Health Information Management

Identify top MIC targets

HIM-HIPAA Insider, December 15, 2009

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What will Medicaid Integrity Contractor auditors be looking for? Here are some possible issues, courtesy of James G. Sheehan, the Medicaid Inspector General for New York:
  • Dead or alive. This pertains to whether the patient was alive when treatment was allegedly rendered. “This may seem obvious, but in a number of states, their system controls process usually takes three to four months to identify a patient as deceased,” said Sheehan. “That’s a pretty straightforward issue for the MIC to focus on.” MICs also may investigate whether physicians were deceased at the time they allegedly wrote an order, he said.
  • Inpatient at time of ambulatory service. MICs will look for patients who were inpatients at the hospital at the time they received home healthcare or were transported by ambulance.
  • Hysterectomy on males. This example highlights inconsistent coding, said Sheehan. “There are computerized techniques for identifying things that are impossible or highly unlikely. Hysterectomy on a male is one of them,” he said.
  • Debridement requiring actual cutting. MICs will review regulations, statutes, and coding guidance, such as Coding Clinic, to determine whether documentation justifies reporting debridement.
  • Heart failure and shock. MICs will determine whether heart failure and shock meet InterQual criteria for inpatient care.
  • Ambulatory surgery with no complications to justify inpatient stay. Commonwealth Fund recently ranked states on this issue and found that some are better than others, said Sheehan. Learn your state’s ranking to determine whether this might be an problem area, he said.
  • DRG assignment. Consider a code pair with fairly clear criteria, such as temporary paralysis and more permanent paralysis.Determine which code pair your facility reports more often. If your facility is heavily weighted toward the more expensive alternative and many other hospitals are weighted the other way, you might want to take a good hard look, said Sheehan.
  • Observation beds. This is always a popular issue because Medicaid rules differ by state and also differ from Medicare in most states, explained Sheehan.
Editor’s note: For more tips, view the December 2009 issue of Briefings on Coding Compliance Strategies.

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