Documentation –Inpt vs. Documentation –Inpt vs. Obs-Obs-

It is all about the patient’s It is all about the patient’s storystory

Plus UpdatesPlus Updates

Presented By:Presented By:

Day Egusquiza, PresidentDay Egusquiza, President

AR Systems, Inc.AR Systems, Inc.12015

Goal of the Audit CultureGoal of the Audit Culture

To ensure billed services are reflected in the To ensure billed services are reflected in the documentation in the recorddocumentation in the record

To ensure billed services are in the medically To ensure billed services are in the medically correct setting for the pt’s conditioncorrect setting for the pt’s condition

To ensure billed service reflect the ‘rules’ To ensure billed service reflect the ‘rules’ regarding billing for the specific serviceregarding billing for the specific service

To ensure documentation can support all To ensure documentation can support all billed services according to the payer rules. billed services according to the payer rules. (setting)(setting)

Physician Order matches what was done Physician Order matches what was done matches what was documented matches matches what was documented matches what was billed.what was billed.

22015

All Payers are auditing…All Payers are auditing…

Each payer has their own set of Each payer has their own set of ‘criteria’ for coverage.‘criteria’ for coverage.

Each payer has their own standards Each payer has their own standards for appeals for appeals

Each payer determines if the Each payer determines if the documentation supports the service documentation supports the service that was billed.that was billed.

And then the provider community And then the provider community gets to keep the money the payer gets to keep the money the payer paid.paid.

2015 3

RAC 2013 4

Key elements for Payers- Key elements for Payers- as ordered by providersas ordered by providers

ALL PAYERSALL PAYERS Admit to inpatientAdmit to inpatient DiagnosisDiagnosis Reason for Reason for

Admit/Plan for Admit/Plan for why an inpt for why an inpt for dx.dx.

All part of a pre-All part of a pre-determined order determined order set.(Ques in the set.(Ques in the EMR or paper)EMR or paper)

MEDICARE ONLYMEDICARE ONLY ““Clarify” that the LOS is Clarify” that the LOS is

an estimated 2 an estimated 2 MN/PresumptionMN/Presumption

““Clarify’ that after the 1Clarify’ that after the 1stst outpt MN, a 2outpt MN, a 2ndnd ‘in ‘in hospital’ MN is hospital’ MN is required/Benchmarkrequired/Benchmark

After 1-1-15, provider still After 1-1-15, provider still outlines why the 2 MN, outlines why the 2 MN, what is the plan that will what is the plan that will take 2 MN. No longer take 2 MN. No longer ‘certify’ but still needs to ‘certify’ but still needs to clarify the order/signed clarify the order/signed prior to discharge and prior to discharge and rationale for the 2 MN.rationale for the 2 MN.2015 5

““In CY 2014, IPPS Final Rule, CMS adopted revised certification requirements for all inpt admissions. In CY 2014, IPPS Final Rule, CMS adopted revised certification requirements for all inpt admissions. Because all elements of the new certification had to be signed by the physician prior to discharge, this Because all elements of the new certification had to be signed by the physician prior to discharge, this requirement has created a great deal of difficulty for hospitals and arguably required the most changes to requirement has created a great deal of difficulty for hospitals and arguably required the most changes to computerized documentation systems of all changes in 2014. The proposal would modify the regulation on computerized documentation systems of all changes in 2014. The proposal would modify the regulation on certification to ONLY require the certification for OUTLIER cases and long stays, defined as 20 days or longecertification to ONLY require the certification for OUTLIER cases and long stays, defined as 20 days or longer. r. CMS is careful to note that the CMS is careful to note that the order requirements from the Final Rule are not proposed to order requirements from the Final Rule are not proposed to change and an order complying with the new order requirements is still necessary to change and an order complying with the new order requirements is still necessary to demonstrate the patient is considered an input during the stay.”(Final: pg 901-912; demonstrate the patient is considered an input during the stay.”(Final: pg 901-912; http://3.amazonaws.com/public-inspection.federalregister.gov/2014-26146.pdf)http://3.amazonaws.com/public-inspection.federalregister.gov/2014-26146.pdf)

We still need: OPPS FINAL RULE, Nov 2014, effective 1-1-15 -We still need: OPPS FINAL RULE, Nov 2014, effective 1-1-15 -CLARIFICATIONCLARIFICATION

An order to admit to “inpt” (beginning of the pt story)- An order to admit to “inpt” (beginning of the pt story)- STILL REQUIRED STILL REQUIRED and signed prior to discharge.and signed prior to discharge.

A reason for admit/WHY the pt needs 2 MN in a ‘hospital’ (middle)A reason for admit/WHY the pt needs 2 MN in a ‘hospital’ (middle)

A discharge note/plan (ending/wrap up)A discharge note/plan (ending/wrap up)

The full medical record must support the REASON/plan demonstratedThe full medical record must support the REASON/plan demonstrated

Just Just no longer a statementno longer a statement: “I Certify..by provider directing care/mid : “I Certify..by provider directing care/mid levels .” levels .”

