ACDIS day2-10 track4-6 pres 0517-Hirsch-f · hypotension, fever, tachypnea, and metabolic encephalopathy. Admit as inpatient. 21 What ... Microsoft PowerPoint - ACDIS_day2-10_track4-6_pres_0517-Hirsch-f

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Ronald Hirsch, MD, FACP, CHCQMVice President, Regulations and Education

R1 Physician Advisory ServicesChicago, IL

Medicare Regulation Update: Practical Application for CDI Professionals

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Learning Objectives

• At the completion of this educational activity, the learner will be able to:

– Discuss the conflicting priorities facing physicians

– Describe the role of documentation in the 2‐midnight rule

– Interpret medical necessity guidelines and documentation requirements

– Articulate patient notification requirements

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It’s Not Easy Being a Doctor

• Evaluation and management coding

– 5 levels in the office

• What is allowed as a nurse visit (99211)?

– 3 levels in the hospital

• If they need the hospital, aren’t they all high level 3?

– 2 different hospital levels—inpatient and outpatient

• What do you mean I use office codes for an observation patient consultation?

• Time‐based codes

– Is someone watching me with a stopwatch?

2017 Copyright, HCPro, an H3.Group division of Simplify Compliance LLC. All rights reserved. These materials may not be copied without written permission.

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Critical Care Physician in Brooklyn, NY

FFS Medicare patients only• 2,968 ‐ 99223 x 20 min* = 989 hrs• 2,706 ‐ 99308 SNF visits x 10 min* = 451 hrs• 2,559 crit care x 30 min = 1,279 hrs• 1,645 ‐ 99232 x 15 min* = 411 hrs• 931 ‐ 99223 x 45 min* = 698 hrs• 428 ‐ 99309 SNF visits x 20 min* = 143 hrs• 120 ‐ 99306 SNF visits x 30 min* = 60 hrs• 81 ‐ 99305 SNF visits x 20 min* = 27 hrs• 100 other visits• 4,058+ minimum hours = 78 hrs/week no vacation

https://projects.propublica.org/treatment/doctors/1942244348

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DRG CC/MCC Coding

• Heart failure Avg length of stay

– 293: $5,597 2.6

– 292: $7,523 3.6

– 291: $10,831 4.6

• Colon resection

– 331:‐ $11,922 4.1

– 330: $17,770 7.0

– 329: $34,110 11.5

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HCC Coding

• Demographics

• Acute and chronic conditions

• Disease interactions

• Yearly visits

• Medical record copying requests

• MA plans on hiring companies to do home visits to collect HCC info (and bill annual wellness visit)

– Can you really diagnose E11.21 Type II DM with nephropathy in a patient’s living room?


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Documentation of Medical Necessity for Care

• Radiographic evidence of arthritis:

– Subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis

• Pain and functional disability from arthritis.

• Unsuccessful history of appropriate conservative therapy (non‐surgical medical management) that is clearly addressed in the pre‐procedure medical record. Nonsurgical medical management is usually implemented for 3 months or more to assess effectiveness.

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Medical Advances and Reversals

• Xigris

• Insulin drips for all in ICU

• PCSK9 inhibitors

• Robotic surgery

• Fenofibrate

• Hormone replacement therapy

• BMT for breast cancer

• Mammograms

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The 2‐Midnight Rule

• Why midnight? I’m asleep at that hour!

• Observation patients and inpatients share rooms and RNs and doctors—how can they be different?

• Patients want to be admitted as inpatient—don’t I need to please the patient?


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So Do You Feel Sorry for Them?

https://commons.wikimedia.org/wiki/File%3AStainer.jpg

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The 2‐Midnight Rule

• CMS wants patients who need a short period of time in the hospital to be treated as outpatient and those with longer needs to be inpatient

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Review of Patient Status

Two patient status options

– Inpatient: Patient who is formally admitted subsequent to an order for admission from qualified practitioner, with an expectation of two midnights of necessary hospital care (unless an exception is met)

– Outpatient: Patient registered to receive services who has not been admitted as inpatient


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What Is Observation?

Outpatients can receive a service called observation ordered by a provider.

– They have finished their ED evaluation and treatment

– Or they were referred directly from a physician office and they now require additional testing and/or monitoring to determine if they must be admitted as inpatient or can be discharged

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First Question: Do They Need Hospital Care Beyond the ED?

• “The crux of the medical decision is the choice to keep the beneficiary at the hospital in order to receive services or reduce risk, or discharge the beneficiary home because they may be safely treated through intermittent outpatient visits or some other care”

• Need = medically necessary = only safe place

• Not safe at home ≠ medical necessity for hospital care

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Second Question: How Long Will They Need?

• Under 2 midnights: Observation

• Over 2 midnights: Inpatient

• Unsure: Start with observation

• Doctors should use experience and judgment to decide; document factors that led to decision

– Use “CDI words” to describe findings and concerns


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Counting Midnights

• Starts at the time that symptom‐related care begins in the ED

– Presents at 11:45 pm with shortness of breath, triage done, EKG done at 11:55 pm—EKG starts the clock, first midnight in 5 minutes.

