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Like many other industries, today’s healthcare system is filled with prospective controls. The majority — infection control, medical error management, fall prevention, and safety — are directly connected to patient care and employee safety.


All prospective-control programs have one thing in common: Hospital staff anticipate or expect the errors based on past history. They have set up processes and training to prevent future errors, and if they do occur, established protocols quickly respond to the error. Staff track and trend all errors and utilize quality-improvement plans to decrease error rates and liabilities related to patient care and employee safety.


Hospital managers need to ask questions like the following: What prospective controls do we have in place to ensure correct payment? Does our facility have a “pay it right” program in place that is clearly evident to all employees? Does the program include quality-improvement plans and dedicated education to teach compliant billing and reimbursement practice to employees?


This article will identify some prospective controls that may be implemented to answer these questions with a focus upon medical necessity, documentation, and the coding process to ensure correct payment.


Current Coding State


At the present time, the primary focus is on coding productivity and accounts receivable. Controls integrated into coding processes are limited due to the priority of “dropping bills” and meeting unbilled day targets. Oftentimes, these controls delay the coding or billing process. Therefore, they are limited for the sake of productivity-a fact that has the tendency to increase financial exposure and decrease data integrity.


Common controls may include the following:


Concurrent (in-house queries during hospital stay):

  • A clinical documentation improvement (CDI) program that integrates concurrent queries, increases reimbursement and avoids delays of post-discharge queries is in place.


Prebill (queries post-discharge [but before billing])t;/h4>

  • Second-level reviewer (referred to another coder for confirmation of code assignments) is employed for any cases with one or no major complications and/or co-morbidities (MCCs) and one or no complications and/or co-morbidities (CCs).
  • Coders validate and enter the final discharge disposition.
  • Post-discharge queries occur until a response is received.
  • A hold is in place for receipt of the operative note, pathology report, discharge summary, or other key documents.


Integrated State


The primary focus is on prebilling and concurrent quality documentation with an integrated approach. Controls apply to all parties who have an effect on documentation, coding, and bill submission, including utilization management. These prospective controls reduce financial exposure and increase data integrity and, therefore, protect revenue.


Concurrent (during hospital stay)

  • Use CDI program to integrate in-house queries focused on achieving correct reimbursement, avoiding delays, and post-discharge queries.
    • Evaluate complete documentation for MCC and CC data capture.
    • Implement prospective control for coding and billing.
    • Evaluate appropriateness and completeness of documentation for principal diagnosis assignment.
    • Expand CDI to include responsibilities related to controls to avoid financial exposure.
    • Validate appropriateness and completeness of the admission order for the setting (inpatient versus observation or outpatient versus outpatient).

Prospective control for case management and billing

  • Evaluate for complete documentation to support
    • Intensity of service for inpatient (medical necessity); and
    • severity of illness for inpatient level of care (medical necessity).
  • Evaluate procedures to ensure they are appropriate to meet inpatient level of care.
  • Evaluate appropriateness of documentation for accurate discharge-disposition assignment.
  • Prebill (after discharge, before billing)
    • Enter all of the criteria below as shown in the table below, into the coding claims analyzer, which screens the codes and key billing data elements after MS-DRG grouping, but before billing.
  • Know your high-risk MS-DRGs and analyze case mix and RAC-approved issues, including a cross-section of the highest revenue, relative weight, volume, and risk (sequencing procedure, diagnosis, MCC, CC, procedures, documentation, medical necessity).


Cases are electronically queued to a prebill reviewer (such as a coder, data analyst, payment analyst, or internal auditor). The prebill reviewer analyzes for data-quality and payment impact at the claims level and checks details related to medical necessity and clinical documentation.