PLUS if mid levels have admitting privileges – MD does not have to PLUS if mid levels have admitting privileges – MD does not have to countersign.countersign.

96 hr certification for critical access hospitals – 96 hr certification for critical access hospitals – still requiredstill required..

Proposed/FINAL change to Proposed/FINAL change to Certification (Effective 1-1-Certification (Effective 1-1-

15)15)

2015 6

Key elements of new Medicare Key elements of new Medicare inpt regulations – 2 methodsinpt regulations – 2 methods

2midnight presumption2midnight presumption ““Under the 2 midnight Under the 2 midnight

presumption, inpt hospital presumption, inpt hospital claims with lengths of stay claims with lengths of stay greater than 2 midnights after greater than 2 midnights after formal admission following the formal admission following the order will be presumed order will be presumed generally appropriate for Part generally appropriate for Part A payment and will not be the A payment and will not be the focus of medical review efforts focus of medical review efforts absent evidence of systematic absent evidence of systematic gaming, abuse or delays in gaming, abuse or delays in the provision of care.the provision of care.

Pg 50959Pg 50959

Benchmark of 2 midnightsBenchmark of 2 midnights The new Medicare InptThe new Medicare Inpt ““the decision to admit the the decision to admit the

beneficiary should be based on beneficiary should be based on the cumulative time spent at the the cumulative time spent at the hospital beginning with the initial hospital beginning with the initial outpt service. In other words, if outpt service. In other words, if the physician makes the decision the physician makes the decision to admit after the pt arrived at to admit after the pt arrived at the hospital and began receiving the hospital and began receiving services, he or she should services, he or she should consider the time already spent consider the time already spent receiving those services in receiving those services in estimating the pt’s total expected estimating the pt’s total expected LOS. LOS.

Pg 50956Pg 50956

2015 7

Understanding 2 MN Benchmark –Understanding 2 MN Benchmark –72 Occurrence Span MM8586 1-24-1472 Occurrence Span MM8586 1-24-14 EX) Pt is an outpt and is receiving EX) Pt is an outpt and is receiving

observation services at 10pm on observation services at 10pm on 12-1-13 and is still receiving obs 12-1-13 and is still receiving obs services at 1 min past midnight on services at 1 min past midnight on 12-2-13 and continues as an outpt 12-2-13 and continues as an outpt until admission. Pt is admitted as until admission. Pt is admitted as an inpt on 12-2-13 at 3 am under an inpt on 12-2-13 at 3 am under the expectation the pt will require the expectation the pt will require medically necessary hospital medically necessary hospital services for an additional midnight. services for an additional midnight. Pt is discharged on 12-3 at 8am. Pt is discharged on 12-3 at 8am. Total time in the hospital meets the Total time in the hospital meets the 2 MN benchmark..regardless of 2 MN benchmark..regardless of Interqual or Milliman criteria.Interqual or Milliman criteria.

ER, Observation, outpt surgery = all ER, Observation, outpt surgery = all included in the 2 MN Benchmark.included in the 2 MN Benchmark.

Ex) Pt is an outpt surgical Ex) Pt is an outpt surgical encounter at 6 pm on 12-21-13 encounter at 6 pm on 12-21-13 is still in the outpt encounter at is still in the outpt encounter at 1 min past midnight on 12-22-1 min past midnight on 12-22-13 and continues as a outpt 13 and continues as a outpt until admission. Pt is admitted until admission. Pt is admitted as an inpt on 12-22 at 1am as an inpt on 12-22 at 1am under the expectation that the under the expectation that the pt will required medically pt will required medically necessary hospital services for necessary hospital services for an additional midnight. Pt is an additional midnight. Pt is discharged on 12-23-13 at 8am. discharged on 12-23-13 at 8am. Total time in the hospital meets Total time in the hospital meets the 2 MN benchmark..regardless the 2 MN benchmark..regardless of Interqual or Milliman criteria.of Interqual or Milliman criteria.

