Download - Empire State Medical, Scientific and Educational Foundation, Inc. 1 Empire State Medical Scientific and Educational Foundation, Inc. DISPUTE RESOLUTION

Empire State Medical, Scientific and Educational Foundation, Inc. 1

Empire State Medical Scientific and Educational Foundation, Inc.

DISPUTE RESOLUTION REVIEW PROGRAM

Health Care Financial Management Association

April 14, 2011


About Us

Not for profit corporation focusing on quality medical peer review

Independent Medical Review Organization sponsored by the Medical Society of the State of NY

Registered Utilization Review Agent with the NYS Bureau of Managed Care

Pursuing certification with URAC, NCQA 27 years experience in medical peer review


Relevant Experience

Provide Dispute Resolution Review services throughout New York State

Provide External Appeal Review services for the State of Connecticut

Serve as Medicaid Peer Review Agent through subcontract with IPRO

Perform coding/compliance review for physician offices throughout NYS


Dispute Resolution Program

Internal Review Process Providers and Payors contractually agree to

an internal dispute resolution/appeal process

External Review Process Providers and Payors contractually agree to an

external dispute resolution/appeal process Contract should designate an outside entity to

serve as the dispute resolution/external appeal agent


Dispute Resolution Program (con’t.)

Items your Contract should address: Internal Review/Appeal Process

Specify the timeframe for initiating the appeal process

Specify the number of reviews available (initial and final versus final review only)

Specify the steps for initiating each step of the process

Specify the issues that may be appealed



Items your Contract should address (con’t.):

External Dispute Resolution Review Process

Designate the Entity to be used for external dispute resolution review

Identify who will initiate the review process (ie hospital or payor or either)

Specify the timeframes for initiating the dispute resolution review process

Identify the issues that may be disputed



Items your Contract should address (con’t.):

External Dispute Resolution Review Process (con’t.)

Specify if one or two reviews are available through the external process

Designate the final responsibility for the review fee

Contractually agree that both parties will be bound by the decision of the external agent



Issues ReviewedCorrect coding and/or DRG assignmentMedical necessity of admission and/or

length of stay (Acute and/or Exempt Unit)Level of care

Acute/Observation/Skilled/Alternate Inpatient versus outpatient level of care

Other issues as requested



Review Criteria Utilized Interqual® Adult and Pediatric Level of Care

criteriaMilliman Care Guidelines® NYS Rules and RegulationsUHDDS Coding Guidelines3M/HIS NYS Grouper/PricerAMA 1995/1997 CPT Coding Guidelines


Dispute Resolution Review Process

1. Materials received from requesting partyI. Dispute Resolution Application

II. Copy of the Medical Record

III. Supporting documentation for issue in dispute

2. ‘Notification of Review Request’ is sent to other party with instructions to submit comments

Dispute Resolution Review Process

(con’t)

3. Case is reviewed by nurse and/or coder

I. Nurse reviews medical necessity issues

II. Coder reviews DRG/coding issues

4. Case is referred to physician specialist

5. Review results are published



Important to Remember

Documentation is Key!!! State clearly the issue in question State clearly your position and supporting

argument Cite any applicable medical criteria or coding

guidelines referenced for your review Always respond to a denial Documentation is Key!!


Case #1

Case submitted by hospital because payor disagrees with secondary diagnosis dehydration (276.51).

Hospital Argument:“Briefly, this case involves a 70 year old male

admitted emergently with nausea, vomiting, weakness and passing out on the day of admit. The admission diagnosis on the ER record was weakness and dehydration. The MD ordered IV fluids for treatment of the dehydration. These were continued through day #4 of the hospital stay.


Case #1 (con’t.)

Hospital Argument (con’t.)

“The dehydration was an additional diagnosis that affected this episode of care. It meets the criteria for a secondary diagnosis as it was clinically evaluated, required treatment and increased nursing care. The…diagnosis of hypovolemia is included in the discharge summary as a final diagnosis.”

Parts of Record Referenced by Hospital: Discharge summaryAdmission physician orderEmergency room record


Case #1 (con’t.)

Payor Argument:“We continue to maintain that this patient was

not dehydrated. This 70 year old man with adrenal insufficiency presented with weakness and episodes of falling with inability to get up. His BUN/Creatinine was 7/0.9 which is not consistent with dehydration, but rather than hypokalemia which we agree the patient had. Dehydration is deleted.”

Parts of the Record Referenced:None specifically referenced


Case #1 (con’t.)

ESMSEF Decision:

Per our physician specialist, the principal reason for this patient’s symptoms and admission is adrenal crisis from acute renal insufficiency. Weakness, hypotension and dehydration are medical consequences. He also had hypokalemia during this admission. Dehydration is a valid diagnosis and was evaluated and treated during this hospital stay.


