Finding your lost revenue and keeping it

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CAHs have similar services = same as OPPS hospitals

CAHs have different claim submission rules for outpt to inpt but documentation of billable services are the same.

CAHs are paid differently than the OPPS hospital, but the rule for billable services are the same.

EXCEPTION: J codes/pharmacy are only required for LCD/NCD drugs; G codes for OBS. CAHS are paid by billed charges/outpt.

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Does the order match the service that matches the billed item/UB- the 3 step! (charge/chart audit)

Hot spots for audit:Wastage – SDV vs MDV; SDV wastage must be documented to bill. No ability to bill wastage with MDV. (CMS pub 100-04 Chpt 17, section 40)

Nursing, pharmacy, RT, imaging, anesthesia = hot!

Original order changed after receipt.. Did referring physician’s order change in the record? Protocol – must be ordered pt specific

(OB, LAB, Imaging, RT, pharmacy, others?

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Lost Charges/Revenue Daily Charge Reconciliation Cost of Late Charges

And easy chart/charge audit ideas to identify documentation challenges and charge alignment

Recovery – house wide – up to 4-6 hrs Nursing services in ancillary areas Drug Administration – Observation OB –HBC scheduled visits, delivery

rates/levels, labor levels, unplanned Hospital based clinics – E&M visits Blood transfusion – house wide Scheduled procedures done in the ER OR – Implantables & invoice reconciliation OR – unscheduled, interrupted/7x modifer Ancillary – reduced/52 modifier

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Department Benchmark UB04 audits: Compare 10 UB-04/billing documents against the

itemized statement– Outpt areas 1st (Obs, ER, Surgery, Hospital based clinics/IV therapy/Chemo)

Look for potential lost charges (ER: sutures but no procedure)

Look for billing combinations that were missed: 250/pharmacy –how was it given? IV Infusion, injection

Look for non-billable items present: Medicare outpt self administered medications/pt pays; routine supplies

Look for descriptions that won’t pass the ‘Mom’ test Look for charges that are not uniform across the

facility

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Not ‘new revenue’ but lost revenue Question: “What services are we

currently not billing for or costs that we are not covering?”

Brainstorm with department heads, compile a master list and start looking – primarily outpatient but limited inpt.

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Nursing is not good at charge capture..so… Aggressively look for ways to move

ownership with nursing still responsible for charting, not charging: Lab – Blood Transfusions/36430. Auto have Blood

products/P + 36430 bill together. (Safety net: billing edit to reject any claims without both 390 and 391 present.)

Charge Capture Analyst – identifies charges, completes charge ticket and logs all lost charges due to missing documentation. Nursing’s partnership is to ensure the start and stop times of each bag are present. CCA ‘s partnership is charge capture. WORKS!

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Daily Dept-Specific Audits: Compare scheduled/resulted/completed

patients against charges generated. (2 day lag)Manual schedules or automatedRegistrations with no charges. Why?Ensure each patient activity is accounted

for.

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Focus on high stress/severity of illness areas

Focus on labor intensive processes Ask all depts to look for potential

lost revenue Code Blue – how is nursing assuring charges

made it to the bill? Drugs? Supplies? 92950/Cardiac Arrest? Procedures done?

“Sticky” for supplies – nursing has them on their clothing. Who do they belong to? How many go down on the sheets?

Patient complaints – once research, corrected claim –but is research done to determine who the charge really does belong to?

Drug adm – nursing floating outside the care area. Who is completing the charge ticket?

OB – look at the aspects of outpt : ER to OB; scheduled visits; post inpt discharge/lactation HBC visit, delivery rates

Scheduled visits in the ER – bill as a HBC visit Drop in pts for after care as an outpt – bill as a

HBC visit (suture removal, follow up care) All Drug Adm and Blood –outpt housewide Physician orders, medically necessary

services, E&M leveling for all HBC visits, incident to the physician

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Rework – to the individual dept, to PFS and the pt –as they get corrected bills/EOBs

Reprocessing the claim, lost productivity

Lost Revenue with limited accountability

Decreased patient satisfaction

Track and trend repeat late activity, dept specific

Do dept heads know what a late charge is?

