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

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

Presented By:Presented By:

Day Egusquiza, PresidentDay Egusquiza, President

AR Systems, Inc.AR Systems, Inc.12014

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.

22014

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.

2014 3

Compliance 360 Free Compliance 360 Free Webinar – Attacking the 2 Webinar – Attacking the 2 MN rule – All payers are MN rule – All payers are

auditingauditing

2014 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 ““Certify” that the LOS is an Certify” that the LOS is an

estimated 2 estimated 2 MN/PresumptionMN/Presumption

““Certify’ that after the 1Certify’ that after the 1stst outpt MN, a 2outpt MN, a 2ndnd ‘in hospital’ ‘in hospital’ MN is requiredMN is required

““Certify” that the pt is Certify” that the pt is expected to be transferred expected to be transferred or discharged within 96 hrs.or discharged within 96 hrs.

Outline a discharge plan Outline a discharge plan prior to dischargeprior to discharge

““Certify” the reason for why Certify” the reason for why beyond 96 hrs-with no delay beyond 96 hrs-with no delay in the provision of care.in the provision of care.

2014 5

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 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.

(The new Inpts!)(The new Inpts!)Pg 50956Pg 50956

2014 6

Complex Denials/Setting Complex Denials/Setting By Dollar By Dollar 64% of denials 64% of denials

=wrong setting=wrong setting

AHA RACTrac AHA RACTrac

% of Complex Denials for Lack of Medical Necessityfor Admission – thru 3rd Q 2013/4th Q 2011- by $$ Impacted

Syncope and collapse (MS-DRG 312)15/14/18/14/17/

25/21% Percutaneous Cardiovascular Procedure (PCI) w drug-eluting stent w/o MCC (MS-DRG 247)

19/17%/19/21/23/24/14%

T.I.A. (MS-DRG 69) 4/0/0/0/0/6/8%

Chest pain (MS-DRG 313)

10/10/10/13/10/9

/8%

Esophagitis, gastroent & misc digest disorders w/o MSS (392)

11/13/16/13/10/3

/0%Back & Neck Proc exc spinal fusion w/o CC/MCC (DRG 491) 0/5/5/5/5%//

7

2014

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.

2014 8

More audit guidance –More audit guidance –Recovery Audit Recovery Audit

Contractors/RACContractors/RAC ““CMS will not permit RAC to CMS will not permit RAC to conduct pt status reviews on conduct pt status reviews on inpt claims with dates of inpt claims with dates of admission admission between Oct 1, 2013-between Oct 1, 2013-March 31, 2015March 31, 2015. These reviews . These reviews will be disallowed will be disallowed PERMANENTLY, that is, the RAC PERMANENTLY, that is, the RAC will never be allowed to conduct will never be allowed to conduct pt status reviews for claims with pt status reviews for claims with DOS during that time period. “DOS during that time period. “

MAC/Medicare claims MAC/Medicare claims processing will audit until March processing will audit until March 2015. No financial incentive to 2015. No financial incentive to deny.deny.

““In addition, CMS will In addition, CMS will not permit RAC to not permit RAC to review inpt admissions review inpt admissions of LESS than 2 MNs of LESS than 2 MNs after formal inpt after formal inpt admission that occur admission that occur between Oct 1-March between Oct 1-March 31, 2014. (now 3-15)“31, 2014. (now 3-15)“

www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medical-review/inpatienthospitalreviews.html

2014 9

What is a Medicare Inpt?What is a Medicare Inpt?

Per WPS-MAC/Medicare claims processer/auditor Per WPS-MAC/Medicare claims processer/auditor (July 23, (July 23, 2014)2014)

