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The HCPCS codes for the drug medroxyprogesterone acetate changed at the beginning of this year. Medroxyprogesterone acetate is known by the brand names of Depo-Provera, Provera, Prempro, Depo-Provera Contraceptive, Cycrin, Lunelle, Premphase, Amen, depo-subQ provera 104, Curretab, Premphase 14/14.

The “old” codes (for dates of services prior to January 1, 2013) were:

• J1051 – Injection, medroxyprogesterone acetate, 50 mg*
• J1055 - Injection, medroxyprogesterone acetate for contraceptive use, 150 mg*

For dates of service on and after January 1, 2013, the following code replaces the above codes:

• J1050, Injection, medroxyprogesterone acetate, 1 mg

As a result of this code change, Alabama Medicaid is requiring the use of a modifier to distinguish between use of the drug for contraceptive use and other (non-contraceptive) uses. Modifier FP is used to indicate the injection of the drug for contraceptive use and modifier U1 indicates non-contraceptive use. The Medicaid Alert also lists the following restrictions for usage.

Contraceptive Use Restrictions (J1050-FP)

• Limited to female recipients 10-55 years of age
• Dosage of 104 – 150 mg per injection
• Allowed once every 70 days
• Claim must include a contraceptive management diagnosis code

Non-contraceptive Use Restrictions (J1050-U1)

• Covered for recipients of all ages
• Limited to 1000 mg per injection
• Claim must not include a contraceptive management diagnosis code

Providers should report the drug units based on the new “per 1 mg” description – for example 150 mg would be billed with 150 units, 500 mg with 500 units. Alabama Medicaid reimburses J1050 at $ 0.20 per unit (per mg). Claims for J1050 billed without a modifier will be denied by Alabama Medicaid. See the link above for complete information.

This week we would like to acknowledge Cardiac Rehab Week. Cardiac Rehabilitation Week was initiated by the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) to focus national attention on cardiac rehabilitation’s contribution to the improvement of the health and physical performance of individuals at risk for heart disease and/or those individuals diagnosed with heart disease or dysfunction. MMP, Inc. expresses our appreciation to the dedicated individuals who work with patients, physicians, and other health care providers to make us all “heart healthier”. And to assist cardiac rehab providers, we offer the following guidance on Medicare coverage of Cardiac Rehabilitation services.

Make sure the cardiac rehabilitation services you are providing meet all of Medicare’s requirements in order to ensure appropriate reimbursement. Palmetto GBA, the Part A MAC for Jurisdiction 11, has conducted service specific complex reviews of cardiac rehab services in South Carolina, North Carolina, Virginia, and West Virginia. In the last round of reviews, denial rates, although continuing to decrease, were still between 48 – 64%.

In addition to lack of timely submission of medical records and services not documented, the findings demonstrated the following denial reasons:

1. Cardiac Rehab Not Warranted for Diagnosis - Medicare covers cardiac rehabilitation items and services for patients who have experienced one or more of the following:
2. An acute myocardial infarction within the preceding 12 months; or
3. A coronary artery bypass surgery; or
4. Current stable angina pectoris; or
5. Heart valve repair or replacement; or
6. Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting; or
7. A heart or heart-lung transplant.
8. Cardiac Rehab Session Did Not Include the Required Services - Cardiac rehabilitation programs must include the following components:
9. Physician-prescribed exercise each day cardiac rehabilitation items and services are furnished;
10. Cardiac risk factor modification, including education, counseling, and behavioral intervention at least once during the program, tailored to patients’ individual needs;
11. Psychosocial assessment;
12. Outcomes assessment; and
13. An individualized treatment plan detailing how components are utilized for each patient.
14. Physician Must Be Readily Available - All settings must have a physician immediately available and accessible for medical consultations and emergencies at all time items and services are being furnished under the program. This provision is satisfied if the physician meets the requirements for the direct supervision for hospital outpatient therapeutic services.

Also, providers need to be aware of the frequency limitations for Cardiac Rehab services. Cardiac Rehab services are limited to a maximum of two 1-hour sessions per day for up to 36 sessions over up to 36 weeks with the option for an additional 36 sessions over an extended period of time if approved by the Medicare contractor.

