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1 CMS IPPS 2014/2015 and Physician Documentation Joydip Roy, MD Vice President – Compliance and Physician Education 5/29/2015 New York Health Information Management Association
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CMS IPPS 2014/2015 and Physician Documentation Joydip Roy, MD
Vice President – Compliance and Physician Education
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Agenda
• Impact of Observation and Inpatient
• Highlights of FY 2014 IPPS & 2015 OPPS
• “2-Midnight Rule”
• Physician Order & Certification
• Medical Necessity Documentation
• Potential Impact to Physicians
• Recommended Workflow
• RA & MAC Updates
• Summary
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Why is Getting Patient Status Correct Such an Important Issue?
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• Focus of Recovery Audit Contractors
• Potential False Claims issue if no complaint process is in place
• Potential recoupment of reimbursements during audit and loss of opportunity for appropriate OBS APC and ancillary charge payment
Overuse of Inpatient
• Length of stay artificially elevated
• Mortality data artificially elevated
• Qualified stay impact on patient’s skilled care benefit
• Unexpected patient financial responsibility (self-administered medication charges, inflated co-payments)
Overuse of Observation
It’s about getting it right!
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Patient Deductible and Co-Pays
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Source:http://www.medicare.gov/your-medicare-costs/costs-at-a-glance/costs-at-glance.html
• Day 1-60: $1260 inpatient deductible per Benefit Period
• Day 61-90: $315/day
• Day 91-151: $630/day
Inpatient (Part A) 2015:
• $147 per year deductible
• 20% coinsurance for all covered outpatient services
• 100% of non-covered outpatient services
Outpatient (Part B) 2015:
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Valid Admission – What Changed?
OLD “Rules”
Expectation of 24-hour stay Physician order a best
practice
NEW “Rules”
Expectation of 2-midnight stay
Physician order required
Medical Necessity
Certification
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2-Midnight Expectation
Benchmark vs. Presumption
• “Benchmark of 2 midnights”
• “the decision to admit the beneficiary should be based on the cumulative time spent at the hospital beginning with the initial outpatient service. In other words, if the physician makes the decision to admit after the beneficiary arrived at the hospital and began receiving services, he or she should consider the time already spent receiving those services in estimating the beneficiary’s total expected length of stay.”
Page 50946, IPPS
• “Presumption of 2 midnights”
• “Under the 2-midnight presumption, inpatient hospital claims with lengths of stay greater than 2 midnights after formal admission following the order will be presumed generally appropriate for Part A payment and will not be the focus of medical review efforts absent evidence of systematic gaming, abuse or delays in the provision of care…”
Page 50949, IPPS
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Special Circumstances
What if a patient is admitted as inpatient, but stays less than two midnights?
• Inpatient admission may still be appropriate if expectation was documented and reasonable, however:
• Patient left AMA
• Patient expired
• Patient newly elected hospice care
• Patient is transferred to another acute care hospital
• Patient unexpectedly improved
• Best Practice: physician clearly documents that unforeseen improvement
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Documentation of Special Circumstances
It is imperative that the record reflect the details of what happened for any case involving one of these special circumstances; especially in cases where the patient recovers sooner than initially anticipated.
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The Order
• The decision regarding Inpatient or Outpatient should be based upon the medical facts available to the physician at the time of initial evaluation.
• Because this is based upon the physician’s expectation, as opposed to a retroactive determination based on actual length of stay, the physician should not feel compelled to change an Inpatient order to Observation in cases where a patient recovered sooner than anticipated.
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Source: Questions and Answers Relating to Patient Status Reviews (Last Updated: 3/12/2014)
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Exceptions to a Two-Midnight Expectation
A patient may still be an inpatient without a 2-midnight expectation if:
• The patient is having a surgical procedure on Medicare’s Inpatient Only List (IOL).
• The patient is receiving newly instituted mechanical ventilation for respiratory failure.