2015 8

More on decision making-More on decision making-InptInpt

If the beneficiary has If the beneficiary has already already passed passed the 1 midnight as an the 1 midnight as an outpt, the physician should outpt, the physician should consider the 2consider the 2ndnd midnight midnight benchmark met if he or she benchmark met if he or she expectsexpects the beneficiary to the beneficiary to require an additional midnight require an additional midnight in the hospital. (MN must be in the hospital. (MN must be documented and donedocumented and done) )

Note: presumption = 2 Note: presumption = 2 midnights AFTER obs. 1 midnights AFTER obs. 1 midnight after 1 midnight OBS midnight after 1 midnight OBS = at risk for inpt = at risk for inpt auditaudit

Pg 50946Pg 50946

....the judgment of the physician the judgment of the physician and the physician’ s order for and the physician’ s order for inpt admission should be based inpt admission should be based on the on the expectation of care expectation of care surpassing the 2 midnights surpassing the 2 midnights with with BOTHBOTH the expectation of time the expectation of time and the and the underlying need for underlying need for medical care medical care supported by supported by complex medical factors complex medical factors such such as history and as history and comorbidities, the severity comorbidities, the severity of signs and symptoms , of signs and symptoms , current medical needs and current medical needs and the risk of an adverse the risk of an adverse event. event. Pg 50944Pg 50944

2015 9

National UB committee – National UB committee – Occurrence code 72 MLN CR 8586, effective 12-13Occurrence code 72 MLN CR 8586, effective 12-13

First /last visit datesFirst /last visit dates The from/through dates of outpt services. For use on outpt bills where the entire The from/through dates of outpt services. For use on outpt bills where the entire

billing record is not represented by the actual from/through services dates of billing record is not represented by the actual from/through services dates of Form Locator 06 (statement covers period) ……. ANDForm Locator 06 (statement covers period) ……. AND

On inpt bills to denote contiguous outpt hospital services that preceded the On inpt bills to denote contiguous outpt hospital services that preceded the inpatient admission. (See NUBC minutes 11-20-13)inpatient admission. (See NUBC minutes 11-20-13)

Per George Argus, AHA, a redefining of the existing code will allow it to be used Per George Argus, AHA, a redefining of the existing code will allow it to be used Dec 1, 2013. CMS info should be forthcomingDec 1, 2013. CMS info should be forthcoming..

MLM SE1117 REVISED: Correct provider billing of admission date MLM SE1117 REVISED: Correct provider billing of admission date and statement covers period.and statement covers period.

DOS after 10-1-11, admission date (FL 12) is the date the pt was admitted DOS after 10-1-11, admission date (FL 12) is the date the pt was admitted as an inpt to the facility. It is reported on all inpt claims regardless of as an inpt to the facility. It is reported on all inpt claims regardless of whether it is an initial, or interim or final bill.whether it is an initial, or interim or final bill.

The statement covers period (from and thru dates/FL 6) identifies the span The statement covers period (from and thru dates/FL 6) identifies the span of service dates included in a particular bill. The ‘from’ date is the of service dates included in a particular bill. The ‘from’ date is the earliest date of service on the bill.earliest date of service on the bill.

More Med Learn More Med Learn UpdatesUpdates

2015 10

Tough Limitation –document Tough Limitation –document Delays in the Provision of Care.:  FAQ 12-23-Delays in the Provision of Care.:  FAQ 12-23-

13  CMS13  CMS

  Q3.1: Q3.1: If a Part A claim is selected If a Part A claim is selected for Medical review and it is for Medical review and it is determined that the beneficiary determined that the beneficiary remained in the hospital for 2  or remained in the hospital for 2  or more MN but was expected to be more MN but was expected to be discharged before 2  MN absent a discharged before 2  MN absent a delay in a provision of care, such delay in a provision of care, such as when a certain test or as when a certain test or procedure is not available on the procedure is not available on the weekendweekend, will this claim be , will this claim be considered appropriate for considered appropriate for payment under Medicare Part A payment under Medicare Part A as an inpt under the 2 MN as an inpt under the 2 MN benchmark?benchmark?

A3.1A3.1: Section 1862 a 1 A of the SS Act statutory limits Medicare payment : Section 1862 a 1 A of the SS Act statutory limits Medicare payment to the provision of services that are reasonable and necessary for the to the provision of services that are reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body.  As such CMS ' longstanding functioning of a malformed body.  As such CMS ' longstanding instruction has been and continues to be that hospital care that is instruction has been and continues to be that hospital care that is custodial, rendered for social purposes or reasons  of convenience, custodial, rendered for social purposes or reasons  of convenience, and is not required for the diagnosis or treatment of illness or injury, and is not required for the diagnosis or treatment of illness or injury, should be excluded from Part A payment.  Accordingly, CMS expects should be excluded from Part A payment.  Accordingly, CMS expects Medicare review contractors will exclude excessive delays in the Medicare review contractors will exclude excessive delays in the provision of medically necessary services from the 2 MN benchmark.  provision of medically necessary services from the 2 MN benchmark.  Medicare review contractors will only count the time in which the Medicare review contractors will only count the time in which the beneficiary received medically necessary hospital services."beneficiary received medically necessary hospital services."