More information concerning Cardiac Rehab and Medicare coverage and billing requirements can be found at:

• Medicare Benefits Policy Manual, Chapter 15, Section 232
• Medicare Claims Processing Manual, Chapter 32, Section 140
• MLN Matters Article MM6850

CMS’s Medicare Learning Network publishes quarterly Medicare Compliance Newsletters to address the findings from reviews by Medicare contractors such as MACs, RAs (formerly RACs), ZPICs, CERT and the OIG. The January 2013 edition addresses several findings related to review of inpatient hospital claims.

Lack of Medical Necessity for Inpatient Admission always seems to be a big topic and this quarter is no exception. Three different DRGs are discussed with examples of services that should have been provided in a lower level of care setting. Patients did not meet criteria for an inpatient admission for the following DRGs for the reasons noted.

• MS-DRG 491, Back & Neck Procedures excluding Spinal Fusion
• Patient did not experience any intraoperative or post-op complications; and
• Recovery phase was within expectations for this procedure.
• MS-DRG 312, Syncope and Collapse
• Signs and symptoms documented were not significant or severe enough to warrant the need for medical care at the intensity of an inpatient admission.
• Evaluation and treatment could have been rendered as observation services
• The medical record does not establish the need for acute care hospitalization at an inpatient level.
• MS-DRG 516, Other musculoskeletal system & connective tissue operating room (O.R.) procedures with complicating conditions (CC).
• Elective, scheduled, non emergent kyphoplasties for compression fractures in patients with pre-operative medical clearance and a low probability of complications can be performed at an outpatient level of care.

Also, Coding Errors were found for Other OR Procedures for Injuries (DRGs 907, 908, and 909). In the examples given, a procedure or acute injury from a prior admission was coded as occurring during or being the cause of the current admission. Coders should only code procedures performed during the current inpatient admission. Subsequent encounters require the use of an orthopedic after care code.

Refer to the Compliance Newsletter to see the specific examples and the complete discussions.

Last Friday, CMS issued Transmittal R442PI which clarifies the requirements necessary for amendments, corrections and late entries to the medical record to be considered by Medicare contractors during medical review. Medicare contractors that review records for payment determinations include the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT), Recovery Auditors (RAs or RACs) and Zone Program Integrity Contractors (ZPICs).

Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service. If actions that were actually performed were not properly documented at the time of the service, a correction, amendment or late entry is acceptable for Medicare review only if it adheres to the following standards:

• Any amendment, correction or late entry shall be clearly and permanently identified as such,
• The date and author must be clearly identified, and
• Original content must also be clearly identified and not deleted.

These requirements apply to both paper and electronic medical records.

Corrections to paper medical records require that:

• The original content is still readable which can be accomplished by using a single line strike through
• The author of the alteration sign and date the revision
• Amendments or late entries be clearly signed and dated upon entry into the medical record.

Acceptable revisions in an electronic record must:

• Distinctly identify any amendment, correction or delayed entry, and
• Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.

The requirements note that Medicare reviewers shall exclude from consideration undated or unsigned entries handwritten in the margin of a document. The manual also warns against potentially fraudulent entries.

Background

As part of the Deficit Reduction Act of 2005 (DRA), hospitals were required to begin reporting whether or not diagnoses were Present on Admission (POA) on or after October 1, 2007.

General POA Requirements:

• POA indicator is required for all claims involving Medicare inpatients admitted to general IPPS acute care hospitals.
• POA is defined as present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.
• The POA indicator is assigned to the principal diagnosis and secondary diagnoses.
• Inconsistent, missing, conflicting or unclear documentation must be resolved by the provider.
• POA indicator is not reported if a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current Official Guidelines.
• CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an “other diagnosis.”

(Source: CMS POA Fact Sheet)

Office of Inspector General (OIG) November 23, 2012 Report: Assessment of Hospital Reporting of Present on Admission Indicators on Medicare Claims.OEI-06-09-00310

The OIG recently released a report that assessed POA indicator accuracy and the nature of any miscoding. As background to this review the OIG indicated that Section 5001 (c) of the Deficit Reduction Act of 2006 mandated that hospitals would not receive increased Medicare reimbursement for certain conditions that develop during a hospitals stay that were not present on admission. These conditions are referred to as “hospital-acquired conditions” and the list of conditions is updated annually. Assigning POA indicators “provides a necessary framework” for making the determination of whether or not a diagnosis is a “hospital-acquired condition.”

