Revenue Cycle

CMS identifies CERT, Recovery Auditor findings in latest quarterly compliance newsletter

Patient Access Weekly Advisor, May 23, 2012

Last month CMS released the seventh issue of its Medicare Quarterly Provider Compliance Newsletter. The newsletter contains official guidance on problematic billing errors that it has identified in the past quarter. Unlike all of the preceding releases, this issue contains comprehensive error rate testing (CERT) findings in addition to recovery auditor findings.

According to Donna Wilson, RHIA, CCS, CCDS, senior director at Compliance Concepts, Inc. in Wexford, PA., the inclusion of this new information should prove to be beneficial to providers.

“Including CERT findings is an added bonus to this priceless resource tool from Medicare,” she says. “Providers should consider adding these issues to their internal compliance monitoring. Governmental auditing agencies use CERT, RAC, PEPPER and OIG studies to detect suspicious billing practices.”

As has been the case, these documents are provided in order to propagate information on understanding claims submission problems while also providing guidance on avoiding such errors and improper billing activities moving forward. As auditing bodies continue to grow and evolve, the addition of CERT findings only makes sense.

In the report, CMS identified the following findings, with affected provider types in parentheses:

  • CERT finding: Three-day qualifying hospital stay for skilled nursing facility stays (Inpatient hospitals, SNFs)
  • CERT finding: Inpatient hospital consultations (Inpatient hospitals)
  • Recovery audit finding: Cholecystectomy-incorrect secondary diagnosis (Inpatient hospitals)
  • Recovery audit finding: Kidney and urinary tract disorder - incorrect principal diagnosis (Inpatient hospitals)
  • Recovery audit finding: Transient ischemic attack - services rendered in a medically unnecessary setting (Inpatient hospitals)
  • Recovery audit finding: Craniotomy and endovascular intracranial procedures (Inpatient hospitals)
  • Recovery audit finding: Small and large bowel procedures (Inpatient hospitals)
  • Recovery audit finding: Spinal fusion (Inpatient hospitals)

One interesting finding—and something that providers should pay attention to—is the three-day qualifying hospital stay for skilled nursing facility stays, according to William Malm, ND, RN, CMAS, senior data projects manager at Craneware, Inc., based in Edinburgh, Scotland with a US office in Atlanta.

“It is unclear what CMS will do with this information in the longer term. In 2011, CMS conducted a number of conference calls on the impact of observation at facilities and part of that discussion was on the three-day inpatient requirement for SNF admission for a covered stay,” he says. “CMS indicated that they were aware of the concern and would monitor it, and we now have CERTs stating this is an issue and that physicians are trying to admit to ensure covered stays for SNFs.  Clearly the regulation is a challenge to patients and facilities. We would hope that CMS would review this and amend the process for SNF admission to include the most appropriate settings including observation.”

As a result, providers should take a closer look at their records, says Malm.

Providers should take a look at each record in which there was a discharge to a SNF and the transfer should be reviewed by at least two people—perhaps a coder and someone from internal audits, quality review or a physician advisor—to make sure it is compliant.”

To view the most recent quarterly provider compliance newsletter, click here:

To view an archive of the quarterly compliance newsletters, click here:

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