Claim Type |
Improper Payment Rate |
Improper Payment Amount |
|---|---|---|
Overall |
7.66% |
$31.70 B (Billion) |
Part A providers [excluding Hospital inpatient prospective payment system (IPPS)] |
7.56% |
$14.19 B |
Part B providers |
10.35% |
$11.45 B |
Hospital IPPS |
3.89% |
$5.17 B |
CERT Finding |
Resolution |
Resource(s) |
|---|---|---|
Psychiatric evaluation missing |
Medical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the patient is hospitalized. |
|
Psychiatric certification or recertification inadequate |
At the time of admission or as soon thereafter, the admitting physician or a medical staff member with knowledge of the case, must certify the medical necessity for inpatient psychiatric hospital services. The first recertification is required by the 12th day of hospitalization. Subsequent recertifications are required no less than every 30 days. In the initial certification and subsequent recertification, the physician must provide documentation confirming that the admission to the inpatient psychiatric facility was medically necessary for one of two reasons: either for treatment that is likely to enhance the patient's condition or for the purpose of conducting a diagnostic study. Recertifications must also satisfy all the following requirements: The hospital records indicate the services furnished were either intensive treatment services, related services necessary for diagnostic study at admission, or equivalent services. Physicians required to recertify that the patient continues to need, daily, active treatment furnished directly by or requiring the supervision of inpatient psychiatric facility personnel. |
CERT Finding |
Resolution |
Resource(s) |
|---|---|---|
Clinical presentation, prognosis and expected treatment did not support the expectation of the need for hospital care spanning two or more midnights |
The two-midnight presumption outlined in CMS-1599-F specifies hospital stays spanning two or more midnights after the beneficiary is formally admitted as an inpatient will be presumed to be reasonable and necessary for the inpatient status as long as the hospital stay is medically necessary. The clinical presentation, prognosis and expected treatment in the medical documentation should support the expectation of the need for hospital care spanning two or more midnights. |
|
Discharge status incorrectly coded |
The discharge status code identifies where the patient is being discharged to at the end of their facility stay or transferred to such as an acute/post-acute facility. The discharging facility should ensure that documentation in the patient’s medical record supports the billed discharge status code. Billing the incorrect code may affect their payment, but will impact any other facility receiving the patient, often preventing them from successfully submitting their claim to Medicare. Facilities are encouraged to follow-up with the patient after discharge and prior to submitting the claim to Medicare to ensure the patient went to the planned facility that was recorded in the medical record. This will prevent incorrect billing of the discharge status code and avoid unnecessary adjustments to claims when the incorrect code is used. |
|
Preoperative surgeon's office notes were missing - Transcatheter Aortic Valve Replacement (TAVR) |
TAVR is covered for the treatment of symptomatic aortic valve stenosis. The patient (preoperatively and postoperatively) is under the care of a heart team: a cohesive, multi-disciplinary, team of medical professionals. The heart team concept embodies collaboration and dedication across medical specialties to offer optimal patient-centered care. The heart team includes the following: • Cardiac surgeon and an interventional cardiologist experienced in the care and treatment of aortic stenosis who have: • Independently examined the patient face-to-face, evaluated the patient’s suitability for surgical aortic valve replacement (SAVR), TAVR or medical or palliative therapy • Documented and made available to the other heart team members the rationale for their clinical judgment The joint care from the heart team must be documented int eh medical record and available when requested for medical review. |
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