Case #2

Case submitted by hospital because payor denied continued stay from 10/6-10/10 as not medically necessary. Patient was in hospital from 9/24-10/10.

Hospital Argument:Patient was a 38 year old male with a history of AIDS

who was admitted with pneumocystitis pneumonia. He was treated with IV antibiotics and slowly improved. His blood glucose levels remained elevated due to high doses of steroid therapy. On 10/6, patient felt well, was out of bed and had no shortness of breath noted. He was being instructed on Insulin administration and medication teaching. Visiting nurse was being arranged. Patient was discharged 10/10.


Case #2 (con’t.)

ESMSEF Decision:Per our physician specialist, the continued stay

after 10/6 is not substantiated. The patient was afebrile and denied shortness of breath. The O2 sat was greater than 90% consistently on room air and blood sugars were improving. Insulin administration was begun early in the admission and could have been continued on an outpatient basis since patient had in-home nursing care services. The continued stay was not substantiated.


Case #3

Case submitted by hospital because payor disagrees with principal diagnosis diverticulitis (562.10) and secondary diagnosis COPD (496).

Hospital Argument:“This was a 70 year old female admitted with abdominal

pain and diagnosed with diverticulitis. The patient’s history was significant for COPD. This was a complicating diagnosis that was present on admission and affected this episode of care. It was documented by the physician in the H&P, progress notes and on the face sheet. The COPD was clinically evaluated, treated with Combivent inhaler and required nursing monitoring. It was correctly assigned for this episode of care.”


Case #3 (con’t.)

Parts of record referenced by Hospital:

Face Sheet

Discharge Summary

Admission Physician Order

Consultation Report

Physician Progress Notes


Case #3 (con’t.)

Payor Argument:

Hospital Code Payor Code56210 5533V1011 3569496 71403569 40197140 5742057420 4556

Parts of Record Referenced by Payor:None specifically referenced.


Case #3 (con’t.)

ESMSEF Decision:The principal diagnosis is clearly documented as

diverticulitis. The face sheet, progress notes, CT scan report and consultation all document diverticulitis as the reason for admission. Concerning the secondary diagnosis of COPD, Coding Clinic Guidelines allow this diagnosis to be coded as a chronic condition that impacts the care of the patient. Chronic conditions such as, but not limited to, hypertension, CHF, asthma, emphysema, COPD…are reportable per UHDDS criteria (see Coding Clinic, 1990, 2nd Quarter). The hospital has coded this case correctly.


Case #4

Case submitted by hospital because payor denied the acute admission stating patient could have been treated in the ER and been discharged.

Hospital Argument:Patient was 29 year old female who was 7 weeks

pregnant. She came to ER with 2 week history of near constant vomiting of all oral intake, including medication. She had been seen in her MD office 2 days earlier but continued to have intractable vomiting. In addition she had a UTI. She was admitted for IV fluids at 150 cc/hour, IV Protonix and IV Unasyn. Acute admission indicated.


Case #4 (con’t.)

Payor Argument:Patient was a 30 year old female with an anxiety disorder

and gestational age pregnancy of 7 weeks. She was admitted from ER with complaints of vomiting and UTI (diagnosed 2 days prior to admission for which she is taking antibiotics). ER progress notes document the patient was given a single dose of oral Meclizine, “had no episodes of vomiting since admission” and was able to tolerate po (fluids and a banana). She was afebrile and vital signs were stable. Clinical presentation did not support the need for acute admission following care and monitoring in the ER.


Case #4 (con’t.)

ESMSEF Decision:Per our physician specialist, this 29 year old female with

and EDC of 2/20/11 was admitted via the ER with symptoms of nausea and vomiting for 2 weeks. The emesis was bilious and she was unable to take po medications. She was treated with IV fluids at 150 cc/hr, IV Unasyn, IV Protonix and IV Benadryl. On hospital day #3 her symptoms were improved and she was discharged home. The patient had failed outpatient treatment for intractable hyperemesis gravidarum, complicated by UTI and psychiatric disorder. Acute admission was indicated.


In Summary

Be sure Dispute Resolution Review services are defined in the hospital/payor contract

Be sure to understand all required steps of the internal and external appeal processes

When submitting a case for dispute resolution review – support your argument!! Documentation is Key!!


Thank You!!

Frances Scott, RHIADirector of [email protected]

Download - Empire State Medical, Scientific and Educational Foundation, Inc. 1 Empire State Medical Scientific and Educational Foundation, Inc. DISPUTE RESOLUTION

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