Net Revenue Matters

Integrated Revenue Management • 2714 Loker Avenue W., Ste 200, Carlsbad, CA • Phone: (760) 476.0077 • www.IRMinconline.com

July 2010

Signature Guidelines for Medical Review Purposes 1

Does this Procedure Require Pre-Certification? 3

Paracentesis and Abdominal Drains: Confused on the Coding? 3

Is Your Pain Management Coding in Pain? 4

AHIMA on CDI and Physician Queries 6

Client Corner 8

RMetrics Trend Tracker 8

Know Your Managed Care Contract Language 8

What’s In a Reason? 9

Welcome Little Ones! 10

Best Practice Forum 10

Inside this issue:

Welcome to the July edition of Net Revenue Matters, a publication of Integrated Revenue Management, Inc. We hope that in this issue you’ll find several topics of interest.

We extend happy vacation wishes to Executive Vice President Jack Duffy. Please look for news from him next month.

In the meantime, we hope that you’ll appreciate the information presented in the many articles included.

Finally, please note our client corner and upcoming events. We don’t want you to miss anything!

Signature Guidelines for Medical Review PurposesThe Centers for Medicare and Medicaid Services (CMS) issued CR 6698 to spell out how Medicare claims review contractors such as MACs, CERT contractors, RACs, and ZPICS review claims and med-ical documentation. CR 6698 also adds new rules for signatures as well as language for E-Prescribing.

All signature requirements in CR 6698 are effective retroactively for Comprehensive Error Rate Testing (CERT) for the November 2010 report period.

“For medical review pur-poses, Medicare requires that services which are

provided and/or ordered be authenticated by the

‘author.’”For medical review purposes, Medi-care requires that services which are provided and/or ordered be authenticated by the “author.” The

method used must be a handwrit-ten signature or an electronic sig-nature. Stamp signatures are not acceptable.

There are some exceptions to this rule:

Exception one: Facsimiles of original written or electronic signatures are acceptable for the certifications for terminal illness for hospice.

Exception two: There are some circumstances in which an order does not need to be signed. An example of this is an order for a clinical diagnostic test. However, if the order is unsigned, there must be documentation by the treating physician, such as a progress note, that s/he intended that the test be performed. This documentation must be authen-ticated by the author through a handwritten or electronic signature.

Exception three: Other regula-tions and CMS instructions regarding signatures (such as timeliness standards for particu-lar benefits) take precedence. For medical review purposes, if the relevant regulation, NCD,

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LCD, and CMS manuals are silent on whether the signature be legible or present and the signa-ture is illegible/missing, the reviewer shall follow the following guidelines to determine the iden-tity and credentials of the individual signing the document:

If there are reasons for denial unrelated to signature requirements, the reviewer need not proceed to signature authentication. If the cri-teria in the relevant Medicare policy cannot be met but for a key piece of medical documen-tation which contains a missing or illegible signature, the reviewer shall proceed to the signature assessment.

In cases where the relevant regulation, MCD, LCD, and CMS manuals have specific signature require-ments, those signature requirements take precedence.

“Do not add late signatures to the medical record...”

Do not add late signatures to the medical record, if a document is unsigned, use the signature authentica-tion process.

A handwritten signature is a mark or sign by an indi-vidual on a document to signify knowledge, approval, acceptance, or obligation and notes the following:

If the signature is illegible, the review contractors shall consider evidence in a signature log or attes-tation statement to determine the identity of the author of a medical record entry.

If the signature is missing from an order, the con-tracted reviewers shall disregard the order during the review of the claim.

If the signature is missing from any other medi-cal documentation, the contracted reviewers shall accept a signature attestation from the author of the medical record entry.

The following are the signature requirements that the review contractors will apply:

Other regulations and CMS instructions regarding signatures (such as timeliness standards for par-ticular benefits) take precedence.

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Definition of a handwritten signature is a mark or sign by an individual on a document to signify knowledge, approval, acceptance, or obligation.

For medical review purposes, if the relevant regu-lation, NCD, LCD, or other CMS manuals are silent on whether the signature must be dated, the reviewer shall review to ensure that the docu-mentation contains enough information for the reviewer to determine the date on which the ser-vice was performed/ordered.

