Rebilling DRG claims

cseluke

What is your facility's practice with rebilling DRG cases? Our reconciliation process takes place after the bill has been dropped; we rebill some cases when a coding error is found. We rebill for both higher and lower weighted DRG's. I have had some in the industry tell me that any rebill is a "big red flag" for recovery auditors. It would seem that CMS must allow for some level of rebilling. I take the position that if you find errors and rebill whether or not you gain or lose reimbursement you are being compliant. Does anyone know if there is official guidance on this subject?

Cathy Seluke

bbogda@morrishospital.org

We do the same as you do.  If a re-bill is necessary, it is done without regard to what an auditor might think.  The auditors do single out the rebills for scrutiny, but if you are coding the chart accurately you shouldn't have anything to worry about.  If they deny a DRG you should be able to defend why you are coding it.

afloyd24

We also do the same and I am of the same thought as far as auditing.  The only issue we have had is with some of the commercial insurances who have denied a query answer if that was the reason for the rebill.  We have at times, final coded an account if the physician was not compliant in answering the query within our timeframe and then got an answer afterward but still within the rebill timeframe.  The auditor has denied the DRG change stating the chart was not submitted in its entirety initially.  Yep. 

cseluke

Thanks for the feedback. I have another question related to rebilling. Here is the scenario; a 3rd party auditor denies a DRG payment by stating that a secondary diagnosis (e.g., acute hypoxic respiratory failure) is not clinically supported. The diagnosis is documented well in the record, but there are no supporting clinical indicators. The provider agrees that the diagnosis cannot be clinically supported. What procedure do you follow regarding correcting the coding and billing?

katysuegood@gmail.com

Hi there,

I just posted on another thread and then saw this so I figured I would tag on. As to the original question, we do retro DRG mismatch and re-bill if needed. Yes, it is a red flag. But as long as we are well supported in our decision, I am not concerned about an audit.

As for the last question about denials, I believe the auditor simply re-coups the funds from the hospital without it actually being re-coded.

As for my question...

As part of my job, i review all coded HAC's and PSI's. Because it has been difficult to get coding to send these to me pre-bill this has primarily been occurring post-bill though I review within a day or 2 of it being final coded. I had a meeting with Billing recently about some re-billing issues that have arose recently. They mentioned that even if we are within 60 days, if we want to re-bill a claim for quality purposes, the T-file will not be accepted by Medicare as they do not recognize this as a 'significant change'.

For those of you working on PSI's/HAC's/etc, what does your process look like? is it occurring pre or post-bill? If it is retro, have you had any issues with Medicare accepting the claims?

thanks!