– Presents at 11:45 pm with abdominal pain, triage done, vitals stable, sent to waiting room. Called back at 12:30 am and ED doc sees patient—visit starts the clock, first midnight in 23½ hours.

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Before I Forget: Three Clocks

• Counting midnights determines inpatient vs. observation

• For paid postacute SNF, need 3 midnights as inpatient

– Counting starts with admission order time

• For paid observation services, need 8+ hours of observation excluding carve‐out services

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So How Does This Work?

• Patient in ED, doctor determines patient needs to stay

• When does doctor think patient will be medically stable to discharge?

– How many more midnights is that?

– How many midnights already passed?

– If total is 2 or more, admit as inpatient

– If not, place observation


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Documentation Must Support Determination

• An 83‐year‐old man with dysuria. PMH: HTN, CKD.

• Patient in no distress, exam normal.

• UTI with fever, elevated WBC.

• Start antibiotics, admit as inpatient for UTI.

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Documentation Must Support Determination

• An 83‐year‐old man with a history of hypertension and chronic kidney disease presents with a chief complaint of altered mental status. T 39.5, BP 104/64, HR 144, RR 25.

• Initial laboratory testing CBC – WBC 26,500. UA positive for nitrites and leukocyte esterase, 50 white cells per HPF, and gram‐negative rods on Gram's stain. The patient is started on broad‐spectrum antibiotics.

• This patient has possible sepsis with UTI with hypotension, fever, tachypnea, and metabolic encephalopathy. Admit as inpatient.

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What if the Doctor Was Wrong?

• Thought would be over 2 MN but got better faster?

– Unexpected rapid recovery—need H&P that reflected a sick patient and then documentation that patient “got better faster than expected”

• Thought under 2 MN but still sick

– Admit as inpatient. Document why continuing hospital care is needed—still wheezing, pain requiring Dilaudid, abnormal stress test and needs cath.


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Changing Status

• Observation to inpatient

– Ensure medical necessity is documented, write admission order

– Day counting for SNF starts now

• Inpatient to observation

– Only change if initial admission order was incorrect

• Must follow condition code 44 process with UR review if concurrent

• Must go through UR committee process if after discharge

• If incorrect verbal order, can “ignore it” per CMS

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The Approved Exceptions to Two‐Midnight Expectation

• Unexpected mechanical ventilation (e.g., OD, EtOH)

– Can be admitted as inpatient

• Inpatient‐only surgery

– Must be admitted as inpatient no matter what expected LOS

• Physician judgment that inpatient is warranted

– We don’t know what this means

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Patients Who Can Be Discharged as Inpatient Prior to Second Midnight

• Unexpected rapid recovery

• Death after admission that was not expected

• Transfer out that was not planned on admission

• Transfer in from another hospital

– Get to count any medically necessary midnights at transferring hospital

• Hospice—elected after admission

• AMA—against advice of doctor, don’t need form


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Observation After Second Midnight?

• If there was a delay in care, leave observation

• If they have medical necessity to stay, admit inpatient

• If they don’t need to stay, discharge them

• If they are staying for convenience, leave observation—tell them it’s now a hotel, not a hospital

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What About Guidelines?

• Commercial guidelines establish a status for insurers that follow those guidelines. CMS does not.

• Pass inpatient or observation criteria = Needs hospital care.• Fail discharge screening = Needs hospital care.

• Then you count midnights!

• Patient in ED can pass inpatient criteria but if doc plans for one day of care, that’s observation.

• Patient on day 2 who passes observation criteria gets admitted as inpatient.

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So What Do We Need?

• An H&P that paints the picture of how sick the patient is so that any other doctor would read it and agree with the expectation of over or under 2 MN

• An H&P that properly describes all the conditions that the physician is considering and evaluating or planning to evaluate


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What Does CMS Expect?

• Patients who are in the hospital need to be in the hospital

• If patients are in the hospital but don’t need to be there, they should not have to pay for it

• Patients should get the care they need in the optimal (financially appropriate and safe) location to receive it

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Medical Necessity

• Two types of medical necessity:

– Medical necessity of the setting

• Why does the patient need to be in the hospital?

• Now hospital outpatient vs. ASC vs. physician office

– Medical necessity to provide the care itself

• Why does the patient need the treatment being provided?

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How Dare They Tell Me What Is Necessary!

• Section 1862(a)(1)(A) of the Social Security Act states that Medicare payments may not be made for items and services that “are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

• Medicare is a “defined benefit” health plan. It only pays for certain things as defined by the SSA, not for everything that a patient wants or doctor orders.


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Reasonable and Necessary

• Safe and effective• Appropriate, including the duration and frequency that is

considered appropriate for the item or service, in terms of whether it is:– Furnished in accordance with accepted standards of medical

practice for the diagnosis or treatment of the patient's condition or to improve the function of a malformed body member

– Furnished in a setting appropriate to the patient's medical needs and condition

– Ordered and furnished by qualified personnel– One that meets, but does not exceed, the patient's medical need– At least as beneficial as an existing and available medically

appropriate alternative• http://www.cms.gov/Regulations‐and‐Guidance/Guidance/Manuals/downloads/pim83c13.pdf

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How Is Medical Necessity Determined?

