Health Information Management

Healthcare News: MLN Matters article addresses recovery auditor findings regarding renal and urinary tract disorders

JustCoding News: Inpatient, March 14, 2012

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Special Edition MLN Matters article #SE1210, “Recovery Auditors Findings Resulting from Medical Necessity Reviews of Renal and Urinary Tract Disorders,” outlines recovery auditor findings upon completion of medical necessity reviews. In the article, which addresses documentation and billing for inpatients, recovery auditors concluded that providers had been admitting patients even for clinical situations for which outpatient observation services would have been appropriate.

The article provides the following example:

A 69-year-old female presented for an elective outpatient cystoscopy, excision of extruded sling, and insertion of Aris suburethral sling for recurrent urinary incontinence and was admitted and billed as an acute inpatient after the procedure. The patient’s past medical history was significant for recurrent type 1 stress urinary incontinence with possible mild intrinsic sphincter dysfunction, sling extrusion beneath bladder base, mild pelvic relaxation, hypothyroidism, obesity, and recent urinary tract infection.

Past medical history and the pre-existing conditions were stable. The medical record did not document any exacerbation of pre-existing conditions or post-operative complications that would make the acute inpatient admission medically necessary.

In this case, the MLN Matters article explains, there was no clinical evidence to support a stay that exceeds 24 hours even if the surgeon wanted to watch the patient post-surgery.

The article continues:

Medicare states that procedures that require less than 24 hours in the hospital should be considered outpatient. Moreover, the patient could also have been placed in observation if the physician was concerned about sending her home during the usual recovery period. If the patient’s clinical status then changed, the patient could have been admitted as an inpatient at any time.

Access Special Edition MLN Matters article #SE1210 to learn more about billing, and for additional guidance regarding how providers can avoid this problem.



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