Did a MAC Really Imply That the Inpatient Admission Order is Optional?

Dr. Ronald HirschJuly 24, 2023

MAC advice to one hospital seems too good to be true.


Boy, do I have a story to tell.


Now, let me start by noting that I am relaying information provided by a case management leader and did not have access to any medical records, nor was I able to listen in to the calls that took place. As always, before you do anything, be sure to check with your legal and compliance staff to be sure they support what you are doing. I am also not going to name the hospital nor the Medicare Administrative Contractor (MAC) involved, but would be happy to provide that information to someone from the Centers for Medicare & Medicaid Services (CMS).


That said, here is the situation. As you know, CMS has in place a required prior authorization program for specific outpatient procedures performed in the hospital outpatient department, where data has shown increases in utilization. Included in that program are two codes for cervical spine fusion, 22551 and 22552. At this hospital, a patient was scheduled for this surgery, and the prior authorization request was submitted to the MAC and approved.


The surgery proceeded and the patient was discharged from the recovery room. The chart went to coding and the surgery performed was coded as 22830 and not 22551. That code was placed on the outpatient claim and the claim submitted. And lo and behold, the claim was rejected. It turns out that 22830 is on the inpatient-only list.


Well, the hospital called the MAC and were told that since they were within the timely filing period and they received a denial, they could simply submit an inpatient claim and get paid. The MAC never asked if there was an inpatient admission order in the record. The manager was not sure that this advice was sound, so asked for confirmation.


First things first: what happened here? The surgery that was actually performed was 22830. That is exploration of spinal fusion, a procedure that occurs for a patient who previously had a spinal fusion. So, submitting 22551 for prior authorization made no sense in this clinical situation. That was the manager’s first mission: figure out who dropped the ball. Who obtained the prior authorization, and what information did they have that would lead them to the completely wrong surgery? I would hope that the surgeon knew the patient previously had surgery. Maybe their policy is simply to designate every planned fusion as a 22551 simply to get a prior authorization, just in case. If so, that potentially creates a world of hurt when the planned surgery is actually an inpatient-only surgery, as happened here.


Read the full article here.

Author Bio: Dr. Ronald Hirsch is Vice President of the Regulations and Education Group at R1 RCM Inc. Dr. Hirsch was a general internist and HIV specialist and practiced at Signature Medical Associates, a multispecialty practice located in Elgin, IL. He was Medical Director of Case Management at Sherman Hospital in Elgin, IL from 2006 to 2012, where he was Chairman of the Medical Records Committee from 1995 to 2012, and also served on the Medical Executive Committee. Dr. Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, certified in Revenue Integrity by the National Association of Healthcare Revenue Integrity, and on the Advisory Board of the American College of Physician Advisors. He is on the editorial board of RACmonitor.com. He is the co-author of The Hospital Guide to Contemporary Utilization Review, with the third edition published in 2021.

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