2015 11

Let’s Get Updated on Let’s Get Updated on Numerous Numerous

CMS audit activity CMS audit activity

+ Probe and educate + Probe and educate

& Recommendations & Recommendations from MEDPACfrom MEDPAC

2015 12

RAC Activity – they are back! RAC Activity – they are back! 9-149-14

New referrals for audit-New referrals for audit- Medical necessity of the Medical necessity of the

procedure, not if 2 MN was metprocedure, not if 2 MN was met MS – DRG 004- Tracheostomy MS – DRG 004- Tracheostomy

with mechanical ventilation 96+ with mechanical ventilation 96+ hrshrs

Trastuzumab (Herceptin)- multi Trastuzumab (Herceptin)- multi vial wastevial waste

Blepharoplasty (eyelid lifts and Blepharoplasty (eyelid lifts and repairs)repairs)

Intensity Modulated Intensity Modulated RadiationTherapyRadiationTherapy

Cancelled Inpt surgeries -Cancelled Inpt surgeries -OIG-100 records/80 without OIG-100 records/80 without justification ‘why an inpt.”justification ‘why an inpt.”

GuidanceGuidance: if cancelled during the : if cancelled during the pre-op process of an inpt ordered pre-op process of an inpt ordered surgery, reasons for cancellation were surgery, reasons for cancellation were identified, change to outpt as no inpt identified, change to outpt as no inpt surgery was able to be done – known surgery was able to be done – known prior to beginning. prior to beginning. Create a reduced Create a reduced charge/pre-op charge/pre-op chg/prior to chg/prior to anesthesia.anesthesia.

Guidance: Guidance: if cancelled after the if cancelled after the surgery has started/cost has started, surgery has started/cost has started, ensure the record indicates ‘why’, ensure the record indicates ‘why’, create a reduced charge/after create a reduced charge/after anesthesia anesthesia and bill as inpt. and bill as inpt.

2015 13

OIG reports to House Committee on Ways and Means. 3 areas OIG reports to House Committee on Ways and Means. 3 areas of focusof focus: : a) 2 MN must be carefully evaluated, b) CMS should a) 2 MN must be carefully evaluated, b) CMS should enhance oversight with the RAC program and c) Fundamental enhance oversight with the RAC program and c) Fundamental changes are needed in the Medicare appeals system.changes are needed in the Medicare appeals system.

http://oig.hhs.gov/testimony/docs/2014/nudelman_testimony_05202014.pdf Change obs and inpt = 1 flat rate for short stay Change obs and inpt = 1 flat rate for short stay

hospitalization, regardless of obs or inpt historical status. hospitalization, regardless of obs or inpt historical status. Reduced for less than 2 MN= SSP.Reduced for less than 2 MN= SSP.

If change to DRG payment methodology, how will the critical If change to DRG payment methodology, how will the critical access hospitals (1334ish) be paid as they are not paid by access hospitals (1334ish) be paid as they are not paid by DRG but a per diem rate on weekly remittances?DRG but a per diem rate on weekly remittances?

AHA’s commentAHA’s comment: 6-26-14, CAH/96 hr, SSP rate, obs fix & 2 MN : 6-26-14, CAH/96 hr, SSP rate, obs fix & 2 MN rule (Short stay = less than 2 MN=transfer $, 2 MN = full $) rule (Short stay = less than 2 MN=transfer $, 2 MN = full $) NOACTION for 2015/Final IPPS/Aug 2014NOACTION for 2015/Final IPPS/Aug 2014

Reports & chatter in DCReports & chatter in DC

2015 14

2015 IPPS discussion: Reducing payment 2015 IPPS discussion: Reducing payment to a flat fee for ‘short stays’ = how much?to a flat fee for ‘short stays’ = how much?

Will it eliminate audits for ‘being in a bed Will it eliminate audits for ‘being in a bed at all?”at all?”

““If , based on the physician’s evaluation of complex medical factors and If , based on the physician’s evaluation of complex medical factors and applicable risk, the beneficiary may be safely and appropriately applicable risk, the beneficiary may be safely and appropriately discharged, then the beneficiary should be discharged and hospital discharged, then the beneficiary should be discharged and hospital payment is not appropriate on either an inpt or outpt basis.” CMS’s FAQ payment is not appropriate on either an inpt or outpt basis.” CMS’s FAQ 2 MN Inpt Admission Guidance & Pt Status Review for Admissions on or 2 MN Inpt Admission Guidance & Pt Status Review for Admissions on or after Oct 1, 2013.after Oct 1, 2013.

Final IPPS: ‘thanks for the comments, but no Final IPPS: ‘thanks for the comments, but no

change.” 8-3-14change.” 8-3-14 PEPPER is targeting 1 day surgical, 2 day PEPPER is targeting 1 day surgical, 2 day

Surgical, same day medical, and same day surg.Surgical, same day medical, and same day surg.

