A Closer Look at Early Discharges Ranking
Most hospitals should pay special attention to their rank regarding sepsis and in comparison, with urinary tract infection as the principal diagnosis when reviewing their PEPPER reports, says Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, a consulting company based in Shawnee, OK.
Sepsis is the most frequent reason for admission of Medicare patients and it is a relatively high-paying diagnosis, Hale notes.
“It’s on the forefront of everyone’s minds, particularly in the emergency department, and CMS and several other payers have initiatives about early identification of sepsis and the appropriate treatment to reduce mortality and morbidity,” she says. “Physicians have improved their documentation of sepsis, so consequently that increases the hospital’s billing for sepsis. But Medicare Advantage and some of the big players in healthcare insurance are auditing those claims at an alarming rate and indiscriminately changing a well-documented and well-treated diagnosis of sepsis in the medical record to get out of paying the higher amount.”
Hale cautions that a ranking in the 80th percentile should be a warning flag that you are likely to be audited and should spend a lot of time defending your documentation.
“You should be absolutely sure you have a system in place for defending these claims and not just chalk it up to the insurance companies doing their same old thing,” Hale say. “That’s what the insurers are hoping you’ll do — just assume there’s no use in fighting and give up.”
One-day and same-day discharges also should get special attention. A high ranking in that area should prompt the hospital to investigate those discharges and make sure that they meet one of the exceptions allowed by CMS, Hale suggests. If not, improvement in utilization management is needed.
Most hospitals should pay special attention to their rank regarding sepsis and in comparison, with urinary tract infection as the principal diagnosis when reviewing their PEPPER reports, says Deborah K. Hale, CCS, CCDS, president and CEO of Administrative Consultant Service, a consulting company based in Shawnee, OK.
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