In relation to coding, do the following:


  • Analyze  short stays or one-day lengths of stay (LOS) discharged home (01) or supportive care (04) for weak inpatient MS-DRGs (not reviewed by a case manager or CDI specialist); and
  • Enter MS-DRGs defined as “weak” for meeting inpatient criteria for medical necessity into your pre-bill claims analyzer logic (partial list) discharged to home (01) or supportive care (04) with one day or short stay (two to three days).
























































  • Review all cases for coding with no MCC or no CC as well as those with one MCC or one CC.
  • Re-route cases with a discharge summary to the coder when a claim is billed without a discharge summary.
  • Use a non-leading question to validate any cases with a concurrent or retrospective query (CDI and coding) for appropriateness and compliant structure of query.
  • Be sure your validation includes clinical indicators; treatments; and any ambiguous, incomplete, conflicting, illegible, or missing documentation. Also, be sure the condition being queried meets the requirements of the Uniform Hospital Discharge Data Set (UHDDS) (as reported in Section III, Reporting Additional Diagnoses, in  the fiscal year 2010 ICD-9-CM Official Guidelines for Coding and Reporting).
  • Identify all transfer MS-DRGs discharged less than one day of the geometric mean LOS (GMLOS) (medical necessity).
  • Research three-day LOS to discharge disposition 03-anticipated skilled cover with low charges (medical necessity).
  • Resolve issues related to principal diagnosis sequencing (likely secondary diagnosis that could qualify as a principal diagnosis) for high-risk MS-DRGs (partial list for coding) such as the following.

o   Sepsis as a principal diagnosis with urinary tract infection (UTI) as a secondary diagnosis with a short LOS (fewer than three days);

o   Sepsis as a secondary diagnosis with a short LOS (fewer than three days);

o   Urosepsis (UTI);

o   Other kidney and UTI (Foley-related UTIs);

o   Congestive heart failure (CHF) as principal with pneumonia as secondary diagnosis;



o   Chronic obstructive pulmonary disease (COPD) as principal with pneumonia as secondary diagnosis;

o   Aspiration pneumonia or simple pneumonia as principal diagnosis;

o   Acute renal failure as principal with secondary diagnosis such as pneumonia, CHF, respiratory failure, COPD, or UTI;

o   Respiratory failure as principal;

o   Non-specific cerebrovascular disorders;

o   Dehydration with acute renal failure as secondary;

o   Symptom as a principal diagnosis;

o    Hospital-acquired conditions (HACs) with a present-on-admission (POA) indicator of N (No [not present at the time of inpatient admission]);

o   POA indicator of U (Unknown [documentation is insufficient to determine if condition is present at time of inpatient admission]) or W (clinically undetermined [provider is unable to clinically determine whether condition was present at time of inpatient admission or not])

o   Procedure code 86.22 and 86.28 (debridement);

o   Procedure code 96.71 and 97.72 (ventilator);

o   Complication as principal or secondary diagnosis;

o   Extensive operating room (OR) and non-extensive OR procedure unrelated to principal diagnosis;


All of the above edits are prebill controls to ensure correct coding and billing for correct payment, increase data integrity, and reduce financial exposure (revenue integrity). In addition, they are a prospective control for one of the following:

  • Any missed one-day LOS or short-stay case not reviewed by case management or flagged for case management by CDI specialist is identified prior to billing.
  • Any missed concurrent or retrospective query opportunities are flagged.
  • Any incorrect use or application of coding conventions, ICD-9-CM Official Guidelines for Coding and Reporting, and/or the Coding Clinic is noted.


The final inclusion in this section relates to tasks that the Prebill reviewer must perform, which include:

  • Tracking all cases and enters the dollar amounts for each case that increases reimbursement, decreases reimbursement, or has no payment impact; and
  • Performing a root-cause analysis to identify gaps in the process, ineffective processes, or omissions in process as well as training needs to mitigate errors from occurring in the future.


Part two of this series continues on Thursday, July 29 and will cover improper payment audits and metrics. To read Part II, please click here


The third and final installment appears on Friday, July 30, 2010 and proposes measuring productivity in relationship to unbilled charges. To read Part III, please click here


About the Author

Carol Spencer, RHIA, CCS, CHDA is a senior healthcare consultant with Medical Learning, Inc. (MedLearn®) in St. Paul, Minn. MedLearn is a nationally recognized expert in healthcare compliance and reimbursement. Founded in 1991, MedLearn delivers actionable answers that equip healthcare organizations with coding, chargemaster, reimbursement management and RAC solutions.


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