Health Reform Connect

TrailBlazer Health Enterprises, a Medicare administrative contractor (MAC), has provided guidance on spinal fusion (MS-DRG 460) which has become an area of increased scrutiny by CMS because of the growth in billing volume. The most common reason for denial of payment for spinal fusion-related hospital care is the lack of specific information about conservative care administered before the surgical intervention, but often times this missing information may exist in the outpatient records of the surgeon, primary care physician or other practitioner. To reduce audit errors caused by information missing from the hospital record, the hospital should proactively obtain previous diagnostic and therapeutic records from the surgeon and other practitioners including physical assessments, physician history and physical, progress notes, consultations, physical and occupational therapist evaluations and notes, radiology reports and therapeutic procedure notes. The practitioners should also either create clinically meaningful inpatient records or supply the hospital with relevant documents from their outpatient records. By including adequate history of the presenting illness it will improve the likelihood of payment of the hospital claim and payment of physician services performed in conjunction with the hospital stay.  If you have any further questions please contact Meghan Linvill McNab at 317-808-5863 or Kristen L. Gentry at 317-238-6288.