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Update on Appeals Process & Federal Coding Guidelines
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Thank you to the Medicaid Legislative Action team at Harris Health System in Houston for leading this project.

Not only are the Texas Medicaid quarterly DRG reviewers now required by Texas law to follow the federal coding rules when auditing for DRG accuracy, the separate Medical Appeals Unit of the HHSC has recently agreed that they too will be adhering to ALL of the coding rules - including Coding Clinic guidelines - when reviewing appeals sent by the hospitals regarding DRG changes made by the Utilization Review (UR) from the Office of the Inspector General (OIG)

In the past, hospitals typically received a generic DRG change from the OIG UR after an initial review, and then a post-appeal generic form letter from the appeals unit stating, in essence, ‘no, and this was your last shot’. On future DRG changes and on future appeal determinations, expect detailed reasons that specifically reference coding rules, supporting chart documentation, or both. If THOT member hospitals do not see this, I strongly recommend that they contact Maureen Milligan at the Teaching Hospitals of Texas (see below).

Hospitals that are not THOT members should expect the same adherence to coding rules from the Medicaid auditors and appeals staff as required by Texas law. If that is not forthcoming, I urge them to contact their respective Medicaid UR team and/or the Medicaid Appeals Medical Director as listed on their facility’s audit paperwork and request an explanation for the variance.

Maureen Millligan, the CEO of the Teaching Hospitals of Texas (THOT), has been of inestimable value in the past several years in facilitating negotiations between the hospitals and the state agencies and lawmakers; there is no way that any of this would have been accomplished without Maureen with her years of experience in both the Medicaid and legislative worlds. Katherine Lusk, MHSM, RHIA, FAHIMA from Childrens’ in Dallas (and AHIMA President / Chair Elect 2018) has been an active participant along with the Harris Health System from Houston in ongoing Quarterly Stakeholder Meetings with Texas Medicaid’s OIG UR team, and she has been personally involved in the prior negotiations and meetings as well.

Thanks to all representatives from Texas hospitals who helped on this project, and extra gratitude and appreciation to Maureen, THOT, and to Micah Rodriguez of Blackridge in Austin for his help on the legislative side of the project.

Maureen Milligan
President & CEO
Teaching Hospitals of Texas
1005 Congress Suite 830
O: 512.476.1497
C: 512.745.1965