Revenue Cycle

Double trouble: DRG 312 to be reviewed prepayment and postpayment?

Medicare Update for CAHs, September 5, 2012

Following the announcement of the official start date of prepayment reviews (set to begin August 27), providers in certain areas must now brace for an added twist: DRG 312, syncope and collapse, has been listed for review by more than one auditor, and at more than one point in the payment process.

DRG 312, the first issue approved for prepayment auditing, was also announced by the MAC CIGNA Government Services (CGS) as an issue subject to complex medical review for J15 providers.

Ohio and Kentucky make up the J15 states. Ohio is also one the states in the prepayment review demonstration program. Although CMS stated in a December open door forum that claims subject to prepayment review will be off-limits from future postpayment reviews from MACs and Recovery Auditors, it still remains to be seen how this will be done. This puts providers in a difficult position, according to Nancy Beckley, MS, MBA, CHC, president, Nancy Beckley & Associates, LLC, in Milwaukee, Wis.

“If you’re in Ohio, you could potentially have your records requested by the MAC for a complex medical review or you could have your records referred to the RAC [Recovery Auditor] for a prepayment review,” she says. “This will put providers in a squeeze…the [CGS] error rate for DRG 312 is 79.9%.”

Continue reading on HCPro’s Revenue Cycle Institute.

Most Popular