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Tri-State Healthcare Management Conference
Savannah, Ga
Sharon Easterling, MHA, RHIA, CCS, CDIP, CPHM
May 20, 2014
This material is designed and provided to communicate information about audits, coding, documentation, and compliance in an educational format and manner.
Practical and useful information and tools to achieve compliant results in the area of audits, clinical documentation, data quality, and coding are being communicated and should not be mistaken as providing or offering legal advice.
Every reasonable effort has been taken to ensure that the educational information provided is accurate and useful. Applying best practice solutions and achieving results will vary in each hospital/facility and clinical situation.
Medicare RAC Current State
◦ IPPS Final Rule 2014
◦ Guidance
◦ Probe and Educate
◦ AHA Lawsuits
Medicare RAC Future State
◦ Contractor Changes
◦ RAC Statement of Work
Medicaid RAC
Discuss
◦ Process Improvement
◦ Constraints
◦ Turning the Ship
◦ Needs Assessment
◦ Action Steps
CURRENT STATE
No ADRs going out to providers
Automated reviews are still in play
◦ “CMS would like to remind providers that the Recovery
Auditors can continue to conduct automated reviews (reviews
that do not require soliciting medical record documentation
from providers) through June 1, 2014.”
◦ “Recovery Auditors will also continue to complete the reviews
for the ADRs they’ve already sent as of 2/28/2014.”
◦ “CMS will not conduct post-payment patient status reviews for
claims with dates of admission October 1, 2013 through
October 1, 2014.”
MAC Probe and Educate – 2 Midnight Reviews –Patient Status
MAC reviews
Supplemental Medical Review Contractor is VERY active
ZPICS VERY active
Appeals are in play at all levels but SLOW
Providers taking a quick breath
Finding/performing other work
In preparation for next round
Participate in Discussion
Perform Appeals
The discussion period offers the opportunity for the provider to provide additional information to the RAC to indicate why recoupment should not be initiated. It also offers the opportunity for the RAC to explain the rationale for the overpayment decision. After reviewing the additional documentation submitted the RAC could decide to reverse their decision. A letter will go to the provider detailing the outcome of the discussion period.
Who do I contact? Recovery Audit Contractor (RAC)
Timeframe Day 1 - 40
Timeframe Begins
Automated Review: Upon receipt of Demand Letter
Complex Review: Upon receipt of Review Results Letter
Timeframe Ends Day 40 (offset begins on day 41)
Increase your overturn rate
Educate your team/facility
◦ Process Improvement
◦ How to look at denials/regs
Provides a chance to “get inside the mind of an auditor”
Allows leadership to see what we are facing
Educates the contractor
Builds relationship
Time including turnaround dependent on volume
Need for MD (PA) for verbal
Scheduling
Cost Benefit
◦ Dependent on denial
Automated
Coding
Medical Necessity
Written
Verbal
Form
Any team member
Clear
Include rules, guidelines, facts
Redirect to findings in record
Takes time
Connolly Healthcare—Recovery Audit Contractor Region C Request to Open Discussion Period
Please fax to Connolly customer service at 203.529.2995
Connolly Claim Number (submit one form per claim):
Provider/Supplier Name:
NPI/Tax ID#: Patient Name:
Additional documentation attached (Y/N):
Number of pages (including cover):
I do not agree with the RAC’s determination for the following reason(s): __________ has performed retrospective review of the original coding and MSDRG assignment of the above claim and agrees with the coding assigned. Based on review the assignment of the following codes are appropriate:
348.5 Cerebral Edema MSDRG 023
The reviewer has recommended the removal of 348.5, cerebral edema as a secondary diagnosis. However based on the rationale provided by the reviewer and our review we assigned the correct code. The code removal recommended by the reviewer does not reflect their rationale and is appropriate code assignment based on the facts stated by the reviewer.
The documentation below justifies the assignment of cerebral edema. Please review the reference to chart documentation below and reference to Coding Guidelines. Reviewer states diagnosis not supported by physician documentation however: Progress Note dated 01/23/12: “cerebral edema secondary to hemorrhage” in 2 areas of the same note.
