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DISPUTE RESOLUTION REVIEW PROGRAM Health Care Financial Management Association April 14, 2011. Empire State Medical Scientific and Educational Foundation, Inc . About Us . Not for profit corporation focusing on quality medical peer review

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Dispute resolution review program health care financial management association april 14 2011 l.jpg

DISPUTE RESOLUTION REVIEW PROGRAM

Health Care Financial Management Association

April 14, 2011

Empire State Medical Scientific and Educational Foundation, Inc.

Empire State Medical, Scientific and Educational Foundation, Inc.


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About Us

  • Not for profit corporation focusing on quality medical peer review

  • Independent Medical Review Organization sponsored by the Medical Society of the State of NY

  • Registered Utilization Review Agent with the NYS Bureau of Managed Care

  • Pursuing certification with URAC, NCQA

  • 27 years experience in medical peer review

Empire State Medical, Scientific and Educational Foundation, Inc.


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Relevant Experience

  • Provide Dispute Resolution Review services throughout New York State

  • Provide External Appeal Review services for the State of Connecticut

  • Serve as Medicaid Peer Review Agent through subcontract with IPRO

  • Perform coding/compliance review for physician offices throughout NYS

Empire State Medical, Scientific and Educational Foundation, Inc.


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Dispute Resolution Program

  • Internal Review Process

    • Providers and Payors contractually agree to an internal dispute resolution/appeal process

  • External Review Process

    • Providers and Payors contractually agree to an external dispute resolution/appeal process

    • Contract should designate an outside entity to serve as the dispute resolution/external appeal agent

Empire State Medical, Scientific and Educational Foundation, Inc.


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Dispute Resolution Program (con’t.)

  • Items your Contract should address:

    • Internal Review/Appeal Process

      • Specify the timeframe for initiating the appeal process

      • Specify the number of reviews available (initial and final versus final review only)

      • Specify the steps for initiating each step of the process

      • Specify the issues that may be appealed

Empire State Medical, Scientific and Educational Foundation, Inc.


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Dispute Resolution Program (con’t.)

  • Items your Contract should address(con’t.):

    • External Dispute Resolution Review Process

      • Designate the Entity to be used for external dispute resolution review

      • Identify who will initiate the review process (ie hospital or payor or either)

      • Specify the timeframes for initiating the dispute resolution review process

      • Identify the issues that may be disputed

Empire State Medical, Scientific and Educational Foundation, Inc.


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Dispute Resolution Program (con’t.)

  • Items your Contract should address(con’t.):

    • External Dispute Resolution Review Process (con’t.)

      • Specify if one or two reviews are available through the external process

      • Designate the final responsibility for the review fee

      • Contractually agree that both parties will be bound by the decision of the external agent

Empire State Medical, Scientific and Educational Foundation, Inc.


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Dispute Resolution Program (con’t.)

  • Issues Reviewed

    • Correct coding and/or DRG assignment

    • Medical necessity of admission and/or length of stay (Acute and/or Exempt Unit)

    • Level of care

      • Acute/Observation/Skilled/Alternate

      • Inpatient versus outpatient level of care

    • Other issues as requested

Empire State Medical, Scientific and Educational Foundation, Inc.


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Dispute Resolution Program (con’t.)

  • Review Criteria Utilized

    • Interqual® Adult and Pediatric Level of Care criteria

    • Milliman Care Guidelines®

    • NYS Rules and Regulations

    • UHDDS Coding Guidelines

    • 3M/HIS NYS Grouper/Pricer

    • AMA 1995/1997 CPT Coding Guidelines

Empire State Medical, Scientific and Educational Foundation, Inc.


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Dispute Resolution Review Process

  • Materials received from requesting party

    • Dispute Resolution Application

    • Copy of the Medical Record

    • Supporting documentation for issue in dispute

  • ‘Notification of Review Request’ is sent to other party with instructions to submit comments

Empire State Medical, Scientific and Educational Foundation, Inc.


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Dispute Resolution Review Process (con’t)

  • Case is reviewed by nurse and/or coder

    • Nurse reviews medical necessity issues

    • Coder reviews DRG/coding issues

  • Case is referred to physician specialist

  • Review results are published

Empire State Medical, Scientific and Educational Foundation, Inc.


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Important to Remember

  • Documentation is Key!!!

  • State clearly the issue in question

  • State clearly your position and supporting argument

  • Cite any applicable medical criteria or coding guidelines referenced for your review

  • Always respond to a denial

  • Documentation is Key!!

Empire State Medical, Scientific and Educational Foundation, Inc.


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Case #1

Case submitted by hospital because payor disagrees with secondary diagnosis dehydration (276.51).

Hospital Argument:

“Briefly, this case involves a 70 year old male admitted emergently with nausea, vomiting, weakness and passing out on the day of admit. The admission diagnosis on the ER record was weakness and dehydration. The MD ordered IV fluids for treatment of the dehydration. These were continued through day #4 of the hospital stay.

Empire State Medical, Scientific and Educational Foundation, Inc.


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Case #1 (con’t.)

Hospital Argument (con’t.)

“The dehydration was an additional diagnosis that affected this episode of care. It meets the criteria for a secondary diagnosis as it was clinically evaluated, required treatment and increased nursing care. The…diagnosis of hypovolemia is included in the discharge summary as a final diagnosis.”

Parts of Record Referenced by Hospital:

Discharge summary

Admission physician order

Emergency room record

Empire State Medical, Scientific and Educational Foundation, Inc.


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Case #1 (con’t.)

Payor Argument:

“We continue to maintain that this patient was not dehydrated. This 70 year old man with adrenal insufficiency presented with weakness and episodes of falling with inability to get up. His BUN/Creatinine was 7/0.9 which is not consistent with dehydration, but rather than hypokalemia which we agree the patient had. Dehydration is deleted.”