Definition of a Signature Log: providers will sometimes include, in the documentation they submit, a signature log that identifies the author associated with initials or an illegible signature. The signature log might be included on the actual page where the initials or illegible signature are used or might be a separate document. Reviewers will consider all submitted signature logs regard-less of the date they were created.

Definition of an Attestation Statement: in order for an attestation statement to be considered valid for Medicare medical review purposes, the state-ment must be signed and dated by the author of the medical record entry and contain the appro-priate beneficiary information.

CMS does not require or instruct providers to use a certain form or format for the attestation statement.

Claims reviewers will not consider attestation statements where there is no associated medi-cal record entry or from someone other than the author of the medical record entry in question. Even in cases where two individuals are in the same group, one may not sign for the other in medical record entries or attestation statements.

If a signature is missing from an order, claims reviewers will disregard the order during the review of the claim.

Reviewers will consider all attestations that meet the guidelines regardless of the date the attestation was created, except in those cases where the regu-lations or policy indicate that a signature must be in place prior to a given event or a given date.

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The following are the signature guidelines in the manual revision attachment of CR 6698:

In the situations where the guidelines indicate “signature requirements met,” the reviewer will consider the entry.In situations where the guidelines indicate “contact provider and ask a non-standard fol-low up question,” the reviewer will contact the person or organization that billed the claim and ask them if they would like to submit an attestation statement or signature log within 20 calendar days. The 20-day timeframe begins once the contractor makes an actual phone contact with the provider or on the date the request letter is received at the post office. (Reviewers will not contact the provider if the claim should be denied for reasons unre-lated to the signature requirement.)In the situations where the guidelines indi-cate “signature requirements NOT met,” the reviewer will disregard the entry and will make the claims review determination using only the other submitted documentation.

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Does this Procedure Require Pre-Certification?Cigna’s new Pre-Cert Tool Effective Q2 2010

Do you find yourself asking this question and using the phone to get the answer? Online Pre-Certifica-tion can quickly help answer this question about your patients in medical plans administered or insured by Cigna.

When you use the Cigna Online Pre-Certification tool, you will be asked some questions so as to iden-tify your patient. You can then request whether a spe-cific service requires pre-certification.

If the service requires pre-certification, a single but-ton allows you to submit your request. You’ll get an immediate response to your pre-certification request; some requests receive immediate online approval. You can print and keep this response in your patient’s file for reference. Also, you can use online pre-cer-tification to check the status of any pre-certification

Paracentesis and Abdominal Drains: Confused on the Coding?Below are hints that could help in your code assignments.

While there has been quite a bit of confusion regard-ing which code to use for guidance, there also has been confusion regarding when to use the 49081 “subsequent” code. Below is an information excerpt from the coding clinic that explains “subsequent” and when it is appropriate to use code 49081, as opposed to 49080.

Paracentesis, explanation of the descriptor ‘subsequent,’ Cod-ing Clinic for HCPCS - First Quarter 2010 Page: 5.

Question #9: Our facility would like clarification regarding the use of the term “subsequent” in the code descriptor of CPT code 49081, Peritoneocen-tesis, abdominal paracentesis, or peritoneal lavage (diagnostic or therapeutic); subsequent. We have many patients with recurrent ascites that present to our facility for abdominal paracentesis every few months. Is CPT code 49081 intended to be used for any subsequent paracentesis regardless of the time-frame of the initial paracentesis? Or does the use of the term “subsequent” apply to any paracentesis per-formed after an initial paracentesis during the same encounter?

request, whether it was submitted online, by phone or fax.

The most common way to access pre-certification information online is the Cigna for Health Care Pro-fessionals website (www.cignaforhcp.com). The site offers secure and easy access to real-time transactions such as pre-certification, claim status, and eligibility and benefits. Other resources and information on Cigna policies and procedures are also available.

If you are registered on the Cigna for Health Care Professionals website as a Primary Administrator, you have automatic access to the online pre-certification feature. Simply log in to www.cignaforhcp.com and select View and Submit Pre-certification Requests.

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Answer: No. The use of term “subsequent” refers to a paracentesis performed on the same day encounter (short timeframe). If the patient leaves the facility and comes back the next day, this would be considered an initial encounter.

