©2014 executive health resources, inc. all rights reserved. 2015 inpatient prospective payment...

©2014 Executive Health Resources, Inc. All rights reserved.

2015 Inpatient Prospective Payment Services (IPPS) and Insights on Best Practices

Ralph Wuebker, MD, MBA

Chief Medical Officer

Executive Health Resources


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Agenda

• 2014/2015 IPPS Final Rule

• 2015 proposed OPPS

• Transmittal 534/540/541

• Appeals Settlement offer

• Rebilling

• Understand best practices for operating under 2015 IPPS

©2014 Executive Health Resources, Inc. All rights reserved. 3

Final IPPS 2015 AKA CMS 1607-F (Published in Federal Register on August 22, 2014)

1. Calculation of payments. The rule includes a 2.9 percent market basket update, offset by a negative 0.5 percent productivity adjustment and a negative 0.2 percent market basket cut as mandated by the Patient Protection and Affordable Care Act, and a negative 0.8 percent decrease in accordance with the American Taxpayer Relief Act of 2012.

2. Hospital readmission reduction program. CMS has increased the maximum penalty from 2 percent to 3 percent.

3. Hospital-acquired condition reduction program. Hospitals in the lowest quartile, will have their Medicare pay decreased by 1 percent.

4. Price transparency. Under the final rule, hospitals are required to make public a list of their standard charges or provide their policies for allowing the public to view a list of those charges in response to an inquiry.

5. Hospital value-based purchasing program. For 2015, CMS is increasing the applicable percent reduction, the portion of Medicare payments available to fund the value-based incentive payments under the program, to 1.5 percent of Medicare reimbursements, resulting in about $1.4 billion in value-based incentives.

6. Medicare disproportionate share hospitals payments. As part of the PPACA, Medicare DSH payments will be reduced 75 percent by 2019, or $49.9 billion. The final rule cuts overall Medicare DSH payments by 1.3 percent in fiscal year 2015, compared with fiscal year 2014.


Final IPPS 2015

Two Midnight rule remains intact

• Little to no changes

• Pages 50146 – 50148 pertain to the 2 midnight rule

• Several comments regarding defining short or low cost inpatient hospital stays

• No additional clinical exceptions added. However, still taking feedback: email to: [email protected]

• Although the FY 2015 IPPS/LTCH PPS proposed rule did not include any proposed regulatory changes relating to the 2-midnight benchmark, we nonetheless received a number of public comments regarding the current regulation.

• CAH: finalize a policy that a CAH is required to complete all physician certification requirements no later than 1 day before the date on which the claim for the inpatient service is submitted (pg. 50165)


2015 Proposed OPPS

CMS 1613-P

The 2015 Outpatient Prospective Payment System (OPPS) Proposed Rule was released on July 13, 2014

Comments found on www.regulations.gov

Highlights include:• Refinements to Comprehensive APC Policy• Significant Packaging of Ancillary Services• Changes to Inpatient Certification Requirements

http://www.regulations.gov/


The Proposed Rule and Elements of Certification

Documentation is Key:

• There is an expectation that the elements of certification (i.e. the reason for hospitalization, the estimated time the patient will need to remain in the hospital, and the plan of post-hospital care), generally can be satisfied by elements routinely found in a patient’s medical record, such as progress notes (CMS-1613-P at 41057).

• “[I]n most cases, the admission order, medical record, and progress notes will contain sufficient information to support the medical necessity of an inpatient admission without a separate requirement of an additional, formal, physician certification” (CMS-1613-P at 41057).

• “[W]e believe that evidence of additional review and documentation by a treating physician beyond the admission order is necessary to substantiate the continued medical necessity of long or costly inpatient stays” (CMS-1613-P at 41057).


Proposed Changes to Physician Certification Requirements

• A separately signed Physician Certification statement would no longer be required to be submitted with each and every Inpatient Hospital claim.– Only required for long-stay (20 days or more) and outlier cases

• The Inpatient Admission Order will continue to be required as a condition of payment, but is no longer considered an element of certification.


