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Comprehensive Error Rate Testing

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Inpatient Hospital Surgery

National Government Services would like to alert providers on one of the highest dollar and most avoidable denials from the CERT contractor: submitting documentation relating to inpatient hospital surgeries. 

The CERT contractor requests additional documentation to support the medical necessity of the surgery but often does not receive adequate documentation from providers. Documentation for inpatient hospital stays should support both the need for inpatient admission and the surgery performed. 

The CERT contractor contacts providers via phone and follows up with written requests each time records are requested. The providers have the option to receive written request by fax or mail. Fax requests will expedite the process and help avoid denial.

To help support the inpatient hospital level of service and surgery performed providers should review other inpatient or outpatient services that a beneficiary may have received within six to twelve months prior to the billed inpatient stay and surgery as there can be valuable information to support medical necessity in those records. Some of the documentation needed may be located within other hospital departments, at physician offices or other sites.

If during the initial record requests you realize that some of the requested records are housed at another hospital department, physician office or other site, forward a copy of the request as applicable or give enough information to the CDC to assist in contacting the identified location. CERT will follow up with the identified location with additional record requests.

Examples of information to help support the medical necessity of the surgical procedures performed during an inpatient hospital stay are:

  • An in‐depth history and physical is of vital importance. Historical information regarding the patient’s symptoms, past medical care, alternative treatments attempted and pertinent lifestyle changes
  • Documentation of prior conservative treatment such as therapy progress notes – visits prior to admission
  • List of medications administered prior to surgical intervention:
    • Current medications for this hospital stay, along with information on previous medications that the physician has tried.
      • Was the medication effective? If not why?
      • What symptoms did the patient have and did the physician adjust or alter medications?
    • One of the common types of medication documentation being requested by CERT is non-steroidal anti-inflammatory drugs (NSAIDs).
  • Diagnostic Reports: Include any diagnostic report that might have been ordered and performed. The diagnostic tests to support the surgical procedure may have happened during the inpatient stay or prior to it.
  • The Surgical Report will provide an accurate description of the procedure and may include mitigating factors affecting the surgery.

If a denial of payment is received due to insufficient documentation, each provider will receive a letter with details and reason(s) for the denial. The best option for follow up action would be to provide the details from that letter to the admitting and operating physician. Gather additional documentation to support medical necessity of the admission and the surgery as needed from the physician and any site that provided preoperative diagnostics and care. Submit this additional documentation with the Redetermination Request Form (CMS 20027). A copy of the form is available on our website under Part A > Claims & Appeals > Levels of Appeals and Time Limits for Filing > Redetermination or CMS-20027 Medicare Redetermination Request Form.

To help avoid this type of denial in the future providers should share this information with the appropriate person within their facilities and update as appropriate any internal procedures/policies.

Additional information can be found under Medical Policy & Review > CERT > Comprehensive Error Rate Testing web page.

Inpatient Hospital Surgery
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