News: CMS resumes BFCC-QIO short stay reviews

The Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations’ (QIOs) resumed patient status reviews of short stays in acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities on September 12, 2016, according to a statement published by CMS.

BFCC-QIOs began conducting patient status reviews to determine the appropriateness of Part A payment for short stay hospital claims back in October 2015 but by May 2016, CMS suspended the reviews in order to review policies and retrain its auditors.

The BFCC-QIOs will now begin to examine records for compliance with 2-midnight rule and other short-stay Medicare requirements and will follow the same guidelines implemented before the temporary pause when reviewing claims for patient status, according to CMS. Twice a calendar year, the BFCC-QIOs will conduct patient status reviews using a provider sample from claims paid within the previous six months. BFCC-QIOs will request a minimum of 10 records in a 30-45-day time period from hospitals. The maximum number of record requests per 30 days will be 30 records. BFCC-QIOs will develop detailed results letters for all providers, including individualized, claim-by-claim denial rationales and clinical details. Additionally, one-on-one provider education must be completed by the BFCC-QIO within 90 days. A complete list of guidelines is available on the CMS website.

In light of new coding guidelines and increased scrutiny on 2-midnight rule compliance, CDI professionals will need to become more involved with diagnosis validation, says Allen Frady RN-BSN, CCDS, CCS, CDI education specialist for BLR Healthcare in Middleton, Massachusetts. For example, coding guidelines no longer require linking language in provider documentation to assign a combination code or mandatory multiple code, which may lead to medical necessity denials. CDI specialists will need to be vigilant in anticipating potential problems and query for correct diagnostic language to best match the complete clinical picture of the patient.

“This will present its own special set of problems when looking at medical necessity in relation to the expectation that a patient may, or may not, require care crossing two midnights in the eyes of the auditor,” says Frady.

CMS will continue to oversee BFCC-QIO reviews and will re-review a sample of completed claim reviews each month. The agency will also monitor provider education calls and respond to individual provider inquires and concerns. CMS encourages providers to send questions to its Open Door Forum Mailbox at ODF@cms.hhs.gov.