Results of Cahaba GBA’s Probe Review of Inpatient DRGs

on Wednesday, 01 April 2009. All News Items

Cahaba GBA has recently conducted a prepay probe review of Inpatient DRGs 313 (Chest Pain), 552 (Medical Back Problems without MCC) and 690 (Kidney and Urinary Tract Infections without MCC).  The review focused on coding accuracy and medical necessity for acute inpatient hospitalization.  On March 30, Cahaba published a summary of the results of this probe review on their website.  Link to the complete article -

Findings of the review indicated that medical necessity was not established for Acute Inpatient Admission.  Cahaba bases medical review decisions on The 2008 InterQual Level of Care Criteria for Acute Care and the documentation submitted did not meet the inpatient admission criteria.  Most patients were admitted for evaluation and testing after being evaluated in the emergency room.  The documentation indicated that care could have been appropriately managed in a less intense setting.  Cahaba encourages providers to ensure that documentation submitted validates that the patient met severity of illness and intensity of service for Acute Inpatient Hospitalization.

Another finding of the review was that the patient status billed did not match the physician’s admission order.  The physician admitted the patient to an observation bed, but the claim was billed as inpatient.

The DRG accuracy rate for this review was 90-97%.  Issues identified based on the documentation submitted were incorrect discharge dispositions assigned and incomplete records submitted.  Also some documents were not authenticated which could result in coding changes if changes are made to the documents when signed.

Based on the results of the review, Cahaba GBA plans to initiate a prepay targeted review for DRGs 552 (Medical Back Problems without MCC) and 690 (Kidney and Urinary Tract Infections without MCC).  You may want to check the MMP website for our article on monitoring Medicare Medical Reviews.

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