13

The Medicare Reimbursement Manual defines Routine Services in 2202.6 on page 22-7:

“Inpatient routine services in a hospital or skilled nursing facility generally are those services included by the provider in a daily service charge

—sometimes referred to as the “room and board” charge. Routine services are composed of two broad components: (1) general routine services, and (2) special care units (SCU’s), including coronary care units (CCU’s) and intensive care units (ICU’s). Included in routine services are the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and

facilities for which a separate charge is not customarily made. 

“In recognition of the extraordinary care furnished to intensive care, coronary care, and other special care hospital inpatients, the costs of routine services furnished in these units are separately determined. If the unit does not meet

the definition of a special care unit (see § 2202.7), then the cost of such service cannot be included in a separate cost center, but must be included in the general routine service cost center. “ (See § 2203.1 for further discussion

of routine services in an SNF.)

   

Top At Risk Issues for Pt Status Audits

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2 MN rule is alive and well AND we are looking ‘back

to the future’ with an enhanced definition of ‘rare and unusual.’

Still use the physician’s documentation of ‘why an inpt’ but if the provider cannot estimate 2 MN /Presumption –then declare an inpt with rationale for ‘severity of the condition/intensity of the care’ that will require in hospital care. HUGE AUDIT RISK!

QIO/level 2 appeal group will perform all audits (more peer to peer)

High volume of ‘rare and unusual’ flagged for audit = RAC

RAC lookback to 6 months from date of service/30 days to review=more changes but only with new RACS

No change to SNF No Short Stay DRG Comments accepted thru 8-31http://

www.americanbar.org/publications/aba_health_esource/2014-2015/july/wading.html (The HealthLaw Partners)

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-07-01.html?DLPage=1&DLEntries=10&DLFilter=two%20midnight&DLSort=0&DLSortDir=descending15

RAC 2013 16

ALL PAYERS Admit to inpatient Diagnosis Reason for

Admit/Plan for why an inpt for dx.

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

MEDICARE ONLY “Clarify” that the LOS is an

estimated 2 MN/Presumption “Clarify’ that after the 1st

outpt MN, a 2nd ‘in hospital’ MN is required/Benchmark

After 1-1-15, provider still outlines why the 2 MN, what is the plan that will take 2 MN. No longer ‘certify’ but still needs to clarify the order/signed prior to discharge and rationale for the 2 MN. (Do certify 20 day mark/outlier)

Critical Access Hospital – must still certify initial 96 hrs and again, at the 96 hr mark.

2015 17

Does the physician clearly state: Why an inpt? What is the plan that will take 2 MN/Medicare? For non- Medicare – why can’t the pt be treated safely as an outpt. (Same issues as Medicare-just no 2 MN declaration)

Medicare/only-If the pt needs a 2nd MN after 1 MN as an outpt – what is occurring with the pt’s condition that will ‘push the pt’ to stay a 2nd MN? Convert to inpt and include: Why?

Mgd Care Medicare/PartC/Medicare Advantage – HIGH AT RISK. What criteria are they using? Get it in the contract! NOT SUBJECT TO TRADITIONAL Medicare rules

Commercial Mgd Care or Commercial- who knows? Makes their own rules for disallowed charges.

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USA July 27th reported 2 huge potential purchases:Anthem BX purchase of CignaAetna purchase of HumanaMaking United the last of the 3 powerhouse companies.WATCH: Denial for the catch phrase: not medically necessary! MEANS?

Negotiating will be more difficult.Ensure there is arbitration in all contracts.Define an inpt-with no ability to do retro denials ‘after discharge.”Timelines to certify inpt status.

Hot issues with denials or lack of inpt certifications:

Long LOS in obs with no ‘rules’ for conversion to inpt

Each payer gets to define their own coverage rules

Following the 2 MN Medicare Traditional rule AND clinical guidelines. (EITHER Interqual or Milliman.)