Proposed Changes to Physician Certification Requirements

REMINDER, the 2015 OPPS Proposed Rules if finalized as written, would not

take effect, until the implementation date of January 1, 2015.

Until that time, providers should continue to adhere to current guidelines and

regulations pertaining to the Two-Midnight Rule and Physician Certification

Requirements


“Doc Fix” – HR 4302Extension of the Probe & Educate

CMS has extended the Inpatient Hospital Prepayment Review “Probe & Educate” review process through March 2015. This means that:

• Medicare Administrative Contractors (MACs) will continue to select claims for review and deny claims found not in compliance with CMS-1599-F (commonly known as the “2-Midnight Rule”).

• MACs will continue to hold educational sessions with hospitals as described below in “Selecting Hospitals for Review” through March, 2015.

• Generally, Recovery Auditors will not conduct post-payment patient status reviews of inpatient

hospital claims with dates of admission on or after October 1, 2013 through March 2015.


Probe & Educate ProcessNumber of claims in sample that did NOT comply with policy(Dates of admission October–March 2014)

No or minor concern Moderate to significant concerns

Major concerns

10 Claim Sample 0–1 2–6 7 or more

25 Claim Sample 0–2 3–13 14 or more

Action • Deny non-compliant claims

• Send results letters explaining each denial

• No more reviews will be conducted under Probe & Educate Process

• Deny non-compliant claims• Send results letters

explaining each denial• Offer 1:1 Phone Call• REPEAT Probe & Educate

process with 10 or 25 claims

• Deny non-compliant claims• Send results letters

explaining each denial• Offer 1:1 Phone Call• Repeat Probe & Educate• If problems continue,

repeat P&E with increased claim volume of 100–250.


Probe & Educate Status Update As of February 7, 2014:

As of February 24, 2014: • CMS is requesting that the Medicare Administrative Contractors (MACs)

re-review all claim denials under the Probe & Educate process to ensure the claim decision and subsequent education is consistent with the most recent clarifications.

# of medical records requested

# of medical records received

# of medical records with MAC reviews completed

29,158 18,110 6,012

Number of denials: ?????Published data – NGS 30–75% denied

Source: http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/UpdateOnProbeEducateProcessForPosting02242014.pdf

http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/UpdateOnProbeEducateProcessForPosting02242014.pdf

http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/UpdateOnProbeEducateProcessForPosting02242014.pdf


Examples

• Example 3 - Short stays for medical conditions: The beneficiary presented to the ED with recent onset of dizziness and denied any additional complaints. The beneficiary reported a recent adjustment to his blood pressure medication. The physician’s notes stated that the beneficiary was stable and that his blood pressure medication was to be held and dosage adjusted. The notes also indicated that the physician intended to observe the beneficiary overnight. The beneficiary was discharged the next day. The hospital submitted a claim for a 1-day inpatient stay. Upon review of the claim, the MAC denied Medicare Part A payment because the medical record failed to support an expectation of a 2-midnight stay.


Examples• Example 4 - Physician attestation statements without supporting medical record

documentation: The physician’s order contained a checkbox with pre-printed text stating “The beneficiary is expected to require 2 or more midnights of hospital care.” The physician’s plan of care, however, stated that the beneficiary was to have diagnostics performed post-operatively, with a plan to discharge in the morning if stable. The beneficiary was discharged the following day as planned, after a 1-midnight stay. Upon review of the claim, the MAC denied Medicare Part A payment because the medical record failed to support an expectation of a 2-midnight stay when the order was written.

• CMS reminds providers that attestation statements indicating the beneficiary’s hospital stay is “expected to span 2 or more midnights” are not required under the inpatient admissions policy, nor are they adequate by themselves to support the expectation of a 2-midnight stay. Rather, the expectation must be supported by the entirety of the medical record.


Transmittal 541, CR 8802• Earlier versions of Transmittal 541 have previously been introduced as Transmittals 505, 534

and 540; however those versions were rescinded.

• Issued on September 12, 2014, but Implemented and Effective on September 8, 2014 (date of service)

• Provided the MAC, Recovery Auditor, and ZPIC the discretion to deny other related claims submitted before or after the claim in question.

