Retrospective queries for denials

Is it compliant to send  a query based on payer denials when the encounter is almost a year old? 

Comments

  • I don't think so. Most auditors would not accept a query generated after an audit report has been sent to a provider. I can't think of the reference off the top of my head, but I seem to recall that queries can be generated only up to 30 days post-discharge. Some auditors will specifically state that they will not accept queries generated after an audit has been received. In a word, no. 
  • Agree with above.  Most of our denials are from records that are months old so we wouldn't query on those records.  Even if we did get a denial from a recent discharge, we would not query and consider the chart closed at that point.

  • And even if for some reason you did work out a Justification for doing a query on the old case it will have no impact.  The vast majority of payers have time limits placed on the rebill period so even if you make a clear cut case of an error or correction, it will be passed the deadline for refilling and wont matter.  The one exception being that if you discover you owe Medicare Money back..in which case all bets seem to be off and you have to rebill it under the false claims act. 
  • Yes, most payers will not accept such amendments, but more serious issue from my point of view is that you are running a compliance risk.

    Unless you discovered that information for one patient was accidentally documented in the other patient record, adding and amending documentation after such a long time will be non-compliant from HIM perspective.

    JCAHO does not provide a definite timeframe within which documentation amendments post-discharge are allowed, but most facilities accept 30 days as their internal policy..

    You probably have to discuss your internal process for documentation amendments with your HIM and Compliance departments/


  • In regards to the 30 days comment above ... don't know of any specific reference.

    Would suggest as more of a general comment, post discharge queries really should be posed during or immediately after the final coding process.
    There are occasionally cases that don't reach coding for more than 30 days post discharge as there may be other revenue cycle or other processes upstream that delay final coding occurring.

    Don
  • Medicare accepts rebills for 1 year but hospitals do not like to do them unless absolutely necessary as it draws compliance attention and invites unwanted audits. 
  • Alan I thought you had to rebill for a higher-weighted DRG within 60 days of initial remittance and that CMS would accept a rebill for a lower-weighted DRG with no time limit. Has that changed or am I delusional?
  • Thank you to everyone that has provided feedback.  below are some of the references I have found. I still do not feel we have a clear answer. I see this dilemma as ultimately setting the patient record straight. If there is no time limit on reporting a complications then why is there a time limit on clarifying information in the record? I will post more as I peel back this onion...  

    CMS:

    Code of Federal Regulations (CFR) > Title 42 (The Public Health and Welfare) > Chapter IV > Subchapter G > Part 482 > Subpart C > Section 482.24 Condition of participation: Medical record services.

    The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital.

    (c)Standard: Content of record. The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services.

    (4) All records must document the following, as appropriate:

    (viii) Final diagnosis with completion of medical records within 30 days following discharge.

     

    https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R615PI.pdf

     

    https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R732PI.pdf 

    https://www.aapc.com/blog/23844-medical-record-entry-timeliness-what-is-reasonable/

    #3 is mostly related to my question as to whether a retrospective query is compliant or acceptable when seeking clarification on record (even if it is brought to hospital attention by auditing company).  This still does not give a black and whit answer to the question at hand.

    https://www.gpo.gov/fdsys/search/pagedetails.action?collectionCode=CFR&searchPath=Title+42%2FChapter+IV%2FSubchapter+G%2FPart+482&granuleId=CFR-2011-title42-vol5-part482&packageId=CFR-2011-title42-vol5&oldPath=Title+42%2FChapter+IV%2FSubchapter+G%2FPart+482&fromPageDetails=true&collapse=false&ycord=1862

     



  • Although you cant query- these records are great teaching tools to the providers after the fact. You wont change that record but you might prevent future denials.
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