Medicaid Hospital Utilization Review and DRG Audits: Frequently Asked Questions

1
Medicaid Hospital Utilization Review and DRG
AuditsFrequently Asked Questions

• The Department of Medical Assistance Services
• Division of Program Integrity
• August 2007

2
What Is the Code of Federal Regulations (CFR)?

• The Code of Federal Regulations (CFR) is the
  codification of the general and permanent rules
  published in the Federal Register by the
  executive departments and agencies of the Federal
  Government. It is divided into 50 titles that
  represent broad areas subject to Federal
  regulation.
• Each volume of the CFR is updated once each
  calendar year and is issued on a quarterly basis.
  
• Titles 42-50 are updated as of October 1st of
  each year. Title 42 Public Health, Chapter IV
  Centers for Medicare and Medicaid Services (CMS),
  Department of Heath and Human Services, Part 456,
  Utilization Control is used to determine federal
  code compliance when auditing acute care
  hospitals.

3
Where Is the Code of Federal Regulations?

• On Line at http//www.gpoaccess.gov
• Enter 42CFR456 in Quick Search to access the
  codes applicable to Medicaid audits.
• Hard copies may be purchased through U.S.
  Government Online Bookstore.

4
Where Are the Medicaid Manuals Located?

• Provider manuals are available on line at
  www.dmas.virginia.gov
• Click on the Manuals link under Provider
  Services.
• Hard copies may be ordered from Commonwealth
  Martin at [phone].

5
What Documentation Is Needed for Utilization
Review in the Hospital?

• Refer to CFR 456.125- 456.137, for hospital
  admissions.
• Each recipient, including mothers and newborns,
  must have utilization review documentation.
• DRG payment for hospitalization does not preclude
  the requirement for utilization review.

6
Are Extensions Given for the Hospital Utilization
Review Audit?

• An extension may be given for submitting audit
  information to DMAS.
• Contact your DMAS utilization review analyst to
  discuss an extension.
• Extensions are not available for on-site audits.

7
Audits of Acute Medical Care Hospitals

• The Code of Federal Regulations (CFR), Title 42,
  Part 456 addresses utilization controls for acute
  medical inpatient services.

8
Why Does the Certification Have to Be Dated on
the Day of Admission?

• The Code of Federal Regulations (CFR), Title 42,
  456.60 for admissions to hospitals, states that
  the certification must be made at the time of
  admission.
• If an individual applies for benefits while in
  the hospital, the certification must be completed
  before the claim is paid by DMAS.
• It is acceptable to complete a Medicaid admission
  certification even if the patient is Self Pay
  when admitted. The patient might receive
  retroactive Medicaid benefits later.

9
Can Newborns Share Their Mothers Admission
Certifications?

• Newborns must receive their own
• admission certifications.
• They can not share their mothers certifications.

10
What is the Format for an Admission Certification?

• There is no standardized certification form. A
  sample form is found in the Medicaid Hospital
  Manual, Chapter VI, Exhibits section.
• Hospitals may design their own forms.
• Hospitals may use a stamp stating Certified for
  Necessary Hospital Admission. Physician must
  sign and date on date of admission.
• Physicians may write Certified for Necessary
  Hospital Admission in the record, and sign and
  date on the date of admission.
• Refer to CFR 456.60 for information on hospital
  admissions.

11
What is the Specific Wording for Admission
Certification?

• The words Certified for Necessary Hospital
  Admission must be in the statement.
• This can be on a form, or in a handwritten or
  stamped statement in the record.
• Physician must sign and date the certification on
  the date of admission.
• Refer to the Medicaid Hospital Manual, Chapter VI.

12
What Certification Date Should Be Used for
Observation Patients?

• The date of the admission certification must be
  the date that the patient is converted to
  Inpatient status.

13
What is the Format for the Plan of Care?

• There is no standardized format for the plan of
  care.
• Most hospitals combine the admission
  certification and plan of care on one form. A
  sample form is found in the Medicaid Hospital
  Manual, Chapter VI, Exhibits section.
• Refer to the Hospital manual, Chapter VI and the
  CFR, 456.80 for information on plans of care.

14
Psychiatric Hospitals and Freestanding Acute Care
Psychiatric Facilities

• The Code of Federal Regulations (CFR), Title 42,
  Subpart D addresses utilization controls for
  psychiatric inpatient services.

15
Where is the Information Specific to Audits of
Psychiatric Facilities?

• Program and utilization review requirements are
  described in the Psychiatric Services Manual
• Chapter IV describes covered services
• Chapter VI describes utilization review

16
What Information Is Included In the Audits for
Psychiatric Admissions?

• Utilization Management Plan must comply with 42
  CFR 456.100-145
• Review of certifications
• Review of plans of care
• Verification of required evaluations
• Validation of prior authorization documentation,
  including Interqual criteria
• Validation of services provided by qualified
  professionals
• Dated signatures required on all medical
  documentation

17
When Must Psychiatric Admissions Be Certified?

• Certification must be made at the time of
  admission
• On admission is defined as within 4 hours
• Exception to this is retroactive Medicaid
  eligibility

18
When Must Emergency Psychiatric Admissions Be
Certified?

• For emergency admits, the certification for
  admission can be completed up to 14 days from
  admission (42CFR 441.153)
• This applies to general acute care and
  freestanding psychiatric facilities.

19
What is Required for Certification at
Freestanding Psychiatric Facilities?

• Required to be made by an independent team (42CFR
  441.152-153)
• Required to include information specified in
  chapter IV of the Psychiatric Services Manual
• Sample form in Exhibits section
• Recertification is required at least every 60
  days

20
DRG Audits

• The Code of Federal Regulations (CFR), Title 42,
  456.3 addresses the basis for DRG audits.

21
What is the Purpose of the DRG Audit?

• Medical records are audited to ensure that
  appropriate ICD-9-CM diagnoses and procedure
  codes are supported in the medical record.
• The audit identifies inappropriate practices of
  upcoding or inappropriate coding assignments.

22
Why Does DMAS Conduct DRG Audits?

• The federal government requires the Department of
  Medical Assistance Services to verify that
  hospitals participating with Virginia Medicaid
  are in compliance with the Center for Medicare
  and Medicaid Services (CMS) requirements.
• Refer to the CFR 456.3.

23
How Are Claims Selected for DRG Audit?

• The sample is determined at DMAS discretion.
• DRG validation may be done through DMAS or
  through a selected contractor.

24
What Documentation Will Be Reviewed for the DRG
Audit?

• The following should be included in the medical
  records sent for review
• History and Physical
• Discharge Summary
• Operative Report
• Physicians Progress Notes
• Consultation Reports
• Lab/X Ray Reports
• Other relevant data to support the claim

25
The End

• The DMAS Website Address is www.dmas.virginia.gov