• The Recovery Auditors will be allowed to also auto deny if approved by the New Issues Review Board.

• CHANGE FROM Transmittal 534 - Allowed as one approved example: now only a surgeon’s claim could be automatically denied, but NOT recoded to an appropriate outpatient evaluation and management service following the denial of a hospital’s inpatient admission.

• CHANGE FROM Transmittal 540 – Paragraph in Policy section was changed to be consistent with paragraph in Manual, with respect to the surgeon’s claim as outlined above.

Source: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2014-Transmittals-Items/R541PI.html

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2014-Transmittals-Items/R541PI.html

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2014-Transmittals-Items/R541PI.html


The CMS Administrative Agreement


Appeals Backlog• The average processing time for appeals decided in fiscal year 2014 is 398.1 days.• For comparison, the average processing time for a case in 2009 was 94.9 days. • There are currently 480,000 appeals awaiting assignment to an ALJ• In early 2014, OMHA received 15,000 appeal requests per week, up from 1250 appeals per week

2 years ago.• OMHA received a total of 320,000 claims in FY 2012, and over 600,000 claims in FY 2013.• OMHA is currently anticipating the backlog to grow to 1,000,000 appeals by end of FY 2014.• OMHA projects that its FY 2015 caseload will increase to approximately 850,000 total claims.

Processing backlogs• 15 weeks from receipt to open mail (though mail is stamped received as of the date it was

physically received, not the date it is opened)• 20-24 weeks from the date mail is received until it is entered into OMHA’s database (this is the

point at which the case becomes searchable in response to inquiries)• Up to 28 months from receipt until case is assigned to a judge• 6 months for a hearing date after a case is assigned to a judge

Source: http://www.hhs.gov/omha/important_notice_regarding_adjudication_timeframes.html

http://www.hhs.gov/omha/important_notice_regarding_adjudication_timeframes.html

http://www.hhs.gov/omha/important_notice_regarding_adjudication_timeframes.html


OMHA Statistical SamplingIn July, 2014, OMHA announced pilot programs to address the high-volume backlog at the Administrative Law Judge level of appeal.

What is OMHA Statistical Sampling?:

• A statistical expert develops an appropriate sampling methodology in accordance with Medicare guidelines

• Sample units are then randomly selected from a universe of claims based on that methodology

• An Administrative Law Judge then reviews the sample units and makes findings and a decision on those sample units in a single appeal

• The results of the sample are then extrapolated to the entire universe

Source: http://www.hhs.gov/omha/statistical_sampling_initiative.html (last visited September 10, 2014)

http://www.hhs.gov/omha/statistical_sampling_initiative.html



OMHA Statistical SamplingTo be eligible for OMHA statistical sampling:

• A request for hearing must appeal a Medicare Qualified Independent Contractor (QIC) reconsideration decision.

• The appellant must be a single Medicare provider or supplier.• All jurisdictional requirements for a hearing before an Administrative Law Judge must be

met for the request for hearing and all appealed claims.• The claims must be currently assigned to one or more Administrative Law Judges or have

been filed during the time period currently being assigned by OMHA Central Operations – at this time, that includes appeals that were filed between April 1, 2013, and June 30, 2013.

• No hearing on the claim has been scheduled or conducted.• There must be a minimum of 250 claims and all claims must fall into only one of the

following categories: – Pre-payment claim denials;– Post-payment (overpayment) non-Recovery Audit Contractor (RAC) claim denials; or– Post-payment (overpayment) RAC claim denials from one RAC.

Source: http://www.hhs.gov/omha/statistical_sampling_initiative.html (last visited September 10, 2014)



Administrative Agreement

• CMS is offering an Administrative Agreement (Settlement) to:– Any acute care hospital

• Those paid via Prospective Payment System (PPS), Periodic Interim Payments (PIP), and Maryland waiver

– Critical access hospital (CAH) – Willing to resolve their pending appeals (or waive their

right to request an appeal) – In exchange for timely partial payment (68% of the net

payable amount). Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html




Eligible Claims

Claims meeting all of the criteria are eligible and ALL

eligible claims must be included in the request for

Administrative Agreement.