This condition was addressed by the physician and being treated with Decadron (the primary corticosteroid used to control cerebral edema is dexamethasone (Decadron); Medscape) which is
an anti-inflammatory drug to reduce swelling and Mannitol, widely used in the management of cerebral edema and raised intracranial pressure (ICP) from multiple causes (Oxford Journal: British Journal of Anesthesia: CEACCP; http://ceaccp.oxfordjournals.org/content/early/2012/01/12/bjaceaccp.mkr063.full). In conclusion, the AHA Official Coding Guidelines consistently state that for reporting purposes the definition of “other diagnosis” is interpreted as an additional condition affecting the patient care in terms of requiring: clinical evaluation; or therapeutic treatment; or diagnostic procedures; or extended length of hospital; or increased nursing care and/or monitoring. As noted above, this applies via medication treatment, administration, monitoring, and testing as demonstrated. The cerebral edema should be coded as a result.
We respectfully request a written response in a favorable decision. Thank you for your consideration Date: Printed Name: Phone #:xxxxxxxxxxxxx Email: xxxxxxxxxxxx
Upon receipt of your request, the Medical Director will determine if a telephone discussion is
necessary or if a sufficient response can be provided in writing. If a teleconference is necessary,
you will be contacted to arrange a time.
Questions regarding this request should be directed to Connolly customer service at
866.360.2507x4 or [email protected].
MD to MD
When should this occur
Be prepared
Brief your physician advisor
What happens next
Identify and trend success
Takes time
Success process
ASK TO SPEAK WITH THE MEDICAL
DIRECTOR
RAC STATEMENT OF WORK (p. 19) - If the provider
requests to speak to the CMD regarding a claim(s) denial the
RAC shall ensure the CMD participates in the discussion.
Role of team reviewers/auditor
◦ Review all cases
◦ Know your potential winners
◦ Formulate written response
◦ Guide physician through reviews/chart prep for call
◦ Be involved (in the room) for PA support
Know your coding/billing rules, guidelines
◦ Coding diagnoses/procedures “because it was documented is not the defense to WIN”
Challenge clinical denials that you have confidence in/justified clinically
Utilize clinical resources for justification of your denial when clinical
Address chronicity of symptoms (Coding Clinic and guidelines)
Utilize/physician advisor
Need to understand rules of coding and clinical disease process
Coders need to carefully review how codes/charges are
assigned
Use your ICD-9-CM code book
◦ Alpha and Tabular
Documentation must be supported for the assignment
of the code.
◦ Coding from memory is risky
Coding guidelines change
MEDICAL NECESSITY MATTERS!!
Audit and Assess coding/billing competencies
Communicate
Educate
Utilize physician advisor or billing/coding/CDI leader
Enhance clinical knowledge
Participate in RAC appeals process
Utilize Health Information Exchange/ESMD
MAC
QIC
ALJ
Medical Necessity
CMS told the MACs and FIs to take “unusual
steps…necessary to comply with the ALJ decisions.”
When ALJs determine the claim should be paid as an
outpatient because inpatient was not reasonable and
necessary, MACs and FIs are required to instruct
hospitals within 30 days to submit a new outpatient
claim with the accurate HCPCS codes and line-item
charges for the services provided.
ALJ says QIC/MAC figure it Out
ALJ remanded cases back to QIC…
Highlights
“Physicians should use a 24-hour period as a
benchmark, i.e., they should order admission for
patients who are expected to need hospital care for 24
hours or more, and treat other patients on an outpatient
basis.”
“Admissions…are not covered or non-covered solely
on the basis of the length of time the patient actually
spends in the hospital.”
Medicare Benefit Policy Manual, Pub 100-2, Chapter 1, Section 10
Observation admissions were rising
Providers were overturning appeals
ALJ stated something is wrong with this system of payment
Reports were noting problems with process GAO, OIG, etc…
Providers were vocal along with industry; AHA
Government/Legislature proposing new bills to alter or stop the program
Short-stays have been a long-standing issue
Change made sense
In the proposed rule, we stated that the judgment of the
physician and the physician‘s order for inpatient
admission should be based on the expectation of care
surpassing 2 midnights…
IPPS Final Rule CMS-1599-F, Federal Register, p. 50944
“factors that lead a physician to admit a particular beneficiary based on the physician‘s clinical expectation are significant clinical considerations and must be clearly documented in the medical record”
“The physician…to explain in detail why the expectation of the need for care spanning at least 2 midnights was appropriate in the context of that beneficiary‘s acute condition.”
