Empire State Medical Scientific and
Educational Foundation, Inc.
DISPUTE RESOLUTION
REVIEW PROGRAM
Health Care Financial Management Association
April 14, 2011
Empire State Medical, Scientific and Educational Foundation, Inc.
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About Us
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Not for profit corporation focusing on quality
medical peer review
Independent Medical Review Organization
sponsored by the Medical Society of the State
of NY
Registered Utilization Review Agent with the
NYS Bureau of Managed Care
Pursuing certification with URAC, NCQA
27 years experience in medical peer review
Empire State Medical, Scientific and Educational Foundation, Inc.
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Relevant Experience
Provide Dispute Resolution Review
services throughout New York State
 Provide External Appeal Review
services for the State of Connecticut
 Serve as Medicaid Peer Review Agent
through subcontract with IPRO
 Perform coding/compliance review for
physician offices throughout NYS
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Empire State Medical, Scientific and Educational Foundation, Inc.
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Dispute Resolution Program
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Internal Review Process
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Providers and Payors contractually agree to
an internal dispute resolution/appeal
process
External Review Process
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Providers and Payors contractually agree to an
external dispute resolution/appeal process
Contract should designate an outside entity to
serve as the dispute resolution/external appeal
agent
Empire State Medical, Scientific and Educational Foundation, Inc.
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Dispute Resolution Program

(con’t.)
Items your Contract should address:

Internal Review/Appeal Process
Specify the timeframe for initiating the appeal
process
 Specify the number of reviews available (initial
and final versus final review only)
 Specify the steps for initiating each step of the
process
 Specify the issues that may be appealed
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Empire State Medical, Scientific and Educational Foundation, Inc.
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Dispute Resolution Program

(con’t.)
Items your Contract should address

(con’t.):
External Dispute Resolution Review
Process
Designate the Entity to be used for external
dispute resolution review
 Identify who will initiate the review process (ie
hospital or payor or either)
 Specify the timeframes for initiating the dispute
resolution review process
 Identify the issues that may be disputed
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Empire State Medical, Scientific and Educational Foundation, Inc.
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Dispute Resolution Program

(con’t.)
Items your Contract should address

(con’t.):
External Dispute Resolution Review
Process (con’t.)
Specify if one or two reviews are available
through the external process
 Designate the final responsibility for the review
fee
 Contractually agree that both parties will be
bound by the decision of the external agent

Empire State Medical, Scientific and Educational Foundation, Inc.
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Dispute Resolution Program

(con’t.)
Issues Reviewed
Correct coding and/or DRG assignment
 Medical necessity of admission and/or
length of stay (Acute and/or Exempt Unit)
 Level of care
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Acute/Observation/Skilled/Alternate
 Inpatient versus outpatient level of care
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Other issues as requested
Empire State Medical, Scientific and Educational Foundation, Inc.
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Dispute Resolution Program