Cannot Pick & Choose Claims

Eligible claims must be included in a spreadsheet that

the hospital is required to complete and submitted

along with the Administrative Agreement request.


Eligible Claims (con’t) • The claim was denied by any entity that conducted a review on behalf of CMS;

• The claim was not for items or services furnished to a Medicare Part C enrollee;

• The claim was denied based upon a Patient Status Determination - The claim was denied based on an inappropriate setting determination, that is, on the basis that the service might have been reasonable and necessary, but treatment on an inpatient basis was not;

• The first day of the admission was before October 1, 2013;

• The Hospital timely appealed the denial;

• As of the date of an executed Agreement submitted to CMS by the Hospital:– The appeal decision was still pending at the MAC, QIC, ALJ, or DAB levels of review,

or– The Hospital had not yet exhausted its appeal rights at the MAC, QIC, ALJ, or DAB

level; and

• The Hospital did not receive payment for the service as a Part B claim (re-bill).

Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html




Payment by CMSCMS agrees to pay the Hospital sixty-eight (68) percent (‘the percentage”) of the net paid amount of each denied inpatient claim.

• “Net paid amount” means the payment on the original inpatient claim net paid amount;

– Net Paid amount excludes the out-of-pocket obligations that are included in the “gross” or “allowable” amounts.

• This payment will be made in one payment per hospital provider number, or per owner or operator of multiple settling hospitals.

• CMS will refund to the Hospital all interest on any claim included in any appeal covered by the Agreement that CMS has collected from the Hospital as of the effective date of the Agreement

– If CMS fails to make payment within the allotted sixty (60) days, CMS will pay interest to the Hospital for the period beginning on day sixty-one (61) through the date of payment.

– The interest rate shall be the Current Value of Funds Rate (“CVFR”) as promulgated by the United States Department of the Treasury.

Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/External-FAQs8-cleared-909-v2_508.pdf

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/External-FAQs8-cleared-909-v2_508.pdf




Miscellaneous Provisions

• If the Hospital has not fully repaid the originally denied amount on a claim included in an appeal listed on the spreadsheet of eligible claims, the Hospital will receive for that claim payment the percentage value applied less the outstanding overpayment balance.

• If the Hospital has not yet repaid any of the originally denied amounts on a claim included in an appeal, or where the amount retained by the Hospital exceeds sixty-eight (68) percent of the net paid amount, the Hospital will owe CMS a refund for that claim.

– CMS will calculate the refund amount as the difference between the retained amount and

sixty-eight (68) percent of the net paid amount.

– Any refund owed CMS will be subtracted from the total payment due under this Agreement or from future Medicare payments to the Hospital.

Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/AdminstrativeAgreement.pdf

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/AdminstrativeAgreement.pdf





Miscellaneous Provisions

• The Hospital agrees it will not commence any further appeals or actions of any kind challenging the Medicare contractor’s determination(s) regarding the claims included in the appeals

– The Hospital will not attempt to rebill any of those services under Part B.

• CMS retains the right to recoup any duplicate or incorrect payments made for claims that were, but should not have been, included under this Agreement

– Payments that may have been made in the appeals process or secondary to Part B billing inadvertently included among the payment made under this Agreement.

• The Agreement does not include a release of liability of any claims the United States may have under the False Claims Act, (31 U.S.C. section 3729 et seq.), the Civil Monetary Penalties Law, (42 U.S.C. section 1320a-7a), or the common law theories of payment by mistake, unjust enrichment, or fraud.

