New Mexico's Health Quality Improvement Organization

Hospital Payment Monitoring Program

In this Eighth Scope of Work, the Centers for Medicare & Medicaid Services (CMS) is directing Quality Improvement Organizations (QIOs), like the New Mexico Medical Review Association (NMMRA), to continue the Hospital Payment Monitoring Program (HPMP). The purpose of HPMP is to measure, monitor, and reduce the incidence of improper fee-for-service inpatient payments, including errors in:

Diagnostic-related group (DRG) coding
Provision of medically necessary services
Appropriateness of setting, billing, and prepayment denial

The basis of HPMP is statutory and regulatory. Section 1154 of the Social Security Act statutorily mandates utilization review of professional services to the requirements of Subsection (d) (i.e., those of short-term acute care fee-for-service hospitals, for which payment is made). In accordance with 42 CFR §412.508 (a), QIO review shall include short-term and long term-term acute care services. For fee-for-service inpatient hospital claims (paid and denied), HPMP fulfills the CMS requirement to comply with the Improper Payment Information Act of 2002 (Public Law No. 107-300).

In addition to its HPMP work, NMMRA conducts special projects to reduce payment error.

Special Projects

Case Management Admission Protocol (CMAP) Special Project

NMMRA is leading a 15-month, multi-state project that involves using a case management process, or protocol, for assigning bed status when a patient arrives at a hospital. The goal of the project is to reduce unnecessary short-stay admissions and provide appropriate selection of inpatient versus observation bed status while continuing to assure that patients receive appropriate care. A selected group of hospitals in New Mexico is testing this process.

DRG 468 (Extensive Operating Room Procedure Unrelated to Principal Diagnosis) Special Project

NMMRA conducted a state-level special project from April 2006 to October 2007 with selected hospitals aimed at reducing diagnosis-related Group (DRG) 468 coding and billing errors. Project objectives included:

Validating the extent of coding and payment errors within DRG 468 for selected hospitals
Educating personnel about the appropriate interpretation of coding and billing guidelines
Providing savings to the Medicare Trust Fund by reducing the number of inappropriately coded DRG 468 claims
Implementing a successful project that could be spread to other facilities in New Mexico and within the QIO community

Access a summary of the results of this project. Tools developed for this project include:

Coding Roundtables

Coding Roundtables are sponsored by NMMRA and the New Mexico Health Information Management Association (NMHIMA).

2008 International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and Current Procedural Terminology (CPT) Changes WebEx (December 14, 2007)

Coding for Renal Failure: Diseases and Associated Procedures WebEx, presentation and roundtable agenda (September 21, 2007)

The "Ins and Outs" of Coding for Pneumonia WebEx (March 16, 2007)

HPMP Resources

Admission Decisions

Compliance and Billing

Diagnosis Related Group (DRG) Coding

Medicare Payments On Target Newsletters