Levels of appeal clearly included – clarify why not following the 5 levels within CMS’s process. Timelines for each and who does what.

Denials of coverage ‘after discharge’ as the pt ended up getting better faster/not as sick as presented on 1st contact/ other

HAVE AN ATTORNEY READY !!

2015 19

CLEARLY –At the point of conversion – WHY AN INPT for a 2nd MN?

2midnight presumption “Under the 2 midnight

presumption, inpt 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.

Pg

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

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

Pg 50956

2015 20

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

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

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

2015 21

After the 1st MN as an outpt – anywhere – or the first MN in another facility and transferred in –

“The decision to admit becomes easier as the time approaches the 2nd MN, and the beneficaries in necessary hospitalization should NOT pass a 2nd MN prior to the admission order being written.’ (IPPS Final rule, pg 50946)

Never, ever, ever, ever have a 2nd medically appropriate MN in outpt..convert, discharge or free…

2015 22

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

Note: presumption = 2 midnights AFTER obs. 1 midnight after 1 midnight OBS = at risk for inpt audit but still an inpt.

Pg 50946

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

2015 23

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

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

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

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

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

RAC 2014 24

5PC01 Documentation does not support services medically reasonable/necessary

5PC02 Insufficient documentation5PC12 Order missing5PC13 Order unsigned5PC15 Certification not present5PC17 No documentation of 2-midnight

expectation

J5

J8

252015

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)

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%

262015

1st round: 35% denial rate

REASONS: 55% failed to document

need for 2 MN 45% failed admission order

requirements 48% signed after discharge 39% order missing from the

record 13 % order not signed

2nd round:36% denial rate

REASONS: 40% failed to document need

for 2 MN 60% failed admission order

requirements 35% order missing from record 17% order not validated 8% order not signed (as of 2-11-15)

MAC recommendations:Providers document their decision making process. Paint a clear, concise picture of the pt.

2015 27

Begin with the 1st point of contact – ER, direct or Surgery

Why is the pt not safe to be discharged/ED? Why is the surgery an inpt if the CPT is not

on the inpt only list? (Medicare only) What provider laid out a plan for why 2 MN

for a direct admit to the floor? Did the hospitalist see the pt immediately? Did UR talk to the ordering provider?

Who is validating status for transfers in? Who is asking both the sending and the receiving the 2 MN question? Count 1st in sending.

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Day Egusquiza, Pres Daylee1@mindspring.com 208-423-9036 Free Info Line www.arsystemsdayegusquiza

.com

“Finding HealthCare Solutions… together”

P.O. Box 2521Twin Falls, ID 83303

(208) 423-9036daylee1@mindspring.com

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At least quarterly, take a small sample and compare orders, against documentation of service, against actual billed service against the UB.

Ensure they all match –consider: Protocol vulnerabilities LCD/NDC limitations Physician orders present Documentation to match the order Severity of illness /doctor w/intensity of

services/nursing - inpt Evaluate the impacts of the hybrid medical

record DEVELOP CORRECTIVE ACTION with compliance

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For charge capture to work, each individual must understand their role in the process.

Explore observing each area, 24 hr shift

Develop charge capture internal manual – addressing manual process, order entry, and other, more unique processes – pods, HIM, etc.

Develop feedback process for Dept-specific auditing

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Using the ongoing department-specific audits, create tracking systems/T-N-TAccuracy of claimsRevenue identifiedLost charges lost no more!New understanding of ownershipChange of culture REPORT progress at Dept head meetings

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Diagramming the process flow for updating, changing, etc. the CDM-including assessment the volume of items

for activity level. 

Reviews all new or change items to the CDM with a focus on standardizing like items, looking throughout the

organization for other areas providing similar services and educating on same. (Focus on Routine supplies)

 Providing yearly department head education on CDM

issues. 

Like-Item Pricing audits – as new items are added to specific area.

 FOCUS ON PATIENT FRIENDLY

and SIMPLIFY!