Source:http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/MedicalReview/Downloads/AdminstrativeAgreement.pdf

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/MedicalReview/Downloads/AdminstrativeAgreement.pdf




CMS Settlement Process

Basic Settlement Process:• Decision must be made and process started Oct 31, 2014• Provider submits eligible claims spreadsheet • CMS reviews and provides feedback allowing provider

time to abandon/proceed with settlement• Medicare signs initial Administrative Agreement and pays

provider for those claims agreed upon• A repeat of the process occurs with respect to any

discrepancies concerning the eligibility of claims• CMS employs a final reconciliation process and makes

additional adjustments as warranted• Continue to check the CMS website for updates…


Patient Deductible Responsibilities

The providers refund responsibility is as follows:

a. If the Beneficiary co-insurance has been collected at the time the INITIAL administrative agreement is signed by the provider, no refund is required.

b. If the Beneficiary co-insurance has not been collected at the time the INITIAL Administrative Agreement is signed by the provider, the provider must cease collections.

c. If a Beneficiary repayment plan has been executed at the time the INITIAL Administrative Agreement is signed by the provider, the provider may continue to collect the co-insurance in accordance with the repayment plan.

Source: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/External-FAQs8-cleared-909-v2_508.pdf





Key Considerations

Every Hospital Should be Asking These Questions…• Is my hospital an eligible facility?• How do I determine which claims are eligible?• How many eligible claims do I have?• What is the total value of the eligible claims?• What is the value of those claims if I rebill under Part B?• What is the administrative burden to engage in the

settlement?• How long have my appeals been in the appeals process?• What has been my appeals success rate?


Key Considerations

Every Hospital Should be Asking These Questions…

• What is my hospital’s financial situation with respect to the settlement?

• How much reserve did we assign to denied claims (i.e., was it more or less than 68%)?

• What is the impact of denied days on the calculation of GME, IME, and DSH payments?

• What percent, if any, of the patient deductible has been paid?


Finally

• No right answer for every hospital• Every hospital should evaluate the offer• Expect some facilities will accept the offer

and others will reject the offer


Rebilling

• If a case has a physician inpatient order, yet fails “expectation 2 midnight stay” or medical necessity:

– If patient is still in the hospital, hospital may use Condition Code 44 to reclassify patient as in the past

– If patient has been discharged, hospital may use Self Audit/Rebilling if within timely filing requirements

• Rebilling: – Submit provider-liable Part A claim– Summit an inpatient claim for payment under Part B and outpatient

claim for Part B appropriate services– Status does not change – remains IP– Beneficiary responsible for Part B copayments


Rebilling EvolutionPrior to new rulings Interim 1455 CMS final rule

Self-auditing Bill Part B Ancillaries only. Subject to limitations of CC 44

Allows providers to rebill only for claims denied by a Medicare contractor

Allows providers to rebill inpatient Part A claims denied as a result of a “self-audit”

Part B rebilling Only allowed if Judge determined appropriate. No regulations

Rebilling of covered Part B charges when the Part A claim is denied as not medically reasonable and necessary

Part B rebilling to claims for services rendered to beneficiaries enrolled in Medicare Part B

Timeliness for rebilling

Only if within timely filing (one year) or Judge orders (no time limit)

Allows for rebilling 180 days from denial or lost appeal with date of service before Sept. 30, 2013

Standard timely filing requirements (1 year from the date of service) on rebilled claims with an admission date after October 1, 2013.

Impact to beneficiary

To be held harmless Upon rebilling, requires hospital to adjust beneficiary billing

Upon rebilling, requires hospital to adjust beneficiary billing


Does Rebilling Make Cents?• Where are you most likely to miss revenue in the UR process?• Without concurrent reviews hospitals risk losing dollars on

observation/outpatient cases!• Consider:

INPT DRG

> CC44 with 8 hours obs (APC)

> CC 44 with less than 8 hours of obs (No APC)

> Post discharge rebill 12x

> Claimed denied after 1 year


Best Practices to Comply with

Current IPPS


Conditions of Participations Have Not Changed

Conditions of Participations (CoPs) must be followed

• “We did not propose and are not finalizing a policy that would allow hospitals to bill Part B following an inpatient reasonable and necessary self-audit determination that does not conform to the requirements for utilization review under the CoPs.”– Page 50913, 2014 IPPS

• 482.30 (c)(1) The UR plan must provide for review for Medicare and Medicaid patients with respect to the medical necessity of:– Admissions to the institution– Duration of stays – Professional services furnished, including drugs and biologicals


Concurrent UM Still Matters

• “Use of Condition Code 44 or Part B inpatient billing pursuant to hospital self-audit is not intended to serve as a substitute for adequate staffing of utilization management personnel or for continued education of physicians and hospital staff about each hospital’s existing policies and admission protocols.”

