MAC advice to one hospital seems too good to be true.
Boy, do I have a story to tell.
Now, let me start by noting that I am relaying information provided by a case management leader and did not have access to any medical records, nor was I able to listen in to the calls that took place. As always, before you do anything, be sure to check with your legal and compliance staff to be sure they support what you are doing. I am also not going to name the hospital nor the Medicare Administrative Contractor (MAC) involved, but would be happy to provide that information to someone from the Centers for Medicare & Medicaid Services (CMS).
That said, here is the situation. As you know, CMS has in place a required prior authorization program for specific outpatient procedures performed in the hospital outpatient department, where data has shown increases in utilization. Included in that program are two codes for cervical spine fusion, 22551 and 22552. At this hospital, a patient was scheduled for this surgery, and the prior authorization request was submitted to the MAC and approved.
The surgery proceeded and the patient was discharged from the recovery room. The chart went to coding and the surgery performed was coded as 22830 and not 22551. That code was placed on the outpatient claim and the claim submitted. And lo and behold, the claim was rejected. It turns out that 22830 is on the inpatient-only list.
Well, the hospital called the MAC and were told that since they were within the timely filing period and they received a denial, they could simply submit an inpatient claim and get paid. The MAC never asked if there was an inpatient admission order in the record. The manager was not sure that this advice was sound, so asked for confirmation.
First things first: what happened here? The surgery that was actually performed was 22830. That is exploration of spinal fusion, a procedure that occurs for a patient who previously had a spinal fusion. So, submitting 22551 for prior authorization made no sense in this clinical situation. That was the manager’s first mission: figure out who dropped the ball. Who obtained the prior authorization, and what information did they have that would lead them to the completely wrong surgery? I would hope that the surgeon knew the patient previously had surgery. Maybe their policy is simply to designate every planned fusion as a 22551 simply to get a prior authorization, just in case. If so, that potentially creates a world of hurt when the planned surgery is actually an inpatient-only surgery, as happened here.
But the even bigger issue is that the MAC told them simply to rebill the stay as inpatient. Is this correct? Can every hospital bill inpatient-only surgeries as inpatient, even without an inpatient order? Everyone tries to ascertain that an inpatient-only surgery is being planned, and tries to get the order, but some slip through. Surgeries also change in the OR, and sometimes the surgeon ends up doing an inpatient-only surgery that was not planned. The Medicare Benefit Policy Manual allows the billing of inpatient admission without an order in rare and unusual circumstances if the intent to admit can be established, but this MAC seems to be going much, much further with their instruction to this hospital. No caveats about establishing intent. No caveats about how often this can occur.
I do think that CMS wants to pay hospitals for the work they do. I do think that CMS has established a process for hospitals to get paid for inpatient-only surgeries without an inpatient order, but it should not be a regular occurrence. I truly don’t know what to do with this advice from this MAC to this hospital. Since CMS won’t answer questions about specific cases, hospitals must rely on the MAC to give accurate and compliant recommendations.
I so want this recommendation to be true, but it seems almost too good to be true. I would love to hear from you if you got the same or a different response when you contacted your MAC on a similar issue.
Programming note: Listen to Dr. Ronald Hirsch every Monday as he makes his rounds on Monitor Mondays with Chuck Buck and sponsored by R1-RCM.
EDITOR’S NOTE: The author of this article used AI-assisted tools in its composition, but all content, analysis, and conclusions were based on the author’s professional
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