Medicaid Hospital Utilization Review and DRG Audits: Frequently Asked Questions The Department of Medical Assistance Services Division of Program Integrity August 2007

What Is the Code of Federal Regulations (CFR)?  The Code of Federal Regulations (CFR) is the codification of the general and permanent rules published in the Federal Register by the executive departments and agencies of the Federal Government. It is divided into 50 titles that represent broad areas subject to Federal regulation.  Each volume of the CFR is updated once each calendar year and is issued on a quarterly basis.  Titles are updated as of October 1st of each year. Title 42 – Public Health, Chapter IV – Centers for Medicare and Medicaid Services (CMS), Department of Heath and Human Services, Part 456, Utilization Control is used to determine federal code compliance when auditing acute care hospitals.

Where Is the Code of Federal Regulations?  On Line at  Enter 42CFR456 in Quick Search to access the codes applicable to Medicaid audits.  Hard copies may be purchased through U.S. Government Online Bookstore. U.S. Government Online Bookstore

Where Are the Medicaid Manuals Located?  Provider manuals are available on line at  Click on the Manuals link under Provider Services.  Hard copies may be ordered from Commonwealth Martin at (804)

What Documentation Is Needed for Utilization Review in the Hospital?  Refer to CFR § § , for hospital admissions.  Each recipient, including mothers and newborns, must have utilization review documentation.  DRG payment for hospitalization does not preclude the requirement for utilization review.

Are Extensions Given for the Hospital Utilization Review Audit?  An extension may be given for submitting audit information to DMAS.  Contact your DMAS utilization review analyst to discuss an extension.  Extensions are not available for on- site audits.

Audits of Acute Medical Care Hospitals The Code of Federal Regulations (CFR), Title 42, Part 456 addresses utilization controls for acute medical inpatient services.

Why Does the Certification Have to Be Dated on the Day of Admission? o The Code of Federal Regulations (CFR), Title 42, § for admissions to hospitals, states that the certification must be made at the time of admission. o If an individual applies for benefits while in the hospital, the certification must be completed before the claim is paid by DMAS. o It is acceptable to complete a Medicaid admission certification even if the patient is “Self Pay” when admitted. The patient might receive retroactive Medicaid benefits later.

Can Newborns Share Their Mothers’ Admission Certifications?  Newborns must receive their own admission certifications.  They can not share their mothers’ certifications.

What is the Format for an Admission Certification?  There is no standardized certification form. A sample form is found in the Medicaid Hospital Manual, Chapter VI, Exhibits section.  Hospitals may design their own forms.  Hospitals may use a stamp stating “Certified for Necessary Hospital Admission.” Physician must sign and date on date of admission.  Physicians may write “Certified for Necessary Hospital Admission” in the record, and sign and date on the date of admission.  Refer to CFR § for information on hospital admissions.

What is the Specific Wording for Admission Certification?  The words “Certified for Necessary Hospital Admission” must be in the statement.  This can be on a form, or in a handwritten or stamped statement in the record.  Physician must sign and date the certification on the date of admission.  Refer to the Medicaid Hospital Manual, Chapter VI.

What Certification Date Should Be Used for Observation Patients?  The date of the admission certification must be the date that the patient is converted to Inpatient status.

What is the Format for the Plan of Care?  There is no standardized format for the plan of care.  Most hospitals combine the admission certification and plan of care on one form. A sample form is found in the Medicaid Hospital Manual, Chapter VI, Exhibits section.  Refer to the Hospital manual, Chapter VI and the CFR,§ for information on plans of care.

Psychiatric Hospitals and Freestanding Acute Care Psychiatric Facilities The Code of Federal Regulations (CFR), Title 42, Subpart D addresses utilization controls for psychiatric inpatient services.

Where is the Information Specific to Audits of Psychiatric Facilities?  Program and utilization review requirements are described in the Psychiatric Services Manual Chapter IV describes covered services Chapter VI describes utilization review

What Information Is Included In the Audits for Psychiatric Admissions?  Utilization Management Plan must comply with 42 CFR  Review of certifications  Review of plans of care  Verification of required evaluations  Validation of prior authorization documentation, including Interqual criteria  Validation of services provided by qualified professionals  Dated signatures required on all medical documentation

When Must Psychiatric Admissions Be Certified?  Certification must be made at the time of admission On admission is defined as within 4 hours Exception to this is retroactive Medicaid eligibility

When Must Emergency Psychiatric Admissions Be Certified?  For emergency admits, the certification for admission can be completed up to 14 days from admission (42CFR )  This applies to general acute care and freestanding psychiatric facilities.

What is Required for Certification at Freestanding Psychiatric Facilities?  Required to be made by an independent team (42CFR )  Required to include information specified in chapter IV of the Psychiatric Services Manual Sample form in Exhibits section  Recertification is required at least every 60 days

DRG Audits  The Code of Federal Regulations (CFR), Title 42, § addresses the basis for DRG audits.

What is the Purpose of the DRG Audit?  Medical records are audited to ensure that appropriate ICD-9-CM diagnoses and procedure codes are supported in the medical record.  The audit identifies inappropriate practices of upcoding or inappropriate coding assignments.

Why Does DMAS Conduct DRG Audits?  The federal government requires the Department of Medical Assistance Services to verify that hospitals participating with Virginia Medicaid are in compliance with the Center for Medicare and Medicaid Services (CMS) requirements.  Refer to the CFR §

How Are Claims Selected for DRG Audit?  The sample is determined at DMAS’ discretion.  DRG validation may be done through DMAS or through a selected contractor.

What Documentation Will Be Reviewed for the DRG Audit? The following should be included in the medical records sent for review: History and Physical Discharge Summary Operative Report Physicians’ Progress Notes Consultation Reports Lab/X Ray Reports Other relevant data to support the claim

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