If I was a skeptic -If I was a skeptic -

2015 15

Nov 2014Nov 2014 Hospital short stay policy issues.Hospital short stay policy issues.    Staff presented a short stay payment policy that would reduce payment Staff presented a short stay payment policy that would reduce payment

differences between short inpatient and similar outpatient hospital stays.  They differences between short inpatient and similar outpatient hospital stays.  They modeled this by looking at 94 existing DRGs and split each into a DRG for stays of modeled this by looking at 94 existing DRGs and split each into a DRG for stays of at least 2 days and a DRG for 1-day stays only.  They then collapsed the 94 1-day at least 2 days and a DRG for 1-day stays only.  They then collapsed the 94 1-day stays into 44 DRGs by grouping similar conditions together.  The new model stays into 44 DRGs by grouping similar conditions together.  The new model reduces the payment cliff between outpatient and 1-day inpatient stays, but also reduces the payment cliff between outpatient and 1-day inpatient stays, but also creates a new cliff between 1-day and 2-day inpatient stays.  creates a new cliff between 1-day and 2-day inpatient stays. 

  Staff also presented policy changes to RACs, which included the following:Staff also presented policy changes to RACs, which included the following:   Targeted RAC reviews of short stays for those hospitals that have a higher rate of Targeted RAC reviews of short stays for those hospitals that have a higher rate of

short stay admissions (e.g. top 10%);short stay admissions (e.g. top 10%); Allow hospitals to rebill denied inpatient claims as outpatient claims within some Allow hospitals to rebill denied inpatient claims as outpatient claims within some

period after the RAC notice of denial or shorten RAC look-back period for review of period after the RAC notice of denial or shorten RAC look-back period for review of short hospital stays;short hospital stays;

Modify RAC contingency fees to be based in-part on the RAC’s overturn rate.Modify RAC contingency fees to be based in-part on the RAC’s overturn rate.

Lastly, staff presented options for addressing beneficiary concerns related to Lastly, staff presented options for addressing beneficiary concerns related to observation, including 3-Day SNF qualifying stay and self-administered drugs.   observation, including 3-Day SNF qualifying stay and self-administered drugs.  

  

MEDPAC MEDPAC RECOMMENDATIONSRECOMMENDATIONS

2015 16

HOT: Related Claims DenialsHOT: Related Claims DenialsEffective 9-8-14 Transmittal 534/now Effective 9-8-14 Transmittal 534/now

540/now 541540/now 541 ““Claims that are related”Claims that are related” PurposePurpose: to allow the MAC : to allow the MAC

and ZPIC/Audit groups within and ZPIC/Audit groups within Medicare to have discretion to Medicare to have discretion to deny other ‘related’ claims deny other ‘related’ claims submitted before or after the submitted before or after the claim in question. If claim in question. If documentation associated documentation associated with one claim can be used to with one claim can be used to validate another claim, those validate another claim, those claims may be considered claims may be considered ‘related.’‘related.’

SituationsSituations: The MAC : The MAC performs pre or post-payment performs pre or post-payment review/recoupment of the review/recoupment of the admitting physician’s and/oradmitting physician’s and/or

Surgeon’s Part B services. Surgeon’s Part B services. For services related to inpt For services related to inpt

admissions that are denied, the admissions that are denied, the MAC reviews the hospital records MAC reviews the hospital records and if the physician services and if the physician services were reasonable and necessary, were reasonable and necessary, the service will be re-coded to the service will be re-coded to the appropriate outpt E&M. the appropriate outpt E&M.

540/changed- HOLD - For 540/changed- HOLD - For services where the H&P, services where the H&P, physician progress notes or other physician progress notes or other hospital record documentation hospital record documentation does not support for medical does not support for medical necessity of the procedure, post necessity of the procedure, post payment recoupment will occur payment recoupment will occur for the Part B service. for the Part B service.

2015 17

More Transmittal More Transmittal 534/now 540/now 541534/now 540/now 541

If Documentation associated with one claim can be used If Documentation associated with one claim can be used to validate another claim, those claims may be considered to validate another claim, those claims may be considered related.related.

Upon CMS approval, the MAC shall post the intent to Upon CMS approval, the MAC shall post the intent to conduct ‘related’ claims reviews on their website.conduct ‘related’ claims reviews on their website.

If ‘related’ claims are denied automatically- shall be an If ‘related’ claims are denied automatically- shall be an ‘automated’ review. If ‘related’ claims are denied after ‘automated’ review. If ‘related’ claims are denied after manual intervention, MACs shall count these as denials as manual intervention, MACs shall count these as denials as routine review.routine review.

The RAC shall utilize the review approval process as The RAC shall utilize the review approval process as outlined in their Statement of work when performing outlined in their Statement of work when performing reviews of ‘related’ claims. (Note: New RACs = new SOW. reviews of ‘related’ claims. (Note: New RACs = new SOW. Pending)Pending)

Contractors shall process appeals of the ‘related’ claims Contractors shall process appeals of the ‘related’ claims separately.  separately.  