For the report, the OIG utilized contracted certified coders that reviewed medical records and “documented all misreported POA indicators and described circumstances that may have contributed to the errors.”

The OIG found that “hospital coders incorrectly reported 3 percent of the 5,491 POA indicators reviewed, resulting in the presence of at least one incorrect indicator on 129 claims (18 percent).” There were three main groups of errors identified and include:

• Twenty-One Percent were related to the assessment of developing or chronic conditions
• Conditions that were developing at the time of admission with misreported POA indicators included systemic inflammatory response syndrome (SIRS), septic shock, blood infections, urinary tract infections, pneumonia, pressure ulcers, constipation, and malnutrition.
• Chronic conditions with misreported POA indicators included diabetes and patient’s experiencing an exacerbation of a chronic condition such as congestive heart failure.

• Thirty-Two Percent involved errors in assigning POA indicators to exempted conditions.
• In these cases the hospital coder either assigned a POA indicator code when he/she should have identified the diagnosis as exempt or coded a diagnosis as exempt when it was not on the published list of exemptions and should have been assigned POA indicators.

• Forty-Seven Percent involved other reporting errors not associated with developing or chronic conditions or with exemptions. Specific examples in the report include:

• The OIG coders found documentation contradicting the POA designation.
• Medical record review clearly indicated the presence or absence of a diagnosis at the time of admission. “This suggests that hospital coders may have failed to notice or disregarded the information necessary to make an accurate POA assessment.”
• Physician’s documentation not clearly indicating when a condition developed.
• Other issues such as a diagnosis changing during the hospitalization.

The OIG concluded that the 3-percent error rate is relatively low and no recommendations were made. At MMP we believe that it is important to point out that in their conclusion, the OIG indicates that “POA indicators provide an opportunity for monitoring hospital quality of care and are critical to CMS’s efforts to link payment to quality, but they must be accurate to serve these purposes. Encouraging hospitals to assess POA reporting practices related to developing conditions and exemption codes, and to retrain staff as needed, could help to ensure accuracy.”

When talking to hospital staff and Physicians about high resource consumption, high readmission rates and high mortality rates, one explanation you almost always hear is “my patients are sicker.”

But how do you know if your patients are sicker? Understanding your facility’s Case Mix Index (CMI) is a good way to answer this question. However, to understand CMI you need to first understand the basic fundamentals of the Inpatient Prospective Payment System (IPPS) and how a Coder in a hospital determines the Diagnosis-Related Group (DRG) assignment for every hospital inpatient stay.

Background:

In 1983, Congress mandated the Inpatient Prospective Payment System (IPPS) for all Medicare inpatients. IPPS uses Diagnosis-Related Groups (DRGs) to determine reimbursement for hospitals.

Beginning October 1, 2007 the DRG system began transitioning to a new system called Medicare Severity MS-DRG. The transition to MS-DRGs allowed for an improved accounting of a hospital’s resource consumption for a patient and the patient’s severity of illness.

Assigning a DRG:

Principal Diagnosis:

The Uniform Hospital Discharge Data Set (UHDDS) defines the Principal Diagnosis as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Comorbidities and Complications (CCs and MCCs):

These are conditions that increase a patient’s resource consumption and may cause an increase in length of stay compared to a patient admitted for the same condition without a co-morbidity or complication. When the DRG system transitioned to MS-DRGs the comorbidites and complications were divided into three levels. The three levels are DRGs without a CC or MCC, DRGs with a CC and DRGs with a MCC.

