Adding More PEPPER and a Questionable QIO Decision

I talk a lot about the PEPPER here. It really is a quite valuable tool for seeing not only hospital compliance risk but also revenue opportunity.

And since the revamping of the report, it seems that every time I look at a report, I find another issue. Last week I described what the Centers Medicare & Medicaid (CMS) called a methodology refinement that significantly changed a measure. And the issue of this week is the CMS description of one of the measures, the reporting of single CC or MCC.

This measure looks at how many inpatient admissions are billed with only one CC or MCC.

Now as you may know, the assignment of the appropriate diagnostic related groups (DRs) that are specified as CCs or MCCs. If there is one MCC, the assigned DRG is the highest weighted DRG. There is no change in the DRG if there are additional MCCs on the claim.

But, as we all know, auditors love to do DRG validation audits. Nothing pleases them more than being able to remove a diagnosis from a claim and recoup money. And that is what happens if there is only one CC or MCC. So, when your PEPPER shows a high number of single CC/MCC claims, that’s a bad thing. But if you read the PEPPER, for a high outlier, it states that “This could indicate that there are coding or billing errors related to over-coding due to unsubstantiated CCs or MCCs.”

What? There is only one CC or MCC and that represents overcoding? Are they suggesting the doctor made up that one diagnosis simply to get to the higher weighted DRG? I certainly hope that is not the case. What should one do when there is only one CC or MCC? Take another look at the chart and see if there are any undocumented CCs or MCCs and query the doctor. And check with the coding team to be sure they are scouring the chart for every codable diagnosis and not moving on to the next chart after finding one MCC.

And just as I was preparing this, CMS released their weekly MLN Matters with an article entitled “All Medicare Facility Types: Get Ready for the PEPPER Relaunch.” Are they serious? Acute care hospitals have now received three quarterly PEPPERs since the revamp. Was that not the relaunch? I am so confused.

Now for those sick of PEPPER, let me change gears and voice my frustration with one of the BFCC-QIOs. An unnamed hospital in an unidentified state whose QIO shall remain unnamed had an inpatient appeal their discharge as allowed. The hospital sent the medical records.

The QIO issued a timely decision which read: “The patient and representative as asking to extend admission by a day until the patient’s sister gets paid and can get the patient a place to stay while recovering and finishing the rest of the antibiotics course. Otherwise, the latest vital signs are stable and the patient’s presenting medical issues have stabilized.

From the clinical perspective, the patient is medically stable to discharge to a different setting where continued post-hospitalization care, monitoring, medical management, and skilled therapies can be provided if needed. However, given the patient’s social circumstances, and to minimize chance of further decline and re-hospitalization, it would be reasonable to extend by a day or two until the patient has a safe place to stay upon discharge.”

What the heck is going on? The QIO admits there are no medical issues, yet they give the patient “a day or two?“ Who is going to tell that patient in a gurney in the ED waiting for an inpatient bed that they need to stay there two more days until this patient’s sister gets her paycheck? Is this the new standard? Can we start admitting patients whose caregiver wants to go on vacation and get paid for the stay?

I doubt any hospital would object to that.