose significance was not documented by the physician; the use of adverse effects versus poisoning codes; and coding a UTI in the presence of a Foley catheter.

Outpatient Probe Review Results

Cahaba GBA recently completed a widespread prepay probe review of CPT 11055-11057, 11719-11721 and G0127, Foot Care, for type of bill 13X. Based on the outcome of this review, a pre-pay targeted review will be initiated.

In addition to the lack of timely submission of requested documentation, the findings from the review indicated that documentation did not:

  • Include a physician’s signature to validate intent for the service provided,
  • Support that the patient had a systemic disease of sufficient severity for skilled services.
  • Support evidence of indications (class findings) consistent with the diagnosis for routine foot care*,
  • Support coverage for the treatment of mycotic nails*.

*See the complete Results Notification for details of the documentation required to support services for routine foot care and treatment of mycotic nails.

All the Probe Review results notifications and announcements can be found on the Part A What’s New page of the Cahaba GBA website at

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