Remember these cases still require a valid Inpatient order on the chart
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Transmittal 3217
IPO Procedures Order Timing
5. Inpatient Only List
• We are revising our billing instructions to allow payment for inpatient only procedures that are provided to a patient in the outpatient setting on the date of the inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission to be bundled into billing of the inpatient admission, according to our policy for the payment window for outpatient services treated as inpatient services.
• Effective April 1, 2015, inpatient only procedures that are provided to a patient in the outpatient setting on the date of the inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission, according to our policy for the payment window for outpatient services treated as inpatient services will be covered by CMS and are eligible to be bundled into the billing of the inpatient admission.
• CMS is updating Pub. 100-04, Medicare Claims Processing Manual, chapter 4, sections 10.12 and 180.7 to reflect the revised impatient only payment policy.
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Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3217CP.pdf
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Physician Order and Certification
Physician Order and Certification • “While the physician order and the physician certification are required for all
inpatient hospital admissions in order for payment to be made under Part A, the physician order and the physician certification are not considered by CMS to be conclusive evidence that an inpatient hospital admission or service was medically necessary. Rather, the physician order and physician certification are considered along with other documentation in the medical record.”
Page 50940, 2014 IPPS
• In the Medical Review Requirements Section states “(b) Physician’s order and certification regarding medical necessity. No presumptive weight shall be assigned to the physician’s order under § 412.3 or the physician’s certification under Subpart B of Part 424 of the chapter in determining the medical necessity of inpatient hospital services under section 1862(a)(1) of the Act. A physician’s order or certification will be evaluated in the context of the evidence in the medical record.”
Page 50965, 2014 IPPS
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Physician must be involved in Order Determination
Some commenters commented that their current processes provide for admission “to case management” or “to utilization review” rather than specifying inpatient admission.
Response: “As we discussed above, many public comments from physicians indicated that they believed the physician should be involved in the determination of patient status, and we agree. To reinforce this policy and reduce confusion among hospitals, beneficiaries, and physicians on the differences between outpatient observation and inpatient services, we are providing in this final rule that the order for inpatient admission must specify admission “to or as an inpatient.”
Page 50942, IPPS
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Physician Order Clarification
• Qualifications of the ordering/admitting practitioner:
• At some hospitals, practitioners who lack the authority to admit inpatients under either State laws or hospital by‐laws may nonetheless frequently write the sets of admitting orders that define the initial inpatient care of the patient. In these cases, the ordering practitioner need not separately record the order to admit … the order must identify the qualified “ordering practitioner”, and must be authenticated by the ordering practitioner (or by another practitioner with the required admitting qualifications) prior to discharge.
• Verbal orders:
• A verbal or telephone inpatient admission order must be authenticated (signed, dated and timed) by the ordering practitioner (or by another practitioner with the required admitting qualifications in his or her own right) in the medical record prior to discharge, unless the hospital or the State requires an earlier timeframe
• Timing:
• The order must be furnished at or before the time of the inpatient admission.
Sept 5, 2013 CMS Update Memo
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2015 OPPS Final Rule
CMS-1613-FC
The 2015 Outpatient Prospective Payment System (OPPS) Final Rule effective January 1, 2015.
Highlights include:
• Refinements to Comprehensive APC Policy
• Significant Packaging of Ancillary Services
• Changes to Inpatient Certification Requirements
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What Does the Final Rule Say?
“[W]e believe the additional certification requirements now specified under 42 CFR 424.13(a)(2), (a)(3), and (a)(4) (that is, the reason for hospitalization, the estimated time the patient will need to remain in the hospital, and the plan of posthospital care, if applicable) generally can be satisfied by elements routinely found in a patient’s medical record, such as progress notes” (79 FR 66997).
“[A]s we look to achieve our policy goals with the minimum administrative requirements necessary, and after considering previous public comments and our experience with our existing regulations, we believe that, in the majority of cases, the additional benefits (for example, as a program safeguard) of formally requiring a physician certification may not outweigh the associated administrative requirements placed on hospitals” (79 FR 66997).
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2015 OPPS and Elements of Certification
Documentation is Key:
• “[T]he additional certification requirements now specified under § 424.13(a)(2), (a)(3), and (a)(4) (that is, the reason for hospitalization, the estimated time the patient will need to remain in the hospital, and the plan of posthospital care, if applicable) generally can be satisfied by elements routinely found in a patient’s medical record, such as progress notes” (79 FR 66997).
• “[I]n most cases, the admission order, medical record, and progress notes will contain sufficient information to support the medical necessity of an inpatient admission without a separate requirement of an additional, formal, physician certification” (79 FR 66998).
• “[W]e believe that evidence of additional review and documentation by a treating physician beyond the admission order is necessary to substantiate the continued medical necessity of long or costly inpatient stays” (79 FR 66998).
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Changes to Physician Certification Requirements • A separately signed Physician Certification statement is no
longer be required to be submitted with each and every Inpatient Hospital claim.
• Only required for long-stay (20 days or more) and outlier cases
• The Inpatient Admission Order will continue to be required as a condition of payment, but is no longer considered an element of certification.
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Elements of Certification
• While a separately signed Physician Certification statement is no longer required, each Part A inpatient hospital claim must still have:
• An inpatient admission order (signed/authenticated prior to discharge)
• An expectation of a 2-midnight stay
• Documentation of medical necessity
• Discharge planning (where appropriate)
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Documentation Tips for Medical Necessity
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What the Auditors Expect
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What Typically is Perceived
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Physician Documentation Uses
Before:
• Communication with physician partners and consultants
• Reminder notes for self use
• Possible use by nurses
Now:
• Audit defense
• Billing justification
• Malpractice defense
• Quality of Care Measurement
• Government investigations
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Common Documentation Problem Areas • Using a symptom rather than a diagnosis for the impression or
assessment
• N/D/V vs. bowel obstruction
• SOB, chest pain, headache, back pain
• Listing the diagnosis as an intractable symptom (vertigo, abdominal pain, vomiting) without noting the potential diagnosis
• Using a lab value or treatment plan with no diagnosis
• Documentation for medical necessity is different than for billing level or coding
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General Documentation Takeaways
5 key pieces of documentation for medical necessity
(CMS Medicare Benefit Policy Manual, Chapter 1, §10)
• Past Medical History
• Comorbidities
• Complications
• Severity of signs and symptoms
• Current Medical needs
• Plan of care and orders
• Procedure note
• Anesthesia record
• Facilities available for adequate care
• Predictability of an adverse outcome (risk!)
Expectation of a 2-Midnight Stay 28
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A/P Template
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IP/OP/OBS level of care is warranted for this patient…
He/she presents with…
And I have a high/low level of concern for… (Diagnosis, not symptom)
He/she is at high/low risk for…
Plan of care/treatment includes… Must also include intent for 2MN stay
Because…
Suspicions…
Concerns…
Predictable Risks…
Intent…
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Admission Review – Key Considerations
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Physicians Order
Medical Necessity
Expectation of 2-Midnight Stay
Documentation and Certification New
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Inpatient or Observation?
• 70 y/o female presents after a buffet meal with epigastric burning. She has not significant PMH, has normal vital signs, normal physical exam. EKG and initial cardiac enzymes negative.
• 82 y/o female presents with known history of CAD with previous MI and 3vCABG, presents c/o similar chest pain as her previous MI. Her vitals and physical exam are normal. EKG and initial cardiac enzymes negative.
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Inpatient or Observation? Observation level of care warranted because this 70 y/o female with no significant history presents with reflux following a large meal.
My concern is for GERD as symptoms improved with minimal interventions (antacids).
She is at low risk for a cardiac ischemia based on her presentation, history, and objective findings.
Anticipate less than a 2-midnight stay in the hospital as she will need serial cardiac enzymes, cardiac monitoring, and possible exercise stress test.
