Medicare audits

Adam J Schwartz, Henry D Clarke, Adam Sassoon, Matthew R Neville, David A Etzioni
BACKGROUND: To lessen the financial burden of total joint arthroplasty (TJA) and encourage shorter hospital stays, the Centers for Medicare and Medicaid Services (CMS) recently removed TKA from the inpatient-only list. This policy change now requires providers and institutions to apply the two-midnight rule (TMR) to short-stay (1-midnight) inpatient hospitalizations (SSIH). METHODS: The National Inpatient Sample from 2012 through 2016 was used to analyze trends in length of stay following elective TJA...
August 30, 2019: Journal of Arthroplasty
Keith W Lyons, Christian M Klare, Samuel T Kunkel, Jason R Lemire, Mike Bao, Kevin J McGuire, Adam M Pearson, William A Abdu
Background: To evaluate charges, expenses, reimbursement, and hospital margins with noninstrumented posterolateral fusion in situ (PLF), posterolateral fusion with pedicle screws (PPS), and PPS with interbody device (PLIF) in degenerative spondylolisthesis with spinal stenosis. Methods: A retrospective chart review was performed from 2010 to 2014 based on ICD-9 diagnoses of degenerative spondylolisthesis with spinal stenosis in patients undergoing single-level fusions...
August 2019: International Journal of Spine Surgery
Corita R Grudzen, Abraham A Brody, Frank R Chung, Allison M Cuthel, Devin Mann, Jordan A McQuilkin, Ada L Rubin, Jordan Swartz, Audrey Tan, Keith S Goldfeld
INTRODUCTION: Emergency departments (ED) care for society's most vulnerable older adults who present with exacerbations of chronic disease at the end of life, yet the clinical paradigm focuses on treatment of acute pathologies. Palliative care interventions in the ED capture high-risk patients at a time of crisis and can dramatically improve patient-centred outcomes. This study aims to implement and evaluate Primary Palliative Care for Emergency Medicine (PRIM-ER) on ED disposition, healthcare utilisation and survival in older adults with serious illness...
July 27, 2019: BMJ Open
Suveen Angraal, Sudhakar V Nuti, Frederick A Masoudi, James V Freeman, Karthik Murugiah, Nilay D Shah, Nihar R Desai, Isuru Ranasinghe, Yun Wang, Harlan M Krumholz
BACKGROUND: Over the past 2 decades, guidelines for digoxin use have changed significantly. However, little is known about the national-level trends of digoxin use, hospitalizations for toxicity, and subsequent outcomes over this time period. METHODS: To describe digoxin prescription trends, we conducted a population-level, cohort study using data from IQVIA, Inc.'s National Prescription Audit (2007-2014) for patients aged ≥65years. Further, in a national cohort of Medicare fee-for-service beneficiaries aged ≥65years in the United States, we assessed temporal trends of hospitalizations associated with digoxin toxicity and the outcomes of these hospitalizations between 1999 and 2013...
May 8, 2019: American Journal of Medicine
Richard Powell, Matthew Menard, Alik Farber, Kenneth Rosenfield, Phillip Goodney, Bruce Gray, Robert Lookstein, Constantino Pena, Marc Schermerhorn
BACKGROUND: The Best Endovascular vs Best Surgical Therapy for Patients with Critical Limb Ischemia (BEST-CLI) trial compares open surgery and endovascular therapy for the treatment of critical limb ischemia (CLI). This report describes the types and proportion of investigators participating in BEST-CLI and determines how these compare with those specialists treating peripheral artery disease (PAD) outside of the trial. METHODS: To be credentialed to enroll in BEST-CLI, investigators must be approved by the Surgical and Interventional Management Committee to have sufficient experience and skill in the management of patients with CLI...
May 2019: Journal of Vascular Surgery
Alexander R Newman, Nicholas H Andrew
IMPORTANCE: The demand for glaucoma care is projected to increase significantly with the ageing population. BACKGROUND: To characterise trends in Australian practice patterns for glaucoma management over the 15-year period between 2003 and 2017. DESIGN: Retrospective audit. SAMPLES: The Medicare eligible population. METHODS: Audit of Medicare Benefits Schedule item number reimbursements in the private healthcare sector, and dispensed Pharmaceutical Benefits Scheme prescriptions...
December 13, 2018: Clinical & Experimental Ophthalmology
Matthew Daubresse, G Caleb Alexander, Deidra C Crews, Dorry L Segev, Mara A McAdams-DeMarco
BACKGROUND: Hemodialysis (HD) patients frequently experience pain. Previous studies of HD patients suggest increased opioid prescribing through 2010. It remains unclear if this trend continued after 2010 or declined with national trends. METHODS: Longitudinal cohort study of 484,745 HD patients in the United States Renal Data System/Medicare data. We used Poisson/negative binomial regression to estimate annual incidence rates of opioid prescribing between 2007 and 2014...
