Short-term Acute Care Inpatient Hospital Claim Reviews
The Comprehensive Error Rate Testing (CERT) program and Wisconsin Physicians Service (WPS) Medicare Part A recently began requesting and reviewing Prospective Payment System (PPS) short-term acute care inpatient hospital claims for improper billing.
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The official instruction, Change Request 5849 (CR5849), was issued to your Medicare Fiscal Intermediary (FI) or A/B Medicare Administrative Contractor (MAC) in two transmittals, one related to the Medicare Program Integrity Manual and one for the Medicare Claims Processing Manual. These transmittals are available at:
- http://www.cms.hhs.gov/Transmittals/downloads/R264PI.pdf
- http://www.cms.hhs.gov/Transmittals/downloads/R1571CP.pdf
- The Centers for Medicare & Medicaid Services (CMS) has posted a Fact Sheet to the CMS Website. This document can be found at:
- http://www.cms.hhs.gov/AcuteInpatientPPS/downloads/Inpatient
ReviewFactSheet.pdf
Since review of the short-term acute care inpatient hospital claims began the Cert Review Contractor (CRC) has had to request additional documentation on approximately 80% of reviewed claims. The highest incidences of missing documentation were related to:
- Physician progress notes and orders
- Discharge Summaries
- History and Physicals
- Other ancillary department documents such as Laboratory and Radiology results….
What documentation is required for review of a PPS short-term acute care inpatient hospital claim?
- Refer to the appropriate Wisconsin Physicians Service (WPS) Medicare Website for documentation requirements
- Legacy Part A (former Mutual of Omaha providers)
- http://www.wpsmedicare.com/part_a/business/documentation_guidelines.pdf - MAC Part A (Nebraska, Kansas, Missouri, Iowa)
- http://www.wpsmedicare.com/mac/business/partamrdocguidefulldoc.shtml
Documentation must be sent to support every line on the claim.
- Your response is required even if records for the sampled beneficiary dates of service cannot be provided.
- In accordance with 42 U.S.C. § 1320C-5 (a) (3) and § 1833 of the Social Security Act, as a Medicare provider, you must provide documentation and medical records upon request to support claims for Medicare services. It is your responsibility to obtain additional supporting documentation from a third party (hospital, nursing home, etc.), as necessary.
- Providing medical records of Medicare patients to the Comprehensive Error Rate Testing (CERT) contractor is within the scope of compliance with the Health Insurance Portability and Accountability Act (HIPAA).
Page Last Updated: Wednesday, 17-Feb-2010 14:15:38 CST