Parts of the Record Referenced:

None specifically referenced

Empire State Medical, Scientific and Educational Foundation, Inc.


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Case #1 (con’t.)

ESMSEF Decision:

Per our physician specialist, the principal reason for this patient’s symptoms and admission is adrenal crisis from acute renal insufficiency. Weakness, hypotension and dehydration are medical consequences. He also had hypokalemia during this admission. Dehydration is a valid diagnosis and was evaluated and treated during this hospital stay.

Empire State Medical, Scientific and Educational Foundation, Inc.


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Case #2

Case submitted by hospital because payor denied continued stay from 10/6-10/10 as not medically necessary. Patient was in hospital from 9/24-10/10.

Hospital Argument:

Patient was a 38 year old male with a history of AIDS who was admitted with pneumocystitis pneumonia. He was treated with IV antibiotics and slowly improved. His blood glucose levels remained elevated due to high doses of steroid therapy. On 10/6, patient felt well, was out of bed and had no shortness of breath noted. He was being instructed on Insulin administration and medication teaching. Visiting nurse was being arranged. Patient was discharged 10/10.

Empire State Medical, Scientific and Educational Foundation, Inc.


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Case #2 (con’t.)

ESMSEF Decision:

Per our physician specialist, the continued stay after 10/6 is not substantiated. The patient was afebrile and denied shortness of breath. The O2 sat was greater than 90% consistently on room air and blood sugars were improving. Insulin administration was begun early in the admission and could have been continued on an outpatient basis since patient had in-home nursing care services. The continued stay was not substantiated.

Empire State Medical, Scientific and Educational Foundation, Inc.


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Case #3

Case submitted by hospital because payor disagrees with principal diagnosis diverticulitis (562.10) and secondary diagnosis COPD (496).

Hospital Argument:

“This was a 70 year old female admitted with abdominal pain and diagnosed with diverticulitis. The patient’s history was significant for COPD. This was a complicating diagnosis that was present on admission and affected this episode of care. It was documented by the physician in the H&P, progress notes and on the face sheet. The COPD was clinically evaluated, treated with Combivent inhaler and required nursing monitoring. It was correctly assigned for this episode of care.”

Empire State Medical, Scientific and Educational Foundation, Inc.


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Case #3 (con’t.)

Parts of record referenced by Hospital:

Face Sheet

Discharge Summary

Admission Physician Order

Consultation Report

Physician Progress Notes

Empire State Medical, Scientific and Educational Foundation, Inc.


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Case #3 (con’t.)

Payor Argument:

Hospital CodePayor Code

562105533

V10113569

4967140

35694019

714057420

574204556

Parts of Record Referenced by Payor:

None specifically referenced.

Empire State Medical, Scientific and Educational Foundation, Inc.


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Case #3 (con’t.)

ESMSEF Decision:

The principal diagnosis is clearly documented as diverticulitis. The face sheet, progress notes, CT scan report and consultation all document diverticulitis as the reason for admission. Concerning the secondary diagnosis of COPD, Coding Clinic Guidelines allow this diagnosis to be coded as a chronic condition that impacts the care of the patient. Chronic conditions such as, but not limited to, hypertension, CHF, asthma, emphysema, COPD…are reportable per UHDDS criteria (see Coding Clinic, 1990, 2nd Quarter). The hospital has coded this case correctly.

Empire State Medical, Scientific and Educational Foundation, Inc.


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Case #4

Case submitted by hospital because payor denied the acute admission stating patient could have been treated in the ER and been discharged.

Hospital Argument:

Patient was 29 year old female who was 7 weeks pregnant. She came to ER with 2 week history of near constant vomiting of all oral intake, including medication. She had been seen in her MD office 2 days earlier but continued to have intractable vomiting. In addition she had a UTI. She was admitted for IV fluids at 150 cc/hour, IV Protonix and IV Unasyn. Acute admission indicated.

Empire State Medical, Scientific and Educational Foundation, Inc.


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Case #4 (con’t.)

Payor Argument:

Patient was a 30 year old female with an anxiety disorder and gestational age pregnancy of 7 weeks. She was admitted from ER with complaints of vomiting and UTI (diagnosed 2 days prior to admission for which she is taking antibiotics). ER progress notes document the patient was given a single dose of oral Meclizine, “had no episodes of vomiting since admission” and was able to tolerate po (fluids and a banana). She was afebrile and vital signs were stable. Clinical presentation did not support the need for acute admission following care and monitoring in the ER.

Empire State Medical, Scientific and Educational Foundation, Inc.


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Case #4 (con’t.)

ESMSEF Decision:

Per our physician specialist, this 29 year old female with and EDC of 2/20/11 was admitted via the ER with symptoms of nausea and vomiting for 2 weeks. The emesis was bilious and she was unable to take po medications. She was treated with IV fluids at 150 cc/hr, IV Unasyn, IV Protonix and IV Benadryl. On hospital day #3 her symptoms were improved and she was discharged home. The patient had failed outpatient treatment for intractable hyperemesis gravidarum, complicated by UTI and psychiatric disorder. Acute admission was indicated.

Empire State Medical, Scientific and Educational Foundation, Inc.


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In Summary

  • Be sure Dispute Resolution Review services are defined in the hospital/payor contract

  • Be sure to understand all required steps of the internal and external appeal processes

  • When submitting a case for dispute resolution review – support your argument!! Documentation is Key!!

Empire State Medical, Scientific and Educational Foundation, Inc.


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Thank You!!

Frances Scott, RHIA

Director of Operations

[email protected]

315-468-2561

Empire State Medical, Scientific and Educational Foundation, Inc.


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