• Medicare– National coverage determinations (NCD)

• From CMS; apply everywhere, cannot be ignored

– Local coverage determinations (LCD)

• From each Medicare Administrative Contractor (MAC)

• Apply to the area specified by the MAC

• Exceptions allowed, can be overruled by an ALJ

– Clinical judgment of the medical reviewer

• Published medical literature, consensus of expert medical opinion, and consultations with their medical staff and medical associations, including local medical societies and other health experts

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Where to Watch

• Total joint replacements

• All spine surgery

• Bariatric surgery

• Cardiac procedures—pacers, ICDs, stents

• Peripheral vascular procedures

• Eye procedures—cataract extraction, blepharoplasty

• Chronic pain procedures

• Vertebroplasty, kyphoplasty


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What Is Your Hospital’s New Product/Service Evaluation Procedure?

• Do you look at …

– FDA approval?

• 510(k) v. new approval?

– CMS/insurance approvals?

– Medical necessity guidelines?

– Equipment costs—fixed and per procedure?

– Reimbursement—DRG/APC/new technology add‐on?

– Staff training?

– Precertification requirements?

– Expertise of physicians?

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CT Scanner: The “Tunnel of Truth”

• From 1995 to 2007, the number of ED visits that included a CT examination increased from 2.7 million to 16.2 million, constituting a 5.9‐fold increase and a compound annual growth rate of 16.0%.

• The percentage of visits associated with CT increased from 2.8% to 13.9%, constituting a 4.9‐fold increase and a compound annual growth rate of 14.2%.

• Radiology. 2011 Jan;258(1):164–173.

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A CT Scan Is Ordered …

• Patient calls hospital to schedule CT

• Do you have a written order from physician?

• Does the ICD‐10 code support it?

• Is the order signed and dated by doctor?

• Does anyone check to see if a CT scan is actually medically necessary?


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Provider Compliance Tips for CT Scans

• If you receive a documentation request from a Medicare review contractor, submit:

1. The order from the ordering practitioner—

• If you forgot to keep a copy of the order, contact the ordering practitioner and request a copy of the order.

• If the ordering practitioner can’t find a copy of the order in the patient’s medical record, ask him or her to send you the progress notes, plan of care, or any other medical record entry from PRIOR to the day of the CT scan that documents the intent to order the CT scan.

2. The ordering practitioner’s progress notes or other medical record entries (e.g., medical history, physical exam) documenting why the CT scan is needed.CMS Medicare Learning Network ICN907793, April 2014

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Notifications: Outpatient

• MOON (Medicare Outpatient Observation Notice)

– Medicare‐eligible patients—Medicare, MA, MSP

– 24+ hours observation, by hour 36 or at admit/discharge

– No appeal rights, information only

– Must be written notice and verbal notification

– Many states have laws, so can get messy!

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Costs – Inpatient vs. Observation

• Inpatient part A deductible = $1,316 for each 60‐day spell of illness

• Outpatient part B deductible = $183 once a year

• Outpatient coinsurance = 20% of approved charge

• Observation C‐APC payment = $2,227

– 20% = $445 + $183 (+ meds) = $628 (+ meds)


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Advance Beneficiary Notice

• ABN (Advance Beneficiary Notice)

– Notice in advance that an outpatient service might not be covered by insurance

– Lab tests, imaging, observation stay

– Software screens Dx code with NCDs/LCDs

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Inpatient Notices

• IMM (Important Message from Medicare)

– Medicare and MA inpatients

– Within 2 calendar days of admission

– Second copy within 2 calendar days of discharge

– Informs that patients may appeal discharge to QIO

– If appeal, get to stay free of charge while QIO decides

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Hospital‐Issued Notice of Non‐Coverage

• HINN 12

– No medical necessity for continuing hospital care

– Discharge order written, patient will not leave

– Either will not appeal to QIO or lost appeal

– Liability starts noon the next day


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• HINN 10

– No medical necessity for continuing hospital care

– Physician won’t write discharge order

– Asks QIO to decide if hospital can start charging patient

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• HINN 11

– Necessary inpatient admission

– Physician orders test, procedure that is not medically necessary

– Not for use when test is necessary but not as inpatient

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Summary

• Doctors are torn between often conflicting priorities

• Inpatients and observation patients get the same care, but it is paid differently

• The hospital is for sick people

• We should only do things to patients that patients need done to them

• We give patients way too many notices for them to possibly understand any of them


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Thank you. Questions?

[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


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Documents

ACDIS day2-10 track4-6 pres 0517-Hirsch-f · hypotension, fever, tachypnea, and metabolic encephalopathy. Admit as inpatient. 21 What ... Microsoft PowerPoint - ACDIS_day2-10_track4-6_pres_0517-Hirsch-f