QIO Short Stay Audits and the CMS IPO ListRitu Prasad, MD, CHCQM-PHYADV Every year CMS puts out the Inpatient Only list, also known as the IPO list, which dictates which procedures must be performed as hospital inpatient status. With each release, CMS will update the IPO list, often removing some procedures and occasionally adding back procedures that were previously removed. Over the last 2 years, there have been numerous changes to the CMS IPO list, especially for orthopedic surgery. These changes to the IPO list have occurred during the COVID surges, leaving overwhelmed health systems scrambling to update their surgical service lines and patients. In the face of the COVID pandemic, keeping track of these changes has been a challenge. Fortunately, with each set of changes, CMS allows for an “audit-free” window to allow health systems to incorporate and rollout these updates. Now that CMS audit activity has resumed, following are a few thoughts to keep in mind if a short stay procedure is pulled as part of a short stay audit. First, let’s start with the basics: What is a short stay audit? Quality Improvement Organizations (QIOs) are contracted by the Centers for Medicare and Medicaid Services (CMS) to improve the quality and efficiency of healthcare for Medicare beneficiaries. Quality Improvement Organizations (QIO) are resuming short stay reviews to determine if medical services are medically necessary, compliant with the 2 midnight rule, and follow IPPS and OPPS guidelines for Medicare patients. The focus of these reviews is reviewing cases with a length of stay (LOS) under 2 midnights to see if the 2 midnight rule is being correctly appliedi. What are the potential consequences / risks of these audits? After conducting the audit, the QIO will send a determination letter for any denied cases. (No letter is provided for approved cases.) The letter will detail the case reviewed, dates of service, and the QIO’s determination, along with case information to provide a brief rationale for denial. The hospital Is provided an opportunity to respond, typically 20 days. If no response is received from the hospital in that time, the proposed denial becomes the final determination. The MAC and the beneficiary will be notified of the denial. It is important to review the cases pulled for review to ensure the utilization review processes in your hospital are working correctly in regards to following the 2 midnight rule as well as the CMS IPO list. It is also a good opportunity to assess your audit risk and determine if education, process improvement, or internal audits are needed at your institution. As the QIO resumes short stay audits for medical necessity and compliance with the 2 midnight rule, what should you do if they pull a surgical case for audit that was recently removed from the IPO list? In 2021, CMS removed 290+ procedures, many orthopedic, from the IPO list and advised that these procedures would be exempt for audit for compliance with the 2 midnight rule. In 2022, many of those procedures were placed back on the CMS IPO list, and the “audit free windows” are discussed below: In the CY 2021 OPPS/ASC final rule, CMS established a policy in which procedures removed from the IPO list beginning January 1, 2021 would be indefinitely exempted from certain medical review activities related to the two-midnight policy. This policy change was made to accommodate the unprecedented number of procedures being removed from the IPO list beginning in CY 2021 due to the elimination of the IPO list. For CY 2022, because CMS is finalizing the proposal to halt the elimination of the IPO list and to return the majority of services removed in CY 2021 back to the list, CMS is also finalizing the proposal to revise the exemption for procedures removed on or after January 1, 2021 from the IPO list to the exemption period that was previously in effect, that is, a two year period.ii So now you’re thinking, shouldn’t a surgical case just recently removed from the IPO list not be pulled in a short stay audit? What does the audit free window actually mean? QIOs are still able to audit for the purposes of providing education, but not for the purpose of rescinding payment or referring to RAC. So, what to do next? The CMS changes to IPO list have been rapid and dynamic over the last five years, as many of the changes have been quickly rescinded. It’s hard for all parties involved to keep track of the updates, let alone track all the audit free windows for these procedures. If you see an orthopedic surgery pulled for a short stay audit, it may be worth reviewing the timeline of when the procedure was removed from the CMS IPO list to determine if it is still in the audit free window. In addition, consider formulating an appeal that explains the IPO list, the CY 2021 changes, and the audit free window that is well outlined in the CMS fact sheet. And of course, make sure to submit your additional info in the allotted 20 day timeframe! Dr. Prasad is Senior Physician Advisor and Medical Director of Observation Services at MedStar Union Memorial Hospital |