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22670 Haggerty Road, Suite 100, Farmington Hills, Michigan 48335

Phone: 248-465-7300  |  Fax: 248-465-7428 

At MPRO, we are committed to maintaining an environment of equal opportunity and affirmative action. If you need a reasonable accommodation to access the information provided on this website, please contact us at 248-465-7300 for further assistance.

Our current review focus

Reminder

 

It is important that all claims (whether voided or adjusted) include the note “DCH-OIG MPRO” in the comment field. This note ensures that the correction is handled correctly and does not deny for timely filing. This comment should only be used on HPPAC denied claims and should not be appended to claims not specifically identified in a MPRO HPPAC audit findings letter. 

 

Click here to view what MPRO will review beginning April 1, 2015.

 

 

Beginning February 2015, MPRO will review for the following:

 

Sepsis DRG 871 & 872

 

MPRO will review for DRG Validation requiring that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, matches both the attending physician description and the information contained in the beneficiary's medical record. Reviewers will validate principal diagnosis, secondary diagnosis and procedures affecting or potentially affecting the DRG. Reviewers will access for the medical necessity of inpatient services for admissions prior to Oct. 1, 2013.

 

DRG           Description

 

871             Septicemia without mechanical ventilation 96+ hours with MCC

872             Septicemia without mechanical ventilation 96+ hours without MCC

 

If you have any questions, please contact Toria Spencer at 248-465-7368.

 

 

Beginning October 2014, MPRO will review for the following:

 

Respiratory Conditions with Major Complications or Comorbidities (MCC)

 

For the following 4 DRGs, there is a possibility of inappropriate reporting of principal and/or secondary diagnoses.  MPRO will review the documentation in the medical record to validate the presence of a major complication or comorbidity either present on admission of the Medicaid beneficiary to the hospital or subsequently developed during the hospital stay.

 

DRG               Description

 

177           Respiratory infections and inflammation with MCC

186           Pleural effusion with MCC

190           Chronic obstructive pulmonary disease with MCC

193           Simple pneumonia and pleurisy with MCC


If you have any questions, please contact Toria Spencer at 248-465-7368.

 

 

Beginning August 2014, we will review for the following:

 

According to ICD 9 CM Procedure Tabular List, a description of ventilation hours begin with the intubation of the patient (or time of admittance if the patient is admitted while on mechanical ventilation) and continues until the endotracheal tube is removed, the patient is discharged/transferred, or the ventilation is discontinued after a weaning period. In our experience the total number of hours reported has been incorrect.


In addition, coding standards include the review of coded principal diagnosis or secondary diagnosis. The following DRGs will be validated in this audit:
 

DRG       Description

 

003         ECMO or trach w MV 96+ hours or PDX exc face, mouth & neck w maj O.R.

004         Trach w MV 96+ hours or PDX exc  face, mouth & neck w/o maj. O.R.

207         Respiratory system diagnosis w ventilator support 96+ hours

870         Septicemia w MV 96+ hours

927         Extensive burns or full thickness burns with mechanical ventilation 96+         

               hours with skin graft

933         Extensive burns or full thickness burns with mechanical ventilation 96+

               hours without skin graft


If you have any questions, please contact Toria Spencer at 248-465-7368.

 

 

MPRO’s initial focus of review will be on one day inpatient hospital stays with certain DRGs. This review will be a Medical Records Review that will evaluate if these short stay inpatient admissions could have been provided in a different setting. The following are the DRGs that will be audited:
 

101         SEIZURES W/O MCC
153         OTITIS MEDIA & URI W/O MCC
203         BRONCHITIS & ASTHMA W/O CC/MCC
312         SYNCOPE & COLLAPSE
313         CHEST PAIN
314         OTHER CIRCULATORY SYSTEM DIAGNOSIS W MCC
392         ESOPHAGITIS, GASTROENT & MISC DIGEST DISORDERS W/O MCC
395         OTHER DIGESTIVE SYSTEM DIAGNOSES W/O CC/MCC
433         CIRRHOSIS & ALCOHOLIC HEPATITIS W CC
434         CIRRHOSIS & ALCOHOLIC HEPATITIS W/O CC/MCC
866         VIRAL ILLNESS W/O MCC

 

If you have any questions, please contact Toria Spencer at 248-465-7368.

 

 

Providers are required to submit the required documentation to MPRO within 30 days of request. Audited providers will be notified of the findings of these audits and providers that disagree with the findings will have an opportunity to appeal. All appeals will be handled according to the MI Administrative Code, Sections R400.3401 – R400.3424. For all options related to MDCH appeals:

www7.dleg.state.mi.us/orr/Files/AdminCode/106_01_AdminCode.pdf