2019: American Journal of Nephrology
Adolph J Yates, Joshua M Kerr, Mark I Froimson, Craig J Della Valle, James I Huddleston
BACKGROUND: Total knee arthroplasty (TKA) was removed from the Centers for Medicare and Medicaid Services (CMS) Inpatient-Only (IPO) list starting January 1, 2018. Many hospitals responded by instructing surgeons to schedule all TKAs as outpatient procedures, and some local Medicare Advantage contractors began to expect outpatient status for all or most TKA cases. This activity and ensuing confusion has caused considerable unintended disruption for surgeons, hospitals, and patients. The purpose of this study was to gauge the impact on providers and patients...
September 21, 2018: Journal of Arthroplasty
Perry G Fine
After three and a half decades of experience with the Medicare Hospice Benefit in the United States, despite excellent quality outcomes in symptom management, patient and family satisfaction, and reduction in healthcare costs, only 12-15% of beneficiaries' days during the last year of life are spent being cared for within the highly cost-effective interdisciplinary coordinated advanced illness care model known as hospice. Although there are many reasons for this, including difficulties in acknowledging mortality among patients, their families, and physicians, a significant cause of low overall hospice utilization and intractably low median lengths of stay, reflective of late admissions, can be attributed to increasingly difficult and highly variable prognostic determinations for most of the leading causes of death among Medicare beneficiaries...
August 21, 2018: Journal of Pain and Symptom Management
Mae Fa Chong, Helen Hi Cho, A Jonathan Jackson, Sharon A Bentley
BACKGROUND: The number of Australians living with vision impairment or blindness is expected to increase substantially due to the ageing population and prevalence of age-related eye disease. In response, the Australian College of Optometry (ACO) commenced a low vision clinic in 2013. The ACO is a not-for-profit organisation providing eye-care services to more than 60,000 Victorians per year experiencing economic or social disadvantage. Consultation fees are bulk-billed to the Australian national health care scheme - Medicare - while spectacles and visual aids are subsidised through the state government-funded Victorian Eyecare Service...
November 2018: Clinical & Experimental Optometry: Journal of the Australian Optometrical Association
Suniah Ayub, Salvatore T Scali, Julie Richter, Thomas S Huber, Adam W Beck, Javairiah Fatima, Scott A Berceli, Gilbert R Upchurch, Dean Arnaoutakis, Martin R Back, Kristina A Giles
OBJECTIVE: Previous cost analyses have found small to negative margins between hospitalization cost and reimbursement for endovascular aneurysm repair (EVAR). Hospitals obtain reimbursement on the basis of Medicare Severity Diagnosis Related Group (MS-DRG) coding to distinguish patient encounters with or without major comorbidity or complication (MCC). This study's objective was to evaluate coding accuracy and its effect on hospital cost for patients undergoing EVAR. METHODS: A retrospective, single university hospital review of all elective, infrarenal EVARs performed from 2010 to 2015 was completed...
June 21, 2018: Journal of Vascular Surgery
Sarah E Tinkler, Rajiv L Sharma, Raven R H Susu-Mago, Sudeshna Pal, Miron Stano
Tobacco smoking and obesity are leading causes of preventable morbidity and mortality in the US, and primary care physicians are the main source of preventive care. However, it is not known whether access for new patients is affected by an expression of interest in preventive care. In a 2015 audit, we called US primary care physicians' offices to request appointment information regarding new patient physicals for simulated patients. Simulated patients were differentiated by smoking concerns (N = 907), weight concerns (N = 867), or no health concerns ("healthy" patients; N = 3561)...
August 2018: Preventive Medicine
Kyle D Hueth, Brian R Jackson, Robert L Schmidt
Objectives: To evaluate the prevalence of potentially unnecessary repeat testing (PURT) and the associated economic burden for an inpatient population at a large academic medical facility. Methods: We evaluated all inpatient test orders during 2016 for PURT by comparing the intertest times to published recommendations. Potential cost savings were estimated using the Centers for Medicare & Medicaid Services maximum allowable reimbursement rate. We evaluated result positivity as a determinant of PURT through logistic regression...
May 31, 2018: American Journal of Clinical Pathology
Matthew F Covington, Catherine A Young, Catherine M Appleton
Accreditation through the American College of Radiology (ACR) Breast Magnetic Resonance Imaging Accreditation Program is necessary to qualify for reimbursement from Medicare and many private insurers and provides facilities with peer review on image acquisition and clinical quality. Adherence to ACR quality control and technical practice parameter guidelines for breast MR imaging and performance of a medical outcomes audit program will maintain high-quality imaging and facilitate accreditation. Economic factors likely to influence the practice of breast MR imaging include cost-effectiveness, competition with lower-cost breast-imaging modalities, and price transparency, all of which may lower the cost of MR imaging and allow for greater utilization...