IPPS Final Rule CMS-1599-F, Federal Register, p. 50944
“inpatient hospital claims with lengths of stay greater
than 2 midnights after the 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 in an attempt to
qualify for the 2-midnight presumption”
IPPS Final Rule CMS-1599-F, Federal Register, p. 50925
You should have…
◦ expectation of care surpassing 2 midnights…
◦ clinical considerations must be clearly documented in the
medical record
◦ explain in detail why the expectation of the need for care
spanning at least 2 midnights
◦ the care must also be reasonable and necessary
There is MORE…
CMS Guidance:
The physician certification, which includes the practitioner order, is considered along with other documentation in the medical record as evidence that hospital inpatient service(s) were reasonable and necessary. The following guidance applies to all inpatient hospital and critical access hospital (CAH) services unless otherwise specified. The complete requirements for the physician certification are found in 42 CFR Part 424 subpart B and 42 CFR 412.3.
Order
Content
Timing
Authorization to sign Certification
Format
Methodology for certification
An order is obtained from the physician responsible
for the care of the patient
◦ See your State Laws and Medical Staff Bylaws as to who
can authenticate (sign) physician orders at your facility.
◦ Some states allow Residents to authenticate without co-
signature
◦ Most states do not allow Pas, NPs, to authenticate without
co-signature
◦ Orders w/ signatures by Residents, Pas and NPs can begin
the certification of the order
Acceptable for Inpatient:
◦ Verbal orders
◦ Telephone orders
◦ If inpatient not specified, will look for intent (42 CFR 412.3)
◦ Admission to unit or word Admit
Not Acceptable for Inpatient:
◦ No retrospective orders
◦ Considered outpatient
Admit to ER
To Observation
To Recovery
To Outpatient Surgery
Order Certification
Licensed by the state to admit inpatients to
the hospital
Physician knowledgeable about the
physician
Granted privileges by the hospital to admit
inpatients
UR committee physician
Knowledgeable about the patient’s
hospital course, medical plan of care, and
current condition at the time of admission
Verbal order acceptable
Does not have to be the physician the
signs the certification
Must state inpatient
CFR 42 412.3 – states if intent to admit is
clear may be acceptable
The reason for the inpatient admission is usually
covered in the ED Discharge, History and Physical or
initial progress notes. This should be written clearly
and concisely.
◦ Patient is being admitted for inpatient stay because of (1)
diagnosis (symptomatology) (2) treatment needs (3) chronic
conditions/complications.
Can be done at admission or discharge with
exception of order that should be given at
admission.
Remember Certification has to be dated and
documented in the medical record PRIOR to
discharge. Keep in mind a dictated discharge
summary most likely WILL NOT BE AVAILABLE.
Pros and Cons
◦ Paper vs EHR
◦ Who will complete
◦ What if physician is away; i.e., surgeon
Facility Decision
Potential Solution
◦ EHR created form
◦ Elements embedded within EHR
◦ Form created and flagged for signature at discharge
CERTIFICATION FORMPROS OF FORM CONS OF FORM, ESP. PAPER
Addresses new requirements for the certification
(form not required)
Form not well received; we don’t need another form
All components in one place Components spread throughout documentation
Can customize EHR to prevent skipping components
(required field)
Can skip components in paper format, free form, or
fields that can be skipped
Can assist in educating physicians on what to think
about for admission
If no form used, leaves all components on shoulder
of physician/other professionals
Gives the auditor what they need to perform review
to prevent denial
Gives the auditor what they need to perform review
to deny
Makes it easier for provider to self-audit Difficult for provider to audit, manage and correct
problem areas
Gives the provider a uniform area to assist in
defending denials
Time consuming to validate components
Can utilize for financial class/payer type if concerned
with commercial/other payers (EHR)
Could be difficult to manage by payer in paper
format
Possible to customize EHR to pull data from various
fields within the EHR to create a form
Creating a form suitable for all
Step in assisting in identifying inpatient only
procedures
Completing for other patients seen as not applicable
Opportunity to institute the 5Ws for documentation May have components not clearly defined within the
record
Two Midnight Certification
Order
◦ Admit to Inpatient care: based on my medical assessment, after consideration of this patient’s presenting symptoms and acuity; (i.e., acute medical problems), age, and complications, co-morbidities that do not allow for safe outpatient management, I expect that this patient will remain in the hospital for 2 midnights or that the services require inpatient care because the patient will be undergoing a procedure on the Inpatient-Only list.