““If there is one place I would recommend beefing up the If there is one place I would recommend beefing up the documentation, documentation, it is the planit is the plan. There are many patients who . There are many patients who present in very acute , life threatening ways, who do not present in very acute , life threatening ways, who do not require 2 MNs of care. (think CHF) require 2 MNs of care. (think CHF) The plan, along with the The plan, along with the diagnosis/clinical data diagnosis/clinical data on the claim are the 2 biggest on the claim are the 2 biggest supporters of the physician’s reasonable expectation supporters of the physician’s reasonable expectation especially if that expectation isn’t met. If all you have is especially if that expectation isn’t met. If all you have is ‘‘monitor overnight and check in the morning’ monitor overnight and check in the morning’ – you are going – you are going to have a hard time supporting a part A/inpt payment, to have a hard time supporting a part A/inpt payment, regardless of the symptomology. You could also add an regardless of the symptomology. You could also add an unexpected recovery note at the end of the record, if they get unexpected recovery note at the end of the record, if they get well faster than the doctor thought at the time of the inpt well faster than the doctor thought at the time of the inpt order and expectation of 2 MN. But in this ex, you’ll have to order and expectation of 2 MN. But in this ex, you’ll have to explain what you expected and what actually happened. explain what you expected and what actually happened. It It would be less charting if you actually just had a good plan up would be less charting if you actually just had a good plan up front.”front.” 2014 10

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

RAC 2014 11

Still struggling with Certification of 2 Still struggling with Certification of 2 MN Presumption and old language.MN Presumption and old language.

CaseCase: ER doctor admits : ER doctor admits the pt on Sat am. the pt on Sat am. Facility is not using a Facility is not using a certification form/tool . certification form/tool . The ER doc does not The ER doc does not have admitting have admitting privileges, so privileges, so bridge/transitional. Did bridge/transitional. Did not document not document conversation with the conversation with the admitting or hospitalist.admitting or hospitalist.

Mon am UR comes in.Mon am UR comes in. Determines the case Determines the case

does not meet clinical does not meet clinical guidelines/Interqual.guidelines/Interqual.

Asks Admitting to Asks Admitting to convert back to Obs.convert back to Obs.

Pt was discharged Pt was discharged home prior to having home prior to having the UR provider agree.the UR provider agree.

What is broken?What is broken?

2014 12

Still struggling with 2 MN Still struggling with 2 MN BenchmarkBenchmark

EX) Pt came to ER on Fri EX) Pt came to ER on Fri night/1900. ER provider, night/1900. ER provider, after discussing with the after discussing with the hospitalist, determines the hospitalist, determines the pt is not safe to go home.pt is not safe to go home.

They agree that the pt They agree that the pt does not need 2 MN , at does not need 2 MN , at this time, and places in this time, and places in obs.obs.

No UR coverage in the ER No UR coverage in the ER or weekends.or weekends.

11stst MN/ER MN/ER 22ndnd MN/Sat – does the pt MN/Sat – does the pt

need additional services/ need additional services/ care to resolve the care to resolve the condition?condition?

UR discusses with UR discusses with admitting provider and admitting provider and converts to INPT with the converts to INPT with the PLAN clearly outlined in the PLAN clearly outlined in the Reason for Admit for the 2 Reason for Admit for the 2 MN. MN.

NO dedicated Ambulatory NO dedicated Ambulatory Outpt Unit Outpt Unit

2014 13

It never has and never will mean – “meeting clinical It never has and never will mean – “meeting clinical guidelines” (Interqual or Milliman)guidelines” (Interqual or Milliman)

It has always meant – the physician’s documentation to It has always meant – the physician’s documentation to support inpt level of care in the admit order or admit support inpt level of care in the admit order or admit note.note.

SO –if UR says: Pt does not meet Criteria – this means: SO –if UR says: Pt does not meet Criteria – this means: Doctor cannot certify/attest to a medically appropriate 2 Doctor cannot certify/attest to a medically appropriate 2 midnight stay – right?midnight stay – right?

11/1/2013  Section 3, E. Note: “It is not necessary 11/1/2013  Section 3, E. Note: “It is not necessary for a beneficiary to meet an inpatient "level of for a beneficiary to meet an inpatient "level of care" by screening tool, in order for Part A care" by screening tool, in order for Part A payment to be appropriate“payment to be appropriate“

Hint: 1Hint: 1stst test: Can attest/certify estimated LOS of test: Can attest/certify estimated LOS of 2 midnights? THEN check clinical guidelines to 2 midnights? THEN check clinical guidelines to help clarify any medical qualifiers… but the help clarify any medical qualifiers… but the physician’s order with ROA – trumps criteria.physician’s order with ROA – trumps criteria.

““Meeting Criteria” – Meeting Criteria” – means?means?

2014 14

Keys to beyond 96 hrs/CAH Keys to beyond 96 hrs/CAH onlyonly

New onset that can be treated within the New onset that can be treated within the scope of the CAH.scope of the CAH.

Daily documentation as to ‘why’ they are not Daily documentation as to ‘why’ they are not discharged safely or transferred. Must be discharged safely or transferred. Must be clinically appropriate.clinically appropriate.

Nursing documentation must tie to the Nursing documentation must tie to the physician’s reason for admit. (More than physician’s reason for admit. (More than ‘tasks”. Need interventions and action ‘tasks”. Need interventions and action attached to each.)attached to each.)

EMR – need to see the ongoing reason for 1EMR – need to see the ongoing reason for 1stst 96 and then beyond 9696 and then beyond 96

Cannot be a delay in the provision of care. (EX: Cannot be a delay in the provision of care. (EX: surgeon only in town on Tues. delay?)surgeon only in town on Tues. delay?)2014 15

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."

RAC 2014 16

Feedback from attendees atFeedback from attendees atCompliance 360 Webinar Compliance 360 Webinar

(6-14(6-14))

2014 17

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

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

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

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

Per WPS’s Ask the Contractor 7-14Per WPS’s Ask the Contractor 7-144 top reasons for denials with P&E4 top reasons for denials with P&E

2014 18

Hospital and Physician Hospital and Physician Shared RiskShared Risk

192014

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.

202014

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? Then place in obs with an home? Then place in obs with an action plan. Monitor closely. As the action plan. 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.”

2014 21

22

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.”

2014

23

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 and forward – no significant 11, 12 and forward – no significant changeschanges 2014

24

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) 2014

25

Need an updated order

2014

26

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

2014

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

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

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

Each day should continue to speak Each day should continue to speak to the intensity of the services the pt to the intensity of the services the pt is receiving …not just the need for is receiving …not just the need for the 3 day SNF qualifying stay. (SOI the 3 day SNF qualifying stay. (SOI =day 1; IOS = all 3 midnights)=day 1; IOS = all 3 midnights)

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

272014

HOT: Related Claims DenialsHOT: Related Claims DenialsEffective 9-8-14 Transmittal 537Effective 9-8-14 Transmittal 537

““Claims that are related”Claims that are related” PurposePurpose: to allow the MAC : to allow the MAC

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

SituationsSituations: The MAC : The MAC performs post-payment performs post-payment review/recoupment of the review/recoupment of the admitting physician’s admitting physician’s and/orand/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, admissions that are denied, the MAC reviews the hospital the MAC reviews the hospital records and if the physician records and if the physician services were reasonable and services were reasonable and necessary, the service will be necessary, the service will be re-coded to the appropriate re-coded to the appropriate outpt E&M. outpt E&M.

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

2014 28

More Transmittal 534More Transmittal 534

If Documentation associated with one claim can be If Documentation associated with one claim can be used to validate another claim, those claims may be used to validate another claim, those claims may be considered related.considered 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 If ‘related’ claims are denied automatically- shall be an ‘automated’ review. If ‘related’ claims are denied an ‘automated’ review. If ‘related’ claims are denied after manual intervention, MACs shall count these as after manual intervention, MACs shall count these as denials as routine review.denials as 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 reviews of ‘related’ claims. (Note: New RACs = new SOW. Pending)SOW. Pending)

Contractors shall process appeals of the ‘related’ Contractors shall process appeals of the ‘related’ claims separately.claims separately. 2014 29

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 the inpt, OBS and 3 day SNF qualifying stay to learn together.to 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 . Patterns can be identified with education to help prevent be identified with education to help prevent repeat problems.repeat problems.

Create pre-printed order Create pre-printed order forms/documentation forms/documentation forms. Allows for a forms. Allows for a standard format for all caregivers.standard format for all caregivers.

302014

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

www.healthcare-seminar.com

312014