Health Information Management

News: NHIC Inc., finds one-day inpatient stays have high denial rates

CDI Strategies, May 10, 2012

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“This claim was denied after review and it was determined that the documentation did not support the need for an inpatient level of care.”

NHIC Inc., the Medicare Administrative Contractor (MAC) for jurisdiction 14 (which includes Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) issued that statement when it denied nearly 2,000 claims related to inpatient one-day stays in acute care hospitals and Critical Access Hospitals from January 2011 through February of 2012, according to an April 5 report.
NHIC Inc., specifically looked at diagnosis codes for heart failure, unspecified disorders of the back, chest pain, and symptoms involving the abdomen and pelvis region, as well as generic one-day stays with no principal diagnosis listed for claim selection.
The agency identified two key issues:
  1. “Documentation did not support inpatient criteria for severity of illness and intensity of services provided.
  2.  Documentation did not reflect the patient had a change in clinical status and the patient was switched from an outpatient observation status to an inpatient status after being in the hospital for greater than 24 hours.”
In its findings, NHIC Inc., reminds providers to “clearly document all contributing factors” that affected his/her decision to admit the patient as an inpatient.
“Factors such as co-morbidities, surgical history, current medical needs (including medications), abnormal vital signs, presenting or persistent symptoms, availability of diagnostic procedures, and the safety of the patient should all be taken into consideration during the provider’s decision making period. It is also critical that these decisions be clearly documented in the medical record,” the report states.

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