The Reason for the inpatient stay ◦ The patient is being admitted for inpatient stay because of:
Diagnosis/symptomatology:
Adverse conditions, complications, comorbidities:
Treatment Needs
The Plan for Post-hospital Care
I certify that my determination is in accordance with my understanding of Medicare’s requirements for reasonable and necessary inpatient services. [42 CFR 412.39e]
________________ __________ ______________________
Provider Signature Date Supervising Provider (as appropriate)
DOCUMENTATIONWhat are
we treating
Where is treatment needed?
Why is treatment needed?
HoW are we treating it?
When do you think they’ll get
better?
Can not convert to IP just based on crossing the 2nd
midnight benchmark
Medical Necessity still a factor
Timely filing in effect
Can self-audit, file Provider Liable claim and rebill if
within timely filing
Can utilize Condition Code 44
Certification of the Inpatient Stay required
Complete a physician certification via form or
throughout the Medical Record
The time needed to meet the 2 midnight benchmark can
begin when services begin; i.e., triage
Time as outpatient counts toward 2 midnights
Time in observation does not count towards the SNF 3-
day qualifying stay requirement
If admission denied for inpatient, 3 day qualifying stay
coverage will not be affected.
Off-campus ED of same provider counts toward 2
midnights
New
Providers should be aware of the following:
◦ RAC ADRs have ceased
◦ Automated denials will continue through June 1, 2014
◦ Automated Denials still intense
◦ June 1 is the last day a Recovery Auditor may send improper
payment files to the MACs for adjustment
◦ Procurement (RFQuotes) for contacts announced January 18,
2014
Awaiting New Guidance
Unsure of changes
Stay tuned
RACs must:
• Perform Post payment review of all Medicare claim and provider types
(excluding DME/HHH) AND a review of claims/providers that show a "high
propensity for error" as shown in CERT and other CMS analysis measures.
• Perform Prepay review, per the Prepayment Review Demonstration --active
only when CMS has authority to use the RACs for this.
• Support CMS at all level of appeals, including "taking party status" at the
ALJ level in at least 25% of cases reaching that level.
• Share methods, algorithms and edits used to find errors, with CMS and the
MACs.
• Perform "necessary provider outreach to notify provider[s]" of purpose, etc.
(Appeal Academy)
Considerations
Do you have a dedicated RAC coordinator or is this covered along with another full-time job?
Is RAC working well at your facility? Are appeals and discussions being addressed
appropriately? Do you have physician support? How will Medicaid be handled? Medicaid will be even more difficult due to
unknowns and appeal process. How are you addressing other audits? What Medicaid reviews have you had?
Are you a border state?
Do you have a transient population?
MULTIPLE STATE RULES TO FOLLOW!!
Time to Turn the Ship
Moving in a New Direction
◦ Assess all your denials
◦ Do you have Medicaid Claim issues now
Have you heard about Supplemental Review Contractors?
Denials
Duplicate claims
◦ Place of Service
◦ Surgical procedures
Ophthalmology
Radiation Therapy
Drug Injection During Angiography
Evaluation and Management
Diagnosis codes for colonoscopy
Units of Service
Bilateral designation
CASE STUDIES
http://www.gpo.gov/fdsys/pkg/FR-2011-09-16/pdf/2011-23695.pdf
http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Future-Changes.html
http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Recovery-Audit-Program/Recent_Updates.html
IPPS Final Rule CMS-1599-F, Federal Register.
CMS Sub-regulatory Notice; Sept 5, 2013
https://medicaidracinfo.healthdatainsights.com/Public1/Forms/Web_KDHE_Issue_Policy_Log_10_10_2012verfor_QTS_update_on_refill%20_too_soon.pdf
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Medicare-Fee-For-Service-Recovery-Audit-Program-Process-Educational-Tool-ICN908524.pdf
http://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance-
Programs/Recovery-Audit-Program/Downloads/Medicare-
FFS-Recovery-Audit-Program-1st-qtr-2014.pdf
http://www.aha.org/advocacy-issues/rac/ractrac.shtml
http://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance-
Programs/Recovery-Audit-Program/Downloads/RAC-
Program-Improvements.pdf
Easterling, Sharon. “The Discussion.” The National RAC
Summit, December 2013.
Sharon Easterling, MHA, RHIA, CCS, CDIP, CPHM
CEO, Recovery Analytics LLC
888-474-8023 (W)
704-779-8095 (M)
www.recoveryanalyticsllc.com