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R541PI.pdf

2015 18

Feedback from Compliance Feedback from Compliance 360 Webinars (Phase 1 & 2 360 Webinars (Phase 1 & 2

underway)underway)

2015 19

Probe & ED Round 1- Probe & ED Round 1- WPS data- RAC SUMMIT WPS data- RAC SUMMIT

11-1411-14J5 J8

Part A Hospital Provider Count

800* 300*

# of Providers Sampled

412 151

# of Claims Reviewed

3,625 1,328• Approximate number• J5- NE, IA, KS, MO• J8- MI, IN

202015

Overall Denial Rate- WPSOverall Denial Rate- WPS

J5 27%

J826%

212015

Denials by Type - Denials by Type - WPSWPS

5PC01 Documentation does not support services medically reasonable/necessary

5PC02 Insufficient documentation

5PC12 Order missing

5PC13 Order unsigned

5PC15 Certification not present

5PC17 No documentation of 2-midnight expectation

J5

J8

222015

Probe 2 Estimated Probe 2 Estimated TimelineTimeline

232015

Probe 2- WPS (Failed or not Probe 2- WPS (Failed or not 10 in first sweep or had 1/0 10 in first sweep or had 1/0

now)now)J5 J8

Part A Hospital Provider Count

736 253

% of Claims Completed

32% 35%

Top Denial Code 5PC01 5PC01

New in Probe 2•5PC11 - Procedure not reasonable and necessary

242015

Tips- WPSTips- WPS

Verify your procedures for Verify your procedures for inclusion on the inpatient-only listinclusion on the inpatient-only list

Include the signed admission orderInclude the signed admission order Compare physician notes to ordersCompare physician notes to orders Document changes in expected Document changes in expected

patient carepatient care NOTENOTE: If the site ‘failed 2: If the site ‘failed 2ndnd round’ – round’ –

MAC will continue to audit 10-25 MAC will continue to audit 10-25 until 3-15/revised 11-14.until 3-15/revised 11-14.

252015

1) 1) Missed or flawed ordersMissed or flawed orders. (. (EX: a) Order states EX: a) Order states observe and discharge in the am. Billed as inpt. b) observe and discharge in the am. Billed as inpt. b) multiple ‘check boxes’ to pick from. Pick “obs”, billed inpt.multiple ‘check boxes’ to pick from. Pick “obs”, billed inpt.

2) 2) Surgery not on inpt only listSurgery not on inpt only list. . (EX: a)multiple outpt (EX: a)multiple outpt surgeries does not equal an inpt/spinal b) MAC has to flag surgeries does not equal an inpt/spinal b) MAC has to flag for audit/CPT code the file and confirm if on the list.for audit/CPT code the file and confirm if on the list.

33) ) Uncertain CourseUncertain Course. . (EX: a)symptoms/no dx b) no (EX: a)symptoms/no dx b) no plan for why 2 MN.plan for why 2 MN.

4) A4) Attestation/Certification processttestation/Certification process. . (EX: Box (EX: Box marked without a reason/”I certify’ …what the regulation marked without a reason/”I certify’ …what the regulation stated with no further justification. Does use H&P but stated with no further justification. Does use H&P but needs tied to why the 2 MN . (Eliminated 1-1-15)needs tied to why the 2 MN . (Eliminated 1-1-15)

REMEMBER – the 1REMEMBER – the 1stst MN as an outpt does not count toward the 3 MN as an outpt does not count toward the 3 MN for SNF or Swing bed coverageMN for SNF or Swing bed coverage..

Per WPS’s Ask the Per WPS’s Ask the Contractor/7-14Contractor/7-14

4 top reasons for denials-4 top reasons for denials-P&EP&E

2015 26

Novitas -Probe and Educate Novitas -Probe and Educate Medical Reviews – First Medical Reviews – First

RoundRoundJH: CO, NM, OK, TX, AR, LA, MS JL: PA, NJ, MD, DE, Dist of Co

PRESENTED TO THE RAC SUMMIT 11-14

27

# Provider

s

# Claims Reviewe

d

# Claims Denied

% Claims Denied

JH 1004 3794 2206 58%

JL 586 2712 1720 63%

2015

Probe and Educate Medical Probe and Educate Medical Reviews – Second Round*Reviews – Second Round*

28

# Claims Reviewe

d

# Claims Denied

% Claims Denied

JH 3028 1666 55%

JL 1501 901 60%

* To date

2015

Top Reasons for Denial – Top Reasons for Denial – Novitas- First RoundNovitas- First Round

Denial Reason % Denials JH % Denials JL

Documentation did not support two Documentation did not support two midnight expectation (did not support midnight expectation (did not support physician certification of inpatient physician certification of inpatient order)order)