Code assignment can also be confusing for the radio-logical guidance.

If the physician is performing a needle placement with ultrasound, the code choice would be 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation.

77012 is assigned if the physician is performing nee-dle placement for biopsy, aspiration, injection, local-ization device for computed tomography guidance, or radiological supervision and interpretation.

However; if the physician is using radiological guid-ance via fluoroscopy, ultrasound, or computed tomography for percutaneous drainage (eg. abscess, specimen collection), with the placement of a cath-eter, 75989 should be the code choice for radiological supervision and interpretation.

Is Your Pain Management Coding in Pain?As reimbursement for complex pain management continues to decrease, your coding must drive accu-rate reimbursement – netting you a fair payment without creating compliance difficulties.

Coding and sequencing for pain management ser-vices depend on the physician documentation in the medical record and application of the ICD-9-CM Official Coding Guidelines. New procedures or new technology generally benefit patients, but can further complicate pain management coding. So, you need to investigate any coding advice you receive from the company selling the new technology.

In addition to the 2010 CPT Coding Manual guide-lines and CMS’ national coverage determinations, you should review any local coverage determinations your MAC or FI has issued.

What to Look for When Coding

As with other types of coding, watch out for upcod-ing of procedure or diagnosis codes for pain man-agement. If a physician performs pain management procedures too often or gives too many injections, your facility could face a compliance risk with Medi-care and other payers.

Always check CPT codes for unbundling in the NCCI edits whenever you’re billing multiple pro-cedures. CMS posts quarterly updates to the NCCI edits on its website.

Ensure that you correctly sequence CPT codes on claim forms from the highest to lowest value that the payer reimburses, and never list an add-on code for a pain management procedure before the initial code for the initial level. Also, make sure you don’t list add-on codes by themselves on a claim without the code for the initial level.

“As reimbursement for complex pain management continues to decrease,

your coding must drive accurate reimbursement...”

Verify medical necessity for pain management proce-dures. If there’s a lack of medical necessity with pain management injections, that can be a definite compli-ance issue with Medicare and some other payers.

Make sure the operation (OP) notes correctly list where the physician performed the procedure. Was it in your facility or in the physician’s office? Reporting the wrong place of service could land you in trouble with CMS or another payer. Also make sure physi-cians are not using canned OP notes to document pain management procedures. Canned OP notes are used for routine procedures that are the same from patient to patient, where every report looks identical.

Correctly Code Bilateral Procedures

Bilateral procedures can also be a challenge to coders, especially when using modifiers with the procedure codes. Most pain management CPT codes represent unilateral procedures (e.g., CPT code 64479 [trans-

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foraminal ESI]), but not all (e.g., 22526 [percutane-ous intradiscal electrothermal annuloplasty, unilateral or bilateral including fluoroscopic guidance; single level]). Check the code description to see whether a code is inherently bilateral.

“Bilateral procedures can also be a challenge to coders, especially when

using modifiers with the procedure codes.”

You would append modifier -50 (bilateral procedure) in some cases and the -RT or -LT modifiers in others. Just don’t use modifier -50 and the -RT or -LT modi-fiers on the same line item billed.

Consider these methods for billing bilateral procedures:

Bill a single line item with no modifier and two or more units in the units column on the claim form. If you do that, remember to double the fee, but we do not recommend this. Payers frequently make mistakes with units and can underpay you.

Bill the same code as two separate line items with the -RT anatomic modifier on one code and the -LT anatomic modifier on the other code.

Bill a bilateral procedure as two line items with no modifier on the first code and a -50 modifier on the second code.

Bill a single line item listing the code once with a -50 modifier with double the fee.

Bill the same code as two line items with no modifiers. We advise against this billing method because you will likely end up with a denial for a duplicate.

Don’t Unbundle Procedures

Some codes include bundled services, for which payers provide one overall payment. Unbundling is breaking out these individual parts of a procedure and billing for them separately. Unbundling often leads to overpayment, which could once again result in problems with CMS.

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To avoid unbundling, check each procedure code billed with every other code in the NCCI edits. For-tunately, there’s not a lot of unbundling with pain management procedures.