– Page 50914, 2014 IPPS


Components Required for an IP Claim

1. Expectation/completion of a 2-midnight stay⁻ UR review must ensure expectation of 2 midnights is “reasonable”

2. Medical Necessity⁻ UR review must establish hospital level of care is needed to care for the

patient

3. Physician certification/documentation signed by the physician prior to DC⁻ Order, reason for inpatient services, expectation and plan for post-

hospital care


What is Medical Necessity?

• Is the physician's expectation of 2 midnights reasonable?– Achieved with criteria? PA evidence based determination? Other?

• Is hospital level of care needed to care for the patient?– Ensure no care for convenience, no delays in treatment/testing or

custodial


Admission Review – Key Considerations

Initial review for expectation of Length of Stay (LOS)• Physician documentation of an expectation of 2-midnight stay generally falls into

three categories: – Supports expectation of 2-midnight stay

• “I expect this patient to remain in the hospital for longer than…”• Expected LOS > 2 midnights (in document signed by physician)

– No documentation/conflicting documentation

– Clearly conflicts with or fails to support expectation of 2-midnight stay• Order – “Discharge in am” (when care has not already crossed at least one

midnight)• Progress note – “anticipate d/c in am” (when care has not already crossed at

least one midnight)


Recommended Hospital Work Flow

Follow this process when:• Physician documentation of expected discharge is greater than 2 midnights; or• There is no documentation of expected discharge

Patient presents at

hospital*

Inpatient criteria met

Yes

No

Validate or obtain order

change

Review elements of certification

Physician Advisor Review


change

Review elements of certification

Inpatient recommendation

Observation/Outpatient

recommendation


change

Re-review as new information

is available

Expected LOS greater than 2 midnights or unclear

* Patient hospitalized for condition other than Inpatient Only Procedure List


Recommended Hospital Work Flow

Follow this process when:• Physician documentation of expected discharge is less than 2 midnights

Patient presents at Hospital*

IP order?

Yes

No

Resolve conflict between order

and expectation

Condition Code 44

Observation criteria met?

Re-review as new

information is available

Yes/observation

No/obtain order

change

Expectation correct?

Yes Obtain order change

Expected LOS less than 2 midnights

* Patient hospitalized for condition other than Inpatient Only Procedure List. +If the expectation is not correct, follow the workflow for an expected length of stay of greater than two midnights.

No +


Considerations Regarding the Time of UR Review

• Review at admission:– IP

– 2+ midnight expectation AND medical necessity established AND physician certification complete

– Observation/Outpatient– Expectation of <2 midnight stay and medical necessity established

– NOTA – Review for documentation of care for convenience, a delay in treatment/testing or

custodial care

• Review after 1+ midnight:– IP

– 2+ midnights completed or expected AND medical necessity established AND physician certification complete

– Observation status should be rare after 2 midnights

– NOTA – Review for documentation of care for convenience, a delay in treatment/testing or

custodial care


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Summary

• “Get It Right” while the patient is in the hospital and as early in the stay as possible – Implications for hospital, patient and physician

• Admission review – key considerations: – Order– Expectation– Medical Necessity – Documentation and Certification

• Rebill when appropriate

• While the time requirement has evolved, the science at the core of medical necessity remains the same


Questions?

Ralph Wuebker, MD, MBAChief Medical OfficerExecutive Health [email protected] 484-844-2485

mailto:[email protected]


2 Midnight Example 1

Symptoms: 80 year old female admitted with chest pain, positive biomarkers and EKG changes in the emergency room, urgently taken to catheterization lab

Order • Admit as inpatient

Expectationof LOS

• “I expect this patient to remain in the hospital for a time greater than 2 midnights”

Medical Necessity • Documentation present to support inpatient admission

Certification • All elements of certification present per document review

Follow up necessary• Patient does not remain for 2 MN

• Was (presumption not met) due to: death, transfer, AMA, inpatient-only procedure or “recovery faster than anticipated”?

