rebilling Medicare claims, PSI's, HAC's

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?




  • I also review all PSI/HAC's along with our Quality department but it is after they are billed if we aren't able to catch them as inpatient.  The only way Quality can run a report to identify cases is after they are final coded.  The Coders and CDSs alert me when they see an issue and we try to review pre-bill but there are always those that may slip through (some of those measures are a few pages long, lol).  We do query and rebill or correct codes and rebill and have not had an issue with this so far with acceptance of claims by any entity whether Medicare or commercial.  Our coding department has just gotten on the bandwagon and we are having monthly meetings to discuss any cases that we rebilled or simply reviewed for education.  We have picked up on a couple of coding issues we were able to address so that's been a win. 

    We re-run the report after the rebill to ensure that the PSI/HAC fell off the list. 

  • Thanks for the response! Our process sounds similar. And ours will also drop off the report we run because they are recoded and rebilled. BUT... we just found out that these claims, though rebilled, are not actually accepted by Medicare. There is no way I would have known this if it didn't come out in a side conversation with a biller. I had asked numerous times if they were being rebilled and I was always assured that they were (and technically, they were). They were also dropping off my report, as expected. But they will still be on our Data going to CMS, apparently. I have been doing this for a year and JUST found this out. So frustrating!! I don't know of a way to double check this because the HACRP report is so delayed our most recent one only goes to june 2015 and we started in august. I will be checking this years report but I don't think we get it until the spring :(


  • Katy

    We try to do as much as we can pre-bill but didn't know that if rebilled, the data was still going to CMS. Do they only accept the first claim?


  •  this is what I am being 'told' Jeff ;)

    The biller told me that they rebill the claim but Medicare will not accept the T-file because it is not a 'significant change'. I am not 100% confident in what I am being told, which is another reason I am asking. We have been unable to develop a consistent pre-bill process, unfortunately.

  • Well, now.  I'll get a list of some of the patients we have rebilled and get with our Business Office Director and see what response we get from them.  We are able to run reports monthly but am not sure who/where we run them through.

  • I would LOVE to hear what you find. As I said, I am not overly confident with what I am being told. Not because I think anyone is intentionally lying, but because I am not sure anyone truly understands this process fully from start to finish. Clearly, I didn't!! :)

    Thanks so much!

  • I've already fired off that email and will let you know what I find out.....  :)  


  • I look at all of the PSIs, PDIs and HACs in my institution and they are post code, pre-bill.  I have an understanding with billing and occasionally they email me about a case they are chomping at the bit to bill.  They will not bill it if they see it in my workqueue and there is a physician query involved, that is usually what holds it up.  Then I compare my spreadsheet to the info we get from Visient (UCH) to make sure we are all on the same page.

    Kathy Benson
    University of Wisconsin Hospital
  • Thanks Kathy,

    So yours are not be billed prior. What system are you using and how can billing see your queue? Our billing dept works in a different system than CDI but I am wondering if there is something I can do....

  • Ok, Katy.... Our business office VP is not aware of any issues with rebills or T Files.  He actually is not familiar with what a T File is but we have had no notifications of anything rebilled not being accepted. He is going to contact Medicare and inquire about T Files.  We validated that a few we rebilled with only a PSI code change were accepted without issue.  Our PSI/Hac reports are also matching what has been reported by CMS so far according to our Quality Director.  I'm hoping we are all good. 

  • hmmmm..... The plot thickens.....
  • If anything comes from his inquiry regarding T Files, I will post. 

  • thanks so much, I REALLY appreciate it!
  • I have asked our business office VP, coding director and we have even googled "Medicare T File" and none of us have ever heard of this or can find information from CMS on this type file.  The only thing we can think of is that it is something specific at your facility they have named a type file they receive within their particular system. ???  We have re-verified that all accounts rebilled for quality issues whether the RW was changed or not were accepted by Medicare. 

    If anyone else has information to share regarding this, PLEASE do so.

  • UGH!!!! ok. going back to billing. THANK YOU!!!
  • I have found out that there is a "T Status" that is identified on CMS claims when there is some sort of error and they are not accepting the changes.  Ours, however have not given us any problems and have been accepted when codes have been rebilled for quality.  We have a  meeting next week and are going to ask some of our consults if they have had this issue anywhere or have heard of it. 

  • As background -- we have EPIC & 3M 360.
    There is a work flow from 3M into EPIC for a lot of the coding work -- as coding, billing, quality & others focus their workflow with EPIC work queue's.

    There are specific work queue's where potential PSI's show up, post coding but with a bill hold in place. Quality, coding, CDI & physician advisors are involved with validating these before the bill is dropped. With this process, I suspect there are minimal if any rebilling associated with PSI/Quality issues.

  • We have verified that all rebills we submitted to CMS were accepted and updated.  No one we have reached out to has heard of this issue.  Hope you have found the same at your facility! 

  • ughhhhh..... still working on it! thanks so much! I REALLY appreciate you looking into it and apologize that I sent you on a wild goose chase :(
  • I didn't find any geese and didn't mind at all, just glad that it wasn't an issue here.  I am hoping that if they accepted our changes, that yours are secure as well!!!   :)   

  • as an update, our billing dept is maintaining that rebills will not go through for traditional medicare (not HMO's)

    they say... " the HMO’s were fine, but the DDE rejected the claim as a duplicate.  In order to bypass the Medicare DDE edit it has to be of significant change and the POA is not considered significant. We can’t change DDE edits."

    So.... the investigation continues



  • Ok.  Maybe we are on to something.  We have queried and changed codes, but I don't remember any that we changed POA status.  At the most 2-3 in the past several years. That may be the issue.  ???  Our Quality Director has been able to pull all that we rebilled since the beginning of 2015 and they all dropped off of the quality report and our business office was able to verify that all were accepted.  I don't recall any POA changes in that group.
  • ahhhh!!! I often find that POS status is the issue with PSI's. For example, the patient was in OBS for 24 hours and developed the issue during this time. We seem to miss those distinctions sometimes and then they need to be rebilled.

    maybe this is the difference...

  • I review the HACs and PSI's. My question is that if a postprocedural pneumothorax J95.811 and an insertion of an infusion device into right IJ vein 05HM33Z are coded on an encounter but the pneumothorax was not caused by the IJ insertion but by a thoracentesis, there is no way to differentiate this in coding. The PSI outcome measure CDBR:1406 Iatrogenic pneumothorax with venout catheter, will include this patient. As a result of that, it appears on the Harm report. Has anyone had that situation? 
  • Yes, I'm dealing with this right now. So the scenario; pneumothorax after thoracentesis but the patient also had a PICC inserted. Pneumo no relation to PICC insertion. How are you addressing the situation?

  • Did the Physician establish a cause/effect relationship between the Pneumothorax and the Thoracentesis? See Coding Clinic regarding Iatrogenic Pneumothorax. Not all complications are complications, some post procedure findings are routinely expected and do not require additional intervention, resources or extend the patient's stay and should not be captured in Coding.

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