Inpatient level of care warranted because this 82 y/o female with known CAD, CABG, and PCI with recurrent angina similar to her previous cardiac event.
My concern is for unstable angina as it is reoccurring at rest with SL NTG only providing short-term relief.
She is at high risk for progression of cardiac ischemia and myocardial injury.
Anticipate at least a 2-midnight stay in the hospital as she will need serial cardiac enzymes, cardiac monitoring, nuclear stress testing, and Cardiology consultation.
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Why Should the Physician Care?
Transmittal 541, CR 8802
• Earlier versions of Transmittal 541 have previously been introduced as Transmittals 505, 534 and 540; however those versions were rescinded.
• Issued on September 12, 2014, but Implemented and Effective on September 8, 2014 (date of service).
• Provided the MAC, Recovery Auditor, and ZPIC the discretion to deny other related claims submitted before or after the claim in question.
• The Recovery Auditors will be allowed to also auto deny if approved by the New Issues Review Board.
• CHANGE FROM Transmittal 534 – Allowed as one approved example: now only a surgeon’s claim could be automatically denied, but NOT recoded to an appropriate outpatient evaluation and management service following the denial of a hospital’s inpatient admission.
• CHANGE FROM Transmittal 540 – Paragraph in Policy section was changed to be consistent with paragraph in Manual, with respect to the surgeon’s claim as outlined above.
Source: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2014-Transmittals-Items/R541PI.html
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Recommended Hospital Workflow
Recommended Hospital Workflow
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Follow this process when:
• Physician documentation of expected discharge is greater than two midnights; or
• There is no documentation of expected discharge
Expected LOS Greater Than Two Midnights or Unclear
* Patient hospitalized for condition other than Inpatient Only Procedure List
Inpatient Criteria Met?
Review elements of certification
Review elements of certification
Validate or obtain order
change
Re-review as new information is
available
Physician Advisor Review
Inpatient Recommendation
Observation/ Outpatient Recommendation
Patient Presents at Hospital*
No
Yes
Validate or obtain order
change
Validate or obtain order
change
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Recommended Hospital Workflow
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Follow this process when:
• Physician documentation of expected discharge is less than two midnights
Expected LOS Less Than Two Midnights
• * Patient hospitalized for condition other than Inpatient Only Procedure List. • + If the expectation is not correct, follow the workflow for an expected length of stay of
greater than two midnights.
IP Order?
Obtain change order
Resolve conflict between order
and expectation
Re-review as new information is
available
Observation Criteria Met?
Yes
No
Patient Presents at Hospital*
No
Yes
Observation
Obtain order change
Condition Code 44
No+
Yes Expectation
correct?
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Concluding Points
Medicare Considerations: 2014 IPPS
The 3 areas most important to physicians are:
• The Time the patient is expected to stay in the hospital
• The Order to “admit to inpatient” or “refer for observation/outpatient”
• The Documentation & Certification of medical necessary to support the patient’s inpatient admission
Guidelines:
• If the attending believes the patient will be discharged same day or the day following hospitalization, consider ordering Outpatient or Observation.
• If the attending believes the patient will NOT be ready for discharge the day after hospitalization, consider ordering Inpatient if medically necessary.
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Key Takeaways
• 3-4 sentences in impression or assessment will make a significant difference
• Use risk supported diagnosis, avoid symptom based diagnoses
• Time expectation AND medical necessity drives Inpatient or Outpatient Observation status (Medicare)
• The elements of Certification must be completed prior to discharge of the patient (Medicare)
• Make the Obv10uS – OBVIOUS
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THANK YOU. Questions?
Contact information:
Joydip Roy, MD
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©2015 Executive Health Resources, Inc.
All rights reserved.
No part of this presentation may be reproduced or distributed.
Permission to reproduce or transmit in any form or by any means
electronic or mechanical, including presenting, photocopying,
recording and broadcasting, or by any information storage and
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Health Resources. Requests for permission should be directed
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