Medicare Regulation Update: Practical Application for CDI Professionals
Medicare Regulation Update: Practical Application for CDI Professionals Ronald Hirsch, MD, FACP, CHCQM Vice President, Regulations and Education R1 Physician Advisory Services Chicago, IL 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 Two-Midnight
Rule Interpret Medical Necessity Guidelines and Documentation Requirements Articulate Patient Notification Requirements Update on 2018 Proposed Changes 2 Its 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, arent 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 stop watch? 3 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 *- estimated time; no star- clock time 4 DRG CC MCC Coding
Demographics Acute and Chronic Conditions Disease Interactions Yearly Visits Medical Record Copying Requests MA plans 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 patients living room? 6
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. Non surgical medical management is usually implemented for 3 months or more to assess
effectiveness. 7 Medical Advances and Reversals
Xigris Insulin drips for all in ICU PCSK9 inhibitors Robotic surgery Fenofibrate Hormone replacement therapy BMT for breast cancer Mammograms BNP monitoring for HF response CPK to identify MI 8
The Two Midnight Rule Why midnight? Im 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- dont I need to please the patient? 9 So do you feel sorry for them?
https://commons.wikimedia.org/wiki/File%3AStainer.jpg 10 The Two 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. 11 Review of Patient Status Two patient status options
Inpatient- patient who is formally admitted subsequent to an order for admission from qualified practitioner, expectation of two midnights of necessary hospital care (or meet an exception) Outpatient- patient registered to receive services who has not been admitted as inpatient 12 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. 13 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 14 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 15 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 23 hours 16 Before I Forget- Three Clocks Counting midnights determines inpatient v. obs For paid post-acute SNF, need 3 midnights as inpatient Counting starts with admission order date For paid Observation services, need 8+ hours of Observation excluding carve-out services
17 So how does this work? Patient in ED, doctor determine 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 18 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 19
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 20 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 needs continuing hospital care- still wheezing, pain requiring Dilaudid, abnormal stress test and needs cath
21 Changing Status Observation to Inpatient Ensure has medical necessity 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 22 The Approved Exceptions to 2 MN 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 warranted Very sick patients who will get better very quickly STEMI, DKA, ESRD with K and EKG changes 23 Observation after 2nd Midnight? If there was a delay in care, leave observation If they have medical necessity to stay, admit inpatient If they dont need to stay, discharge them If they are staying for convenience, leave observation, tell them its now a hotel, not a hospital
24 What about Guidelines? Commercial guidelines establish a status for insurers that follow those guidelines. CMS does not. Pass inpt or obs criteria = Needs hospital care Fail discharge screening = Needs hospital care Then you count midnights! Patient in ED can pass inpt criteria but if doc plans for one day of care, thats observation. Pt on day 2 who passes obs criteria gets admitted as inpatient. 25
So What do We Need? An H&P that paints the picture of how sick they are 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. 26 What does CMS Expect? Patients who are in the hospital need to be in the hospital.
If patients are in the hospital but dont need to be there, they should not have to pay for it. Patients should get the care they need in the optimal (financially and safety) location to receive it. 27 Medical Necessity Two types of medical necessity Medically necessary of the setting Why does the patient need to be in the hospital? Now hospital outpatient v. ASC v. physician office
Medical necessity to provide the care itself Why does the patient need what is being done to them? 28 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. 29 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 30 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 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, medical associations, including local medical societies, and other health experts 31 Where to Watch
Total Joint Replacements All Spine Surgery Bariatric Surgery Cardiac Procedures- Pacers, ICDs, stents
Peripheral Vascular procedures Eye- Cataract extraction, blepharoplasty Chronic Pain procedures Vertebroplasty, kyphoplasty 32 What is your hospitals 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 Addon? Staff training? Precertification requirements? Expertise of physicians? 33 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):164-73. 34 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? 35 Provider Compliance Tips for CT Scans If you receive a documentation request from a Medicare review contractor, submit: 1. The order from the ordering practitionerIf you forgot to keep a copy of the order, contact the ordering practitioner and request that they send you a copy of the order. If the ordering practitioner cant find a copy of the order in the patients medical record, ask them 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 practitioners 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 36 Notifications - Outpatient MOON- Medicare Outpatient Observation Notice
Medicare-eligible patients- Medicare, MA, MSP 24 or more hrs Obs, 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! 37 Costs Inpatient v. 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) 38 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 NCD/LCDs
39 Inpatient Notices IMM - Important Message from Medicare Medicare and MA inpatients With 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 40 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
41 Hospital-Issued Notice of Non-Coverage HINN 10 No medical necessity for continuing hospital care Physician wont write discharge order Asks QIO to decide if hospital can start charging patient 42 Hospital-Issued Notice of Non-Coverage 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 43 Updates Comprehensive Care of Joint Replacement (CJR)
First mandatory bundled payment program 69 areas, 90 day costs compared to expected costs Excess back to hospital, overage paid back Planned to expand to MI, CABG, hip fx Aug, 2017- CMS announced Cancel expansion to MI, CABG, hip fx Cut CJR in half 44
Inpatient Only List Changes Total Knee Replacement to come off 1-1-18 Implications for SNF, documentation needs for inpt Financial effects on hospitals Robotic prostatectomy to come off 1-1-18 Financial effects Request for comments Taking total hip replacement off inpt only list Allowing all total joints at ASCs Allowing cardiac cath and EP procedures at ASCs
45 Other Proposals Asking for suggestions on changing E&M coding rules Proposing to change 340b to ASP+6% to ASP-22.5% Adjust readmission rates for socioeconomic status Medicare-Medicaid eligibility Increasing role for social determinants of health Does CDI have a role here? 46 We are all are Being Measured
Expected- What should happen Length of Stay, Mortality, 90-day Cost, Readmission rate, Post-Acute use Calculated based on Codes Dont forget to document social determinants of health Non-compliance, substance use, income, insurance coverage Observed- What actually happened LOS, charges, death, readmit, disposition Want Observed to be better than Expected! 47
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. Just when you master it, CMS will change it. 48
Thank you. Questions? [email protected] www.ronaldhirsch.com 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. 49
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