(con’t.)
Review Criteria Utilized
Interqual® Adult and Pediatric Level of Care
criteria
 Milliman Care Guidelines®
 NYS Rules and Regulations
 UHDDS Coding Guidelines
 3M/HIS NYS Grouper/Pricer
 AMA 1995/1997 CPT Coding Guidelines
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Empire State Medical, Scientific and Educational Foundation, Inc.
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Dispute Resolution Review Process
Materials received from requesting
party
1.
I.
II.
III.
2.
Dispute Resolution Application
Copy of the Medical Record
Supporting documentation for issue in
dispute
‘Notification of Review Request’ is sent
to other party with instructions to
submit comments
Empire State Medical, Scientific and Educational Foundation, Inc.
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Dispute Resolution Review Process
(con’t)
Case is reviewed by nurse and/or
coder
3.
I.
II.
4.
5.
Nurse reviews medical necessity issues
Coder reviews DRG/coding issues
Case is referred to physician specialist
Review results are published
Empire State Medical, Scientific and Educational Foundation, Inc.
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Important to Remember
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Documentation is Key!!!
State clearly the issue in question
State clearly your position and supporting
argument
Cite any applicable medical criteria or coding
guidelines referenced for your review
Always respond to a denial
Documentation is Key!!
Empire State Medical, Scientific and Educational Foundation, Inc.
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Case #1
Case submitted by hospital because payor
disagrees with secondary diagnosis
dehydration (276.51).
Hospital Argument:
“Briefly, this case involves a 70 year old male
admitted emergently with nausea, vomiting,
weakness and passing out on the day of
admit. The admission diagnosis on the ER
record was weakness and dehydration. The
MD ordered IV fluids for treatment of the
dehydration. These were continued through
day #4 of the hospital stay.
Empire State Medical, Scientific and Educational Foundation, Inc.
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Case #1
(con’t.)
Hospital Argument
“The dehydration was an additional diagnosis that
affected this episode of care. It meets the criteria for a
secondary diagnosis as it was clinically evaluated,
required treatment and increased nursing care.
The…diagnosis of hypovolemia is included in the
discharge summary as a final diagnosis.”
Parts of Record Referenced by Hospital:
Discharge summary
Admission physician order
Emergency room record
(con’t.)
Empire State Medical, Scientific and Educational Foundation, Inc.
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Case #1
(con’t.)
Payor Argument:
“We continue to maintain that this patient was
not dehydrated. This 70 year old man with
adrenal insufficiency presented with weakness
and episodes of falling with inability to get up.
His BUN/Creatinine was 7/0.9 which is not
consistent with dehydration, but rather than
hypokalemia which we agree the patient had.
Dehydration is deleted.”
Parts of the Record Referenced:
None specifically referenced
Empire State Medical, Scientific and Educational Foundation, Inc.
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Case #1
(con’t.)
ESMSEF Decision:
Per our physician specialist, the principal reason
for this patient’s symptoms and admission is
adrenal crisis from acute renal insufficiency.
Weakness, hypotension and dehydration are
medical consequences. He also had
hypokalemia during this admission.
Dehydration is a valid diagnosis and was
evaluated and treated during this hospital stay.
Empire State Medical, Scientific and Educational Foundation, Inc.
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Case #2
Case submitted by hospital because payor denied
continued stay from 10/6-10/10 as not medically
necessary. Patient was in hospital from 9/24-10/10.
Hospital Argument:
Patient was a 38 year old male with a history of AIDS
who was admitted with pneumocystitis pneumonia.
He was treated with IV antibiotics and slowly
improved. His blood glucose levels remained elevated
due to high doses of steroid therapy. On 10/6, patient
felt well, was out of bed and had no shortness of
breath noted. He was being instructed on Insulin
administration and medication teaching. Visiting nurse
was being arranged. Patient was discharged 10/10.
Empire State Medical, Scientific and Educational Foundation, Inc.
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Case #2
(con’t.)
ESMSEF Decision:
Per our physician specialist, the continued stay
after 10/6 is not substantiated. The patient
was afebrile and denied shortness of breath.
The O2 sat was greater than 90% consistently
on room air and blood sugars were improving.
Insulin administration was begun early in the
admission and could have been continued on
an outpatient basis since patient had in-home
nursing care services. The continued stay
was not substantiated.
Empire State Medical, Scientific and Educational Foundation, Inc.
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Case #3
Case submitted by hospital because payor disagrees
with principal diagnosis diverticulitis (562.10) and
secondary diagnosis COPD (496).
Hospital Argument:
“This was a 70 year old female admitted with abdominal
pain and diagnosed with diverticulitis. The patient’s
history was significant for COPD. This was a
complicating diagnosis that was present on admission
and affected this episode of care. It was documented
by the physician in the H&P, progress notes and on
the face sheet. The COPD was clinically evaluated,
treated with Combivent inhaler and required nursing
monitoring. It was correctly assigned for this episode
of care.”
Empire State Medical, Scientific and Educational Foundation, Inc.
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Case #3
(con’t.)
Parts of record referenced by Hospital:
Face Sheet
Discharge Summary
Admission Physician Order
Consultation Report
Physician Progress Notes
Empire State Medical, Scientific and Educational Foundation, Inc.
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Case #3
(con’t.)
Payor Argument:
Hospital Code
56210
V1011
496
3569
7140
57420
Payor Code
5533
3569
7140
4019
57420
4556
Parts of Record Referenced by Payor:
None specifically referenced.
Empire State Medical, Scientific and Educational Foundation, Inc.
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Case #3
(con’t.)
ESMSEF Decision:
The principal diagnosis is clearly documented as
diverticulitis. The face sheet, progress notes, CT scan
report and consultation all document diverticulitis as
the reason for admission. Concerning the secondary
diagnosis of COPD, Coding Clinic Guidelines allow
this diagnosis to be coded as a chronic condition that
impacts the care of the patient. Chronic conditions
such as, but not limited to, hypertension, CHF,
asthma, emphysema, COPD…are reportable per
UHDDS criteria (see Coding Clinic, 1990, 2nd Quarter).
The hospital has coded this case correctly.
Empire State Medical, Scientific and Educational Foundation, Inc.
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Case #4
Case submitted by hospital because payor denied the
acute admission stating patient could have been
treated in the ER and been discharged.
Hospital Argument:
Patient was 29 year old female who was 7 weeks
pregnant. She came to ER with 2 week history of near
constant vomiting of all oral intake, including
medication. She had been seen in her MD office 2
days earlier but continued to have intractable vomiting.
In addition she had a UTI. She was admitted for IV
fluids at 150 cc/hour, IV Protonix and IV Unasyn.
Acute admission indicated.
Empire State Medical, Scientific and Educational Foundation, Inc.
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Case #4
(con’t.)
Payor Argument:
Patient was a 30 year old female with an anxiety disorder
and gestational age pregnancy of 7 weeks. She was
admitted from ER with complaints of vomiting and UTI
(diagnosed 2 days prior to admission for which she is
taking antibiotics). ER progress notes document the
patient was given a single dose of oral Meclizine, “had
no episodes of vomiting since admission” and was
able to tolerate po (fluids and a banana). She was
afebrile and vital signs were stable. Clinical
presentation did not support the need for acute
admission following care and monitoring in the ER.
Empire State Medical, Scientific and Educational Foundation, Inc.
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Case #4
(con’t.)
ESMSEF Decision:
Per our physician specialist, this 29 year old female with
and EDC of 2/20/11 was admitted via the ER with
symptoms of nausea and vomiting for 2 weeks. The
emesis was bilious and she was unable to take po
medications. She was treated with IV fluids at 150
cc/hr, IV Unasyn, IV Protonix and IV Benadryl. On
hospital day #3 her symptoms were improved and she
was discharged home. The patient had failed
outpatient treatment for intractable hyperemesis
gravidarum, complicated by UTI and psychiatric
disorder. Acute admission was indicated.
Empire State Medical, Scientific and Educational Foundation, Inc.
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In Summary
Be sure Dispute Resolution Review
services are defined in the hospital/payor
contract
 Be sure to understand all required steps
of the internal and external appeal
processes
 When submitting a case for dispute
resolution review – support your
argument!! Documentation is Key!!
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Empire State Medical, Scientific and Educational Foundation, Inc.
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Thank You!!
Frances Scott, RHIA
Director of Operations
fscott@esmsef.com
315-468-2561
Empire State Medical, Scientific and
Educational Foundation, Inc.
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