May 2018: Magnetic Resonance Imaging Clinics of North America
Audrey Deeken-Draisey, Allison Ritchie, Guang-Yu Yang, Margaret Quinn, Linda M Ernst, Ajda Guttormsen, Gyongyi Ella Simionov, Kruti P Maniar
CONTEXT: - The Current Procedural Terminology (CPT) system is a standardized numerical coding system for reporting medical procedures and services, and is the basis for reimbursement of health care providers by Medicare and other third-party payers. Accurate CPT coding is therefore crucial for appropriate compensation as well as for compliance with Medicare policies, and erroneous coding may result in loss of revenues and/or significant monetary penalties for a hospital or practice. OBJECTIVE: - To provide a review of the history, current state, and basic principles of CPT coding, in particular as it applies to the practice of surgical pathology, and to present our experience with initiating a new system of pathologist involvement in the review and verification of CPT codes, including the most common codes that require modification in our practice at the time of sign-out or post-sign-out auditing...
March 27, 2018: Archives of Pathology & Laboratory Medicine
Derek J Chan, Virginia Furner, Don E Smith, Mithilesh Dronavalli, Rohan I Bopage, Jeffrey J Post, Anjali K Bhardwaj
OBJECTIVE: To assess the prevalence of non-AIDS co-morbidities (NACs) and predictors of adverse health outcomes amongst people living with HIV in order to identify health needs and potential gaps in patient management. DESIGN: Retrospective, non-consecutive medical record audit of patients attending a publicly funded HIV clinic in metropolitan Sydney analysed for predictors of adverse health outcomes. We developed a scoring system based on the validated Charlson score method for NACs, mental health and social issues and confounders were selected using directed acyclic graph theory under the principles of causal inference...
March 8, 2018: AIDS Research and Therapy
Stephen E Bartnik, Stephen P Copeland, Angela J Aicken, Angus W Turner
BACKGROUND: Lions Outback Vision has run a state-wide teleophthalmology service since 2011. In September 2015 the Australian federal government introduced a Medicare reimbursement for optometry-facilitated teleophthalmology consultations under specific circumstances. This audit demonstrates the first 12 months experience with this scheme. We aim to provide practical insights for others looking to embed a telemedicine program as part of delivering outreach clinical services. METHODS: A 12-month retrospective audit was performed between September 2015 and August 2016, inclusive...
September 2018: Clinical & Experimental Optometry: Journal of the Australian Optometrical Association
Penni Blazak, Craig Hacking, Jeffrey Presneill, Michael Reade
INTRODUCTION: Computed tomographic (CT) imaging is widely available in Australian rural and remote hospitals and is often performed prior to patient transfer to definitive tertiary hospital care. We hypothesised that critically ill trauma and neurosurgical patients might have CT scans repeated after interhospital transfer and that the utility of this practice might be low in relation to the additional financial cost and radiation exposure. METHODS: We conducted a retrospective review of clinical records to determine the proportion of trauma and neurosurgical patients transferred to our tertiary ICU from other hospitals between 1 June 2013 and 30 June 2014 who underwent a repeat CT scan...
February 5, 2018: Journal of Medical Imaging and Radiation Oncology
Harish Kalra, Nicole Reilly, Marie-Paule Austin
BACKGROUND: There is limited information relating to routine depression screening and psychosocial assessment programs in private maternity settings in Australia. AIMS: To describe the psychosocial profile of a sample of private maternity patients who participated in a depression screening and psychosocial risk assessment program as part of routine antenatal care, and to explore women's experience of receiving this component of pregnancy care. MATERIALS AND METHODS: We conducted a retrospective medical records audit of 455 consecutive women having a routine psychosocial assessment and referral...
January 30, 2018: Australian & New Zealand Journal of Obstetrics & Gynaecology
Rajiv Sharma, Sarah Tinkler, Arnab Mitra, Sudeshna Pal, Raven Susu-Mago, Miron Stano
Medicaid and uninsured patients are disadvantaged in access to care and are disproportionately Black and Hispanic. Using a national audit of primary care physicians, we examine the relationship between state Medicaid fees for primary care services and access for Medicaid, Medicare, uninsured, and privately insured patients who differ by race/ethnicity and sex. We found that states with higher Medicaid fees had higher probabilities of appointment offers and shorter wait times for Medicaid patients, and lower probabilities of appointment offers and longer wait times for uninsured patients...
March 2018: Health Economics
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