Case Management

QIO audits reaching back farther than expected

Case Management Insider, December 29, 2015

Bad news if your organization is still a little shaky on 2-midnight rule compliance. Quality Improvement Organization (QIO) short-stay audits started October 1 and auditors are looking for records as far back as May.

Many people thought that their reviews would only look at records from October 1 forward, so this has been a shock to some organizations, says Ronald Hirsch, MD, FACP, CHCQM, vice president, Regulations and Education Group for AccretivePAS in Chicago.

“It caught everybody off guard. No one expected them to audit any earlier than October 1,” he says. “But audits are starting hot and heavy and it’s important for organizations to understand that it’s permitted and that the QIOs can request charts going back six months.”

QIOs have also been requesting charts for inpatient-only surgeries and they weren’t supposed to, says Hirsch. Auditors apparently can’t tell these cases are inpatient-only because CPT® codes aren’t listed on claims. The auditor is supposed to look at the ICD codes on the case and translate them to figure out if it is inpatient-only, he says. If it is, they know not to request the chart. But it appears that’s not happening. Auditors aren’t translating the codes and instead are just requesting charts, which makes a lot more work for the hospital, says Hirsch.

So the bottom line is if you’re not ready for short-stay audits or have questions about compliance, now’s the time to get ready. To read more about auditing trends, and to get advice from Hirsch and other experts on how to get prepared, check out the February 2015 issue of Case Management Monthly.


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