• Evaluate based on start of service to see if benchmark met



Symptoms:

65 year old male, no previous cardiac history, presents with shoulder pain after exertion, physician suspects musculoskeletal, biomarkers below detection threshold, no EKG changes. Monitor overnight if telemetry, enzymes and EKG’s remainnegative, anticipate discharge in am. No planned stress test or further evaluationduring hospitalization.

Order • Admit as inpatient

Expectation of LOS • 23 hour monitoring

Medical Necessity • Documentation does not support inpatient admission – observation

Certification • Order and physician expectation of 2 midnights are in conflict• Order and medical necessity are in conflict

Follow up necessary

• Consider Condition Code 44 if requirements are met• If patient remains in hospital or new information available, re-review for medical

necessity at inpatient level• If patient discharged – cannot do Condition Code 44, if within rebilling timeframe,

consider for Part B rebilling



Symptoms:78 year old female admitted for atrial flutter, stabilized in Emergency Room. Although expected to be discharged after medication adjustments, patient developed heart block requiring additional adjustments and possible pacemaker

Order • Place in observation

Expectation of LOS • Anticipate short stay, 23 hour monitoring

Medical Necessity • Delayed review suggests that inpatient may be appropriate

Certification • All elements of certification would need to be completed prior to discharge

Follow up necessary

• EHR would recommend inpatient level of service• Call with physician to discuss medical necessity in light of order change requirement• Call with case manager to discuss order change and expectation documentation with

regard to certification requirements• Inpatient order, documentation of expectation and all other elements of certification

would need to be addressed prior to discharge



Symptoms:76 year old woman with UTI, treated with intravenous antibiotics. Fevers continue with tachycardia and hypotension requiring fluid support. Immunosuppressed due to post kidney transplant status.

Order • Admit for inpatient services

Expectation of LOS • Admission orders include order for “discharge in am”

Medical Necessity • Would meet for inpatient by criteria, but documentation clearly violates 2 midnight expectation

Certification • Depending on follow-up activity, if inpatient supported confirm all elements of certification prior to discharge

Follow up necessary

• Although historically inpatient medical necessity would be met, the documentation does not support 2 MN expectation

• Resolve conflict between order/medical necessity and expectation• Update documentation if patient not discharged as planned• Consider Condition Code 44 if expectation of discharge remains



Symptoms:68 year old male, with a history of stroke, known carotid stenosis, and previous neck irradiation making carotid end-arterectomy high risk. Patient scheduled for carotid angiography and stent placement..

Order • Observation

Expectation of LOS • Less than 2 midnights

Medical Necessity • Procedure appropriate for inpatient based on inpatient-only status

Certification • All elements of certification except the 2 MN expectation would be required to be documented prior to discharge to support inpatient claim

Follow up necessary • Order should be corrected for procedure on CMS inpatient-only procedure list• For procedures on the inpatient-only list, order must be present on the medical

record prior to the initiation of the procedure• Inpatient-only procedures are exempted from the 2 midnight expectation, but all

other certification requirements remain


EHR has been awarded the exclusive endorsement of the American Hospital Association for its leading suite of Clinical Denials Management and Medical Necessity Compliance Solutions Services.

EHR received the elite Peer Reviewed designation from the Healthcare Financial Management Association (HFMA) for its suite of medical necessity compliance solutions, including: Medicare and Medicaid Medical Necessity Compliance Management; Medicare and Medicaid DRG Coding and Medical Necessity Denials and Appeals Management; Managed Care/Commercial Payer Admission Review and Denials Management; and Expert Advisory Services.

EHR was recognized as one of the “Best Places to Work” in the Philadelphia region by Philadelphia Business Journal for the past six consecutive years. The award recognizes EHR’s achievements in creating a positive work environment that attracts and retains employees through a combination of benefits, working conditions, and company culture.

AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA.

* HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product.

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