In some cases, even though one code is unbundled from another, you can bill it anyway using modifier -59 (distinct procedural service) as long as it was per-formed at a different area or at a different spinal level. Be sure to choose the correct modifier.

Although -RT and -LT are the most common modi-fiers used for pain management, coders may need to consider other modifiers. Consider some potential scenarios related to the percutaneous implantation of a neurostimulator electrode array (63650).

If the procedure was terminated before the admin-istration of anesthesia, append modifier -73. The facility must have expended significant resources, which usually means the patient is prepared for sur-gery, has an IV, and has been given preoperative pain medication.

The trick to modifier -73 is that the patient must be in the OR or procedure room when the procedure is called off, and it’s not covered by Medicare if the procedure is called off in the preop holding area. If modifier -73 is used, the facility reimbursement is 50% of the allowable payment.

However, if anesthesia was administered before the procedure was terminated, use modifier -74. In this case, Medicare pays 100% of the allowable. The medi-cal record needs very extensive and complete documen-tation to use modifiers -73 and -74. Consider using a check off sheet or template for documentation.

Modifier -78 is used when a patient is returned to the OR for a related procedure during the global period. Facility global periods are 24 hours from the time the procedure performed started. An example of when modifier -78 would be used is when the patient goes to the recovery area and has a postoperative hemor-rhage and must be taken back to the OR.

Use modifier -52 when a procedure was partially reduced or eliminated at the physician’s discretion.

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AHIMA on CDI and Physician QueriesCenters for Medicare and Medicaid (CMS) and their Recovery Audit Contractors (RAC) have been going full throttle with claim review and by now many hos-pitals have received their first demand letters. As the

RAC review has moved from automated reviews to complex MS-DRG validation, RAC have begun to request not only medical records but physician query details, as well. It has been stated that RAC may require physician queries to be recorded into medi- cal records.

“It has been stated that RAC may require physician queries to be recorded into medical records.”

Due to this push for physician query documenta-tion, this article highlights an outline published by The American Health Information Management Association (AHIMA) called “Guidance for Clinical Documentation Improvement Programs,” Journal of AHIMA 81, no.5 that address both Clinical Docu-mentation Improvement (CDI) and the physician query process. AHIMA also provides tips to avoid leading questioning during physician queries. This is especially important because RAC want to make sure that billing and coding are not using queries to increase revenue through “leading questions,” but rather using appropriate queries to determine the services rendered to ensure integrity of coding on the UB-04.

Benefits of CDI

When unclear documentation results in improperly assigned MS-DRGs, it puts facilities at risk for RAC denials. Clinical documentation improvement (CDI) can minimize these financial risks by producing the most accurate and comprehensive medical records that fully support the condition of the patient and the services rendered.

CDI focuses on improving the quality of clinical documentation regardless of its impact on revenue. Arguably, the most vital role of a CDI program is to facilitate an accurate representation of healthcare services through complete and accurate reporting of diagnoses and procedures. A CDI specialist identifies terms and phrases that a physician uses that may lead to the assignment of imprecise or non-specific codes. CDI specialists are a liaison between physicians and their clinical language and the coders and ICD-9 cod-ing language.

Most of the time when modifier -52 is used, Medi-care reimburses 50% of the allowable payment.

When using multiple modifiers on CPT codes, append those modifiers that affect payment before those which are informational only.

Don’t Forget the Diagnosis Codes

ICD-9-CM diagnosis codes are very important for pain management because they support the medical necessity of the procedures performed and billed.

Avoid using unspecific codes. For example, instead of coding 724.2 (lumbago), look for a more spe-cific code that supports the medical necessity of the complex pain management procedure. These could include:

Stenosis, a narrowing or stricture of the spinal canal.

Post-laminectomy syndrome, pain following previous back surgery, also known as failed back syndrome.

Degenerative disk disease.

Displaced or herniated disks.

Spondylosis, a degenerative change of the vertebral joint from osteoarthritis, with or without myelopathy. Most of the pain management procedures performed on an outpatient basis at ambulatory surgery centers and hospitals are going to be for patients without myelopathy.

Occasionally you must use an unlisted CPT code when you cannot find an exact code. Unlisted codes require a paper claim with a hard copy to the payer.

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CDI is heavily connected to RAC processes. When the documentation in the record does not match the services administered, the provider may see a RAC denial that could have been prevented with a sound CDI program.

For example, if a physician defines Urosepsis as an overwhelming infection that starts in the patient’s urinary system and indicates a very sick patient, and a coder thinks Urosepsis is a simple urinary tract infec-tion, services rendered will not match the coding. Thus, RAC will deny the claim due to an incorrect MS-DRG.

AHIMA suggests that CDI must be governed by written policies and procedures. These policies and procedures should be developed with the assistance of the departments affected by clinical documentation, including compliance, case management, and HIM.

The AHIMA article states, “when it comes to docu-menting clinical encounters, providers are expected to provide legible, complete, clear, consistent, precise, and reliable documentation of a patient’s health his-tory, present illness, and course of treatment. This documentation includes observations, evidence of medical decision-making in determining a diagnosis, treatment plan, and outcomes of all tests, procedures, and treatments.” Similar to this statement, CMS now requires that documentation be legible or they have the right to deny the claim.

Using Queries to Ensure Billing Integrity

A query is a routine communication and education tool used to advocate complete and compliant docu-mentation. Typical situations addressed by a query include presenting clinical indicators of an undocu-mented condition, requesting further specificity or the degree of severity of a documented condition, clarifying a potential cause and effect relationship, and addressing present on admission issues. The com-munication can include verbal and written queries, whether concurrent or retrospective.

One of the more difficult issues with written queries is timeliness and provider interpretation of the query. The timing of a query is important, as providers may be reluctant to document a condition that has already

been treated and no longer requires immediate treat-ment (e.g., acute renal failure and asthma exacerba-tion). Often providers disagree with a query if they do not understand the issue posed.

Leading versus Non-Leading Queries

Queries may take many forms, but they are never intended to lead the provider to one desired outcome. The following examples emphasize the difference between leading and non-leading queries:

Clarification for Specificity of a Diagnosis

Obtunded patient admitted with three-day history of nausea and vomiting. CXR revealed right lower lobe (RLL) pneumonia. Clindamycin ordered.

Leading query: Is the patient’s pneumonia due to aspiration?

Nonleading query: Can the etiology of the patient’s pneumonia be further specified? It is noted in the admitting history and physical exam-ination (H&P) that this obtunded patient had a history of nausea and vomiting prior to admission to the hospital and is treated with clindamycin for RLL pneumonia. Based on the above, can the eti-ology of the pneumonia be further specified? If so, please document the type/etiology of the pneumo-nia in the progress notes.

Clarification of a Missing or Vague Diagnosis

Patient admitted with COPD exacerbation. H&P notes respiratory distress. Oxygen saturation on admission is 86 percent on room air, respiratory rate of 28, and arterial blood gas (ABG) results of pO² 45, pCO² 50, pH 7.34, with Bipap and oxygen ordered.

Leading query: The patient has abnormal ABGs and your documentation reflects respiratory dis-tress. If you mean acute respiratory failure, please document on this form or the progress note.

Non-leading query: Can your documentation of respiratory distress be further clarified?

Acute respiratory insufficiency: ______________

Acute respiratory failure: ___________________

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C l i e n t C o r n e r

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Know Your Managed Care Contract LanguageSatilla Regional Medical Center recently received a 50% reduction in reimbursement on a managed care inpatient claim due to late notification of admis-sion by the facility. Ann Yarbrough, Managed Care Analyst, found language in the related managed care contract to the effect of “denial will be reversed if the

RMetrics™ Trend TrackerAuditors should know what the RMetrics Trend Tracker™ represents and all should be using this data-base whenever a trend occurs. So what determines a trend? A trend is an observance of a discrepancy that occurs three or more times. Once identified,

Acute on chronic respiratory failure: __________

Some other cause of respiratory distress: _______

Undetermined:___________________________

Not applicable:___________________________

Whether you utilize verbal or written queries, the main thing is to document the processes. However, with verbal queries the what, where, and how should be documented in policies and procedures.

Retention of the query varies by healthcare organiza-tion. First, an organization must determine if the query will be part of the health record. If the query is not part of the health record, then the organization must decide if the query is to be kept as part of the business record or if only the outcome of the query will be maintained in a database.

With the current culture of governmental audits (e.g., RACs and MACs), it is helpful to keep the query as a permanent part of the health record in order to dem-onstrate compliant and ethical CDI practices. The permanent query demonstrates the CDI professional’s attempt to seek clarification. It can also demonstrate to the administration the CDI professional’s efforts to communicate to the medical staff.

Keeping the query as part of the health record can also refute a healthcare provider’s assertion that he or she was unaware of the need for additional documen-tation. Finally, a permanent document in the health record serves to reduce redundancy and decrease the risk of a duplicate, retrospective query.

the observation should be entered into the RMetrics Trend Tracker™ immediately.

An RMD/RID should determine how to format entries consistently. This will make it easy for every-one in the RMD/RID to read and understand each observation made. Once the format has been deter-mined, it is the responsibility of each team member to add observations when applicable. It is important for all associates to communicate with one another on all observations added.

“Trends are important; they help iden-tify areas of process improvement.”

Every observation is assigned an identification (ID) number, which allows for quick reference. All staff members can select a known ID number to add addi-tional information to the observation. There should be only one observation written per trend observed and adding to that trend every time another occur-rence occurs is highly recommended. Deleting the observation entirely is the only way to remove the ID number and deleting an observation is not a recom-mended practice.

Trends are important; they help identify areas of process improvement. Working a trend through the PDCA process helps your facility financially by identifying and closing areas of revenue leakage, and non-financially through compliance. So remember to write observations, track trends, and work these iden-tified issues through the process improvement pro-cess, both for compliance issues and financial benefit. Be the observer: the one to write up observations on all trends. Mary Reed

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What’s In a Reason?As you, the charge auditor, enter your findings into the charge audit database, it is very important that you provide as much detailed information regard-ing your findings as possible. You may have a need to review these findings at a later date with clinical staff, the clinical department head, your director, or an external auditor in a defense audit situation. The

more detailed you are, the easier it will be to recall the circumstance for the under- or overcharge.With this in mind, there are different ways to pro-vide this detail in the database. In a broad perspec-tive, using a sub audit type for a focused project is appropriate. On a line-by-line detail, reason codes are available to help identify why the charge was added or removed. If further detail is needed, comments are free text and may be used to provide additional detail to the findings, who was notified of the changes, or any other information you may wish to provide.Reason codes are provided in the database; how-ever they are generic reasons and may not reflect all of the detail needed. Some reasons are specific for undercharges, such as omitted charge, and others, i.e, documentation does not support, are for overcharges. There are a few that can be used for either. New reason codes are being added to the database this month as updates occur. Please review the chart below for the mnemonic name, under/overcharge use and a brief description. As always, this list may be customized to meet your needs.

Reason codes:Mnemonic Description Category DefinitionAD Anesthesia Documentation Missing OC Documentation on the Anesthesia record does not support the itemized chargesAT Anesthesia Type change OC/UC An exchange of Anesthesia type, such as a block to a generalBP Bundled Procedure OC Charge is to be removed from bill since it is included in another chargeCC New CDM/charge code UC A new item in the CDM that needs to be captured CD Chart/Documentation does not support OC Documentation does not support the chargeDC Duplicate charge OC Item billed twice, documentation does not support a second chargeDE Data Entry Error OC/UC The amount of the item is in question, either too many or not enough were chargedED ED level change OC/UC An exchange of ED level, should balance outEX Exchange level OC/UC An exchange of levels not specified elsewhereIV IV start stop times missing OC IV stop times are missing, therefore charge must be removedMD MD documentation missing OC Doctors documentation does not support chargeMN MD order missing OC Doctors order is missing, therefore charge must be removedNC Not chargeable OC Old charge that should not be usedNP Service/Procedure not performed OC Procedure or test was not performed, there is no documentation to support this chargeOC Omitted charges UC There is supporting documentation to justify adding missed chargeOR OR/Anesthesia time error OC/UC Time charge corrected for OR Anesthesia per supporting documentationPE Pharmacy Error OC/UC Dose/unit charged incorrectPT Physical therapy documentation missing OC Documentation for physical therapy does not support the chargeRN RN documentation missing OC Nurse documentation does not support the chargeRT Respiratory therapy documentation missing OC Documentation for respiratory therapy does not support the chargeTC Time calculation error OC/UC Time charge corrected per supporting documentationUA Unable to administer medication OC Patient did not take a medication, needs to be creditedUS Unbundled services UC Item is no longer in a bundled service and has supporting documentation

Facility appeals and can show that at the time of ser-vice Facility was unable to determine reasonably that patient was a customer, that the Facility took reason-able steps to learn that the patient was a customer, the Facility promptly provided notification, or filed the claim after learning the patient was a customer.” Ann filed a first level appeal based on the documenta-tion found in the patient record that supported the “reasonable steps” contract language. As a result of that appeal, the facility received full contractual reim-bursement for an additional $57,500. Understanding the details of your managed care contract language pays off!

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Don’t Forget!All CBR activity for the month must be entered into the CBR Software application/DRG Catalyst prior to the 10th of the following month. Be sure to follow the steps below so that results from retrospective CBR audits translate onto the Executive Summary:

Inpatient (DRG Catalyst)

The rebill checkbox must be checked. (Please make sure that you send the checked accounts to PFS for rebilling!)

Outpatient (CBR Database)

The completion date must be entered under the CBR Utilities tab, and

The rebill checkbox must be checked. (Please make sure that you send the checked accounts to PFS for rebilling!)

Before the database closes each month, IRM recom-mends that you complete the following checklist:

Confirm that all completed retrospective audits for the month have an end date entered into the CBR database.

Check the rebill box in the CBR database or DRG Catalyst for each retrospective claim that has been approved for rebilling.

Complete a Summary of Audit Findings form for any projects you closed this month and submit it to the coding Subject Matter Expert (SME).

Ensure that data is entered for all accounts audited for the current month.

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Best Practice ForumPlans are beginning for next year’s Best Practice Forum and we’ll be sure to keep you posted regarding details as they’re finalized.

We hope that you’ll be able to join us!

See you in 2011.

Welcome, Little Ones!We wish to welcome two new bundles of joy. Isaac

and Karson were both born in May.

Congratulations!

Isaac Proud mama:

Chris Martinelli of Intermountain Healthcare

Karson Proud papa:

Eric Liston of Intermountain Healthcare

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Net Revenue Matters is a monthly publication of Integrated Revenue Management, Inc. (IRM), and is offered as an informational service. Due to the nature of this publication, examples cited and advice given must often be general in nature and may not apply to a particular facility or situation. Thus, IRM does not warrant or guarantee the information contained will be applicable or appropriate in all situations. Each facility will have to evaluate its specific opportunities and take such action as to best meet its business needs. To find out more about a given subject or for information tailored to your specific circumstances, contact an IRM professional.

If you have questions or would like to submit information for a future newsletter, please contact: Cynthia Hufferd 760-448-1034 chufferd@irminconline.com

Client Code-Based Reimbursement Project Rollout Topics 2010 Live webinars begin at 11:30 Pacific

Potential Project Rollout Topics

Injections and Infusions

Introduction to Inpatient Audits

Inpatient Mechanical Ventilation

POA and HAC

Observation and One-Day Stays

Device Dependent APCs

Wound Care

Pain Management

Outpatient Orders

Spine Surgery

Chemotherapy

Pathology

Brachytherapy

Moderate Sedation

Radiology Imaging

Erythropoiesis Stimulating Agents

Discharge Dispositions

Interventional Cardiology and Electrophysiology

Emergency Department

Vascular Access Devices

Neurostimulators

GI Endoscopy

Tracking and Trending CCI Edits

For more information, please contact us. Thank You

UpComing Webinars

Client RMD WorkshopWebinars 2010

Jul 22: CA Forum Call

Aug 3: RAC Forum Call TBD: Global PI Project

19: CA Forum Call

Potential Workshop Topics

Consumer-Driven Healthcare/Pay for Performance

Medicare Managed Care

Auditing ICU Accounts

How to Handle Adversity

Silent PPOs

How to Update and Maintain the CPM

How to Interact with Internal Customers

Write-Off Analysis

Software Data Entry and Process

Software Reporting

Please watch for your e-mail invitation approximately three weeks prior to the scheduled event.