Provider Notice issued 09/19/07

Inpatient Utilization Review Update

This informational notice provides notification on changes to the diagnosis codes subject to inpatient utilization review, and identifies changes to utilization review activities. Attachments referenced in this notice can be downloaded from the department’s Web site at http://www.hfs.illinois.gov/proqio/

Eliminate Concurrent Continued Stay Review for DRG-Reimbursed Hospitals Effective with admissions on or after October 1, 2007, HFS no longer requires HealthSystems of Illinois (HSI) to perform concurrent continued stay review for those inpatient hospital admissions that are DRG-reimbursed.

The requirements for DRG-reimbursed hospitalizations are as follows: 

• HFS still requires hospitals to obtain certification of admission from HSI, by calling HSI’s  toll-free certification line or submitting a request through their Web-based review system.
• At the time of discharge, the hospital must contact HSI for a quality of care screening and provide HSI with the discharge date. 
• Throughout the year, HSI will perform a randomly sampled Retrospective Postpayment Review for those DRG-reimbursed hospitalizations with admission diagnoses subject to mandatory concurrent review.

Changes to Diagnosis Codes 

Effective with admissions on and after March 1, 2007, Diagnosis Codes 518.83 and 518.84 have been eliminated from Attachment C.

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  • Effective with admissions on and after October 1, 2007, Diagnosis Code 315.34 – Speech and Language Developmental Delay Due to Hearing Loss, has been added to Attachment A for review.  Based on previously stated coding guidelines, this 5th digit code extension will automatically be subject to review. 

Mandatory Concurrent Review Performed – Admitting Diagnosis Code Changes 

• Effective with admissions on or after June 1, 2007, hospitals may resubmit claims that have rejected for A88 – No Certification on File for payment reconsideration, if the rejection occurred because the admitting diagnosis code on the claim does not match the admitting diagnosis code provided to HSI for concurrent review.  The resubmitted claim must contain the admitting diagnosis code that was reported to HSI for the concurrent review.  These claim resubmittals are not part of the exception process and can be submitted electronically.
  

Mandatory Concurrent Review Exception Process  

• HFS recommends that hospitals submit paper claims to their assigned billing consultant at HFS along with the supporting documentation that relates to one of the mandatory concurrent review exceptions.  These claims are reviewed manually.  Please refer to previous informational notices dated November 28, 2006, and February 27, 2007, for additional information regarding the exceptions and the process.
• Hospitals have the option of submitting their claims electronically.  However, claims containing an admitting diagnosis code that requires a certification of admission will be rejected if the admission certification was not done and the claim is billed (electronically or on paper) without an exception request.  Once a hospital has received the Remittance Advice depicting the Error Code A88 – No Certification on File, the hospital needs to determine the reason for the rejection and resubmit the claim with an exception, if appropriate.

Eliminate Backdated Eligibility from 10% Threshold 

Recognizing that it may be difficult for hospitals to achieve 100% mandatory concurrent review, HFS is allowing up to 10% of the reviews to suspend for retrospective prepayment review that meets one of the exceptions.  HFS will not include those cases that require an exception due to backdated eligibility in this 10% threshold.  Hospitals must continue to provide the necessary documentation to HFS to denote the backdated eligibility and complete HSI’s tracking form when submitting the medical record to HSI.

Any questions regarding the review process may be directed to HSI’s Toll-Free Helpline at 800-418-4045.  Any questions regarding this notice may be directed to the Bureau of Healthcare Quality Improvement at 217-557-1031.