50%50% 51%51%

No Records ReceivedNo Records Received 29%29% 28%28%

Documentation did not support Documentation did not support unforeseen circumstances unforeseen circumstances interrupting stayinterrupting stay

11%11% 11%11%

No inpatient admission order 3% 3%

Admission order not validated/signed 4% 3%

Other 3% 4%

292015

Top Reasons for Denial – Top Reasons for Denial – Second RoundSecond RoundDenial Reason % Denials JH % Denials JL

Documentation did not support two Documentation did not support two midnight expectation (did not support midnight expectation (did not support physician certification of inpatient physician certification of inpatient order)order)

56%56% 53%53%

No Records ReceivedNo Records Received 16%16% 17%17%

Documentation did not support Documentation did not support unforeseen circumstances unforeseen circumstances interrupting stayinterrupting stay

4%4% 3%3%

No inpatient admission order 9% 15%

Admission order not validated/signed 11% 11%

Other 4% 1%

302015

Problematic Clinical Problematic Clinical Situations- NOVITASSituations- NOVITAS

Inadequate historical detail to understand symptoms Inadequate historical detail to understand symptoms of unknown significance in patients with underlying of unknown significance in patients with underlying diseases diseases

Unstated or unclear impressions and treatment plansUnstated or unclear impressions and treatment plans Admissions for management based on clinical Admissions for management based on clinical

guidelines and algorithms then not following those guidelines and algorithms then not following those guidelinesguidelines

Variations in descriptions of patient condition by Variations in descriptions of patient condition by different physicians without explanation or reasondifferent physicians without explanation or reason

Disconnects (and disagreements) between admitting Disconnects (and disagreements) between admitting physician and attending physician and between physician and attending physician and between attending physician and specialist physiciansattending physician and specialist physicians

Unforeseen circumstance vs. incorrect admitting Unforeseen circumstance vs. incorrect admitting diagnosis and treatment plandiagnosis and treatment plan

312015

Examples- NovitasExamples- Novitas

Transient Cerebral IschemiaTransient Cerebral Ischemia Vague neurologic changes, altered mentation, Vague neurologic changes, altered mentation,

uncomplicated syncopeuncomplicated syncope Gastrointestinal bleedingGastrointestinal bleeding Cardiac arrhythmias (atrial fibrillation)Cardiac arrhythmias (atrial fibrillation) Tube replacementsTube replacements Volume depletionVolume depletion Same day outpatient proceduresSame day outpatient procedures Psychiatric problems, suicidal ideation, patient Psychiatric problems, suicidal ideation, patient

non-compliance, alcohol inebriationnon-compliance, alcohol inebriation

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What’s Missing- Novitas?What’s Missing- Novitas?

Solid documentation of the Solid documentation of the nature of an illness, the nature of an illness, the physician’s impression physician’s impression (differential diagnoses), and a (differential diagnoses), and a clear statement of clear statement of diagnostic/therapeutic choices diagnostic/therapeutic choices along with their stated or implied along with their stated or implied rationalerationale

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BILLABLE HRS VS. HRS IN BILLABLE HRS VS. HRS IN A BEDA BED

When an inpt is not appropriate, but When an inpt is not appropriate, but not safe to be discharged – think not safe to be discharged – think

Observation/outpt and watch closelyObservation/outpt and watch closely

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Biggest challengesBiggest challenges

Pt status – inpt, outpt, OBSPt status – inpt, outpt, OBS Myths – OBS = 24 hrs; 23 hrs; Myths – OBS = 24 hrs; 23 hrs; Myth – A) Myth – A) pt can stay overnight in an pt can stay overnight in an

outpt/OBS setting without outpt/OBS setting without documentation to support unplanned documentation to support unplanned event. B) No services can be billed event. B) No services can be billed beyond surgery and routine recovery.beyond surgery and routine recovery.

Myth – Just fix the pt status order in Myth – Just fix the pt status order in the morning; on Mon..orders take the morning; on Mon..orders take effect when orders are written. effect when orders are written.

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Observation challengesObservation challenges

Medicare –Medicare – Can the provider declare Can the provider declare the pt will need 2 MNs at the onset the pt will need 2 MNs at the onset of care? No, but not safe to go of care? No, but not safe to go home? home? Then place in obs with an Then place in obs with an action plan. action plan. Monitor closely. As the Monitor closely. As the 22ndnd MN approaches, safe to go MN approaches, safe to go home? If not, does the pt need a 2home? If not, does the pt need a 2ndnd MN? If yes, CONVERT to inpt.MN? If yes, CONVERT to inpt.

Non-MedicareNon-Medicare – whatever the payer – whatever the payer determines –with some ‘help.”determines –with some ‘help.”