• Comorbidities are the conditions that patients “bring with them” when they are admitted to a hospital and continue to require some type of treatment or monitoring while in the inpatient setting. For example:
• A patient with a history of atrial fibrillation is continued on his home medications and placed on telemetry monitoring.
• A patient with a history of Diabetes is placed on pattern blood sugars with sliding scale insulin
• A patient has a history of hypercholesterolemia and is continued on their home Statin therapy.
• Complications are those conditions that occur during the inpatient hospitalization. For example:
• A patient undergoes hip surgery and experiences acute post-op blood loss anemia in the peri-operative period requiring serial Hemoglobin and Hematocrit checks and possibly blood transfusions.
• A patient with a history of chronic obstructive pulmonary disease undergoes surgery and develops post-op respiratory failure.

• Major Comorbidities and complications (MCCs): DRGs with MCCs reflect the highest level of severity. For example:
• A patient with chronic systolic heart failure is admitted for a GI bleed, becomes volume overloaded and develops acute on chronic systolic heart failure during the admission.

As many times as we have heard it said it remains true, if you don’t document it then it wasn’t done or in the case of DRG assignment it wasn’t present and treated during the hospitalization. A Coder’s ability to code to the most appropriate DRG is dependent upon the Physician documentation in the medical record. Coding Guidelines do not allow coders to interpret lab findings, radiology findings, EKGs or pathology reports to assign diagnosis codes.

A successful DRG program in a hospital is dependent on the Physician providing a complete accounting of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status.

Example:

A patient presents with chest pain and has a known history of GERD. A Myocardial Infarction (MI) was ruled out based on EKG and Cardiac Enzymes and the patient was discharged home with a new prescription for Prilosec. In this case chest pain is a symptom code and a more specific diagnosis would be chest pain related to GERD. However, if the only diagnosis written by the Physician in the record is chest pain then the coder can only assign the code for unspecified chest pain.

This is why Coders and in more recent years Clinical Documentation Specialist send queries to Physicians. As far back as 2007, CMS has indicated that “we do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.” (Source: Federal Register / Vol. 72, No. 162 / Wednesday, August 22, 2007 / Rules and Regulations – page 47180)

Diagnosis-Related Group (DRG) is a diagnosis classification that groups patients that have a similar resource consumption and length-of-stay.

Relative Weight (RW) is a numeric weight assigned to each DRG that is indicative of the relative resource consumption associated with that DRG. For CMS fiscal year 2011 (October 1, 2010 through September 30, 2011) relative weights range from as high as DRG 001: Heart Transplant or Implant of Heart Assist System with MCC at 26.3441 to as low as DRG 795: Normal Newborn at 0.2284. Medical DRGs (e.g. chest pain, pneumonia, congestive heart failure) will have a lower relative weight than surgical DRGs.

Case Mix Index (CMI): The Ingenix 2011 DRG Expert defines CMI as “the sum of all DRG relative weights, divided by the number of Medicare cases. A low CMI may denote DRG assignments that do not adequately reflect the resources used to treat Medicare patients.”

An easier way to explain CMI is to compare it to a student’s Grade Point Average (GPA). A higher GPA is reflective of a student’s academic success. Likewise, a higher CMI for a hospital is reflective of a successful DRG program.

GPA Example:

(A=4 grade points / B=3 grade points / C=2 grade points / D = 1 grade point / F = 0 grade points)

Formula for GPA: Total Grade Points ÷ Sum of Credit Hours = GPA

21 ÷ 10 = 2.10 GPA

Case Mix Index Example A:

Formula for Case Mix Index:

Sum of Relative Weights ÷ Total Number of DRGs Coded = Case Mix Index

Example A Case Mix Index: 3.7543 ÷ 4 = 0.9386 Case Mix Index

Example B: The Potential Impact Physician Queries can have on DRG Assignment:

1. Example B Case Mix Index: 4.9944 ÷ 4 = 1.2036 Case Mix Index

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“The higher the case mix index, the more complex the patient population and the higher the required level of resources utilized. Since severity is such an essential component of MS-DRG assignment and case mix index calculation, documentation and code assignment to the highest degree of accuracy and specificity is of utmost importance.”

(Source: Ingenix 2011 DRG Expert)

Challenges for Hospitals:

Understanding what can make your hospitals CMI fluctuate?

• A decrease in CMI may be reflective of:
• Non-specific documentation by the Physician
• Increase in Medical Volume with a decrease in Surgical Volume as Surgical DRGs have a higher Relative Weight.
• