Short Term Acute Care Hospital (STCH)

Wisconsin Physicians Service (WPS) Medical Review (MR) is providing this article to update providers on the status of service specific prepay edits. MR service specific complex review edits are commonly known as prepay edits. These prepay edits suspend claims from multiple providers when a claim is submitted for payment which includes specific coding criteria for that service.

This article details the initiation of a service specific edit. WPS MR prepay edits are continually reviewed based on reviewed claim data. Edits are modified or terminated as data analysis supports decreased vulnerability to the Medicare Trust Fund and/or workload analysis.

The following MR service specific prepay edit in the WPS MAC J5 region is active.

Reason Code: 5STCH
Date Initiated: February 2, 2011
This prepay edit is the result of: Probe Review Results.

Probe reviews were conducted on inpatient admissions for Short Term Acute Care Hospitals (STCHs) billing various Diagnostic Related Groups (DRGs). Probe results from Fiscal Year 2009 (FY09) and Fiscal Year 2010 (FY10) have been collected and analyzed for inpatient admissions based on DRGs billed. The average error rate for dollars billed in error was 66.2 %. The average error rate for claims billed in error was 67.5%. A prepay edit has been initiated for all providers billing the criteria identified that has a high potential for error based on our probe data analysis.

A complex medical review will be performed on each claim to determine if medical necessity and proper coding requirements have been met. Possible reasons for denial are as follows:

It is important for providers to remember Observation care is appropriate while a decision is being made regarding whether patients will require further treatment as hospital inpatients or receive medically necessary care in an Observation status. Observation services are commonly ordered for patients who present to the emergency department and then require a significant period of treatment or monitoring in order to make a decision concerning admission to inpatient status or their ability to be released.

"In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours." (CMS IOM Publication 100-04, Chapter 4)Adobe Portable Document Format

Page Last Updated: Thursday, 15-Dec-2011 13:59:46 CST