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What is OBS? What is OBS? MedicareMedicare

GuidelinesGuidelines APC regulation (FR 11/30/01, pg 59881)APC regulation (FR 11/30/01, pg 59881)

““Observation is an Observation is an active treatmentactive treatment to determine if a to determine if a patient’s condition is going to require that he or she be patient’s condition is going to require that he or she be admitted as an inpatient or if it resolves itself so that admitted as an inpatient or if it resolves itself so that the patient may be discharged.”the patient may be discharged.”

Medicare Hospital Manual (Section 455)Medicare Hospital Manual (Section 455)““Observation services are those services furnished on a Observation services are those services furnished on a hospital premises, including use of a bed and periodic hospital premises, including use of a bed and periodic monitoring by nursing or other staff, which are monitoring by nursing or other staff, which are reasonable and necessary to evaluate an outpatient reasonable and necessary to evaluate an outpatient condition or determine the need for a possible as an condition or determine the need for a possible as an inpatient.”inpatient.”

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Expanded 2006 Fed Expanded 2006 Fed Reg InfoReg Info

ObservationObservation is a well defined set of is a well defined set of specific, clinically appropriate services, specific, clinically appropriate services, which include ongoing short-term which include ongoing short-term treatment, assessment and treatment, assessment and reassessment, before a decision can be reassessment, before a decision can be made regarding whether a pt will require made regarding whether a pt will require further treatment as hospital inpts or if further treatment as hospital inpts or if they are able to be discharged from the they are able to be discharged from the hospital.hospital.

Note: No significant 2007, 08 ,09 , 10 , Note: No significant 2007, 08 ,09 , 10 , 11, 12, 13,14 and forward – no 11, 12, 13,14 and forward – no significant changessignificant changes2015

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More 2006 More 2006 RegulationsRegulations

Observation statusObservation status is commonly is commonly assigned to pts with assigned to pts with unexpectedlyunexpectedly prolonged prolonged recovery after surgery and to pts recovery after surgery and to pts who present to the emergency who present to the emergency dept and who then require a dept and who then require a significant period of treatment or significant period of treatment or monitoring before a decision is monitoring before a decision is made concerning their next made concerning their next placement. placement. (Fed Reg, 11-10-05, pg (Fed Reg, 11-10-05, pg 68688)68688) 2015

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Need an updated order

2015

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Physician Order Sample-Physician Order Sample-Action Oriented w/triggersAction Oriented w/triggers

Refer/Place in ObservationRefer/Place in Observation

DxDx: “Dehydration”: “Dehydration”

TreatmentTreatment: “2 Liters IV fluid bolus over 2 hours : “2 Liters IV fluid bolus over 2 hours followed by 150cc/hr”followed by 150cc/hr”

Monitor forMonitor for “hypotension, diarrhea, vomiting, urine “hypotension, diarrhea, vomiting, urine output, etc..”output, etc..”

Notify physician when: Notify physician when: Patient urinates or 3 liters Patient urinates or 3 liters have been infusedhave been infused

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HOT:HOT:3 day SNF Qualifying 3 day SNF Qualifying

StaysStays ““Admit to Inpt” orders should Admit to Inpt” orders should

clearly speak to the clinical clearly speak to the clinical reasons for the admit.reasons for the admit.

Each day should continue to speak Each day should continue to speak to the intensity of the services the to the intensity of the services the pt is receiving …not just the need pt is receiving …not just the need for the 3 MN SNF qualifying stay. for the 3 MN SNF qualifying stay.

Difficult –as social issues are Difficult –as social issues are prevalent.prevalent.

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Working together to Working together to reduce risk and improve reduce risk and improve

the pt’s story the pt’s story Joint auditsJoint audits. Physicians and providers audit . Physicians and providers audit

the inpt, OBS and 3 day SNF qualifying stay to the inpt, OBS and 3 day SNF qualifying stay to learn together.learn together.

Education on Pt StatusEducation on Pt Status. Focus on the ER to . Focus on the ER to address the majority of the after hours address the majority of the after hours ‘problem’ admits. ‘problem’ admits.

Identify physician championsIdentify physician champions. Patterns can be . Patterns can be identified with education to help prevent identified with education to help prevent repeat problems.repeat problems.

Create pre-printed order Create pre-printed order forms/documentation forms/documentation forms/electronic ‘ques’. forms/electronic ‘ques’. Allows for a standard format for all Allows for a standard format for all caregivers.caregivers. 432015

Questions and AnswersQuestions and Answers

Contact Info:Contact Info:Day Egusquiza, President, AR Systems, Inc.Day Egusquiza, President, AR Systems, Inc.

PO Box 2521PO Box 2521

Twin Falls, Id 83303Twin Falls, Id 83303

208 423 9036208 423 9036daylee1@mindspring.com

Arsystemsdayegusquiza.comArsystemsdayegusquiza.com

Join us for our fun Physician advisor/Join us for our fun Physician advisor/

UR boot camp. July 2015/San AntonioUR boot camp. July 2015/San Antonio

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