Connolly To Review Physician Inpatient Admission Orders

Lack of Clear Orders Puts Facility at Risk

Inpatient admissions in 17 states can now be audited by Connolly Healthcare, the CMS Recovery Audit Contractor (RAC) for Region C, such as in cases where a short length of stay for certain conditions or treatments (e.g., Chest Pain, Pacemaker) might reasonably be handled in a less intensive site of service, such as outpatient or observation.The lack of a clear written order in the medical record defining the physician's intent for meeting the patient's needs clearly places the facility at risk of recoupment.

Major Losses Possible

In such cases, if Connolly reviews the record and finds no proper physician order for inpatient admission, the claim is not qualified to be paid as an inpatient admission, and Connolly can therefore recoup the entire amount paid to the facility for that inpatient admission. According to a CMS policy statement, other claim types associated with a denied inpatient stay "may be reviewed individually and there may be a need to fully/paritally adjust the claim based on the documentation submitted." (See "Reach Thru Denials")

Connolly posted the new issue, entitled, "Inpatient Admissions without a Physician's Inpatient Admit Order," on their Approved Issues page, on Thursday, July 1, 2010. As the RAC for Region C, Connolly is under contract to CMS to audit Medicare claims in the states of Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma , South Carolina, Tennessee, Texas, Virginia, West Virginia; plus in the territories of Puerto Rico and the Virgin Islands.

Specific Reasons Still Needed for Review

While the new posting does not identify any specific diagnoses or diagnosis related groups (DRGs) which typically accompany other issues approved by CMS for widespread complex review, no RAC can simply decide to review charts at random, but instead must have some valid reason for conducting a complex review. Complex reviews require a human to review the medical record for a claim, to determine if any errors were made in coding or billing, thereby causing improper payments to be sent to the provider(s) filing the claim.

See Connolly's original posting using the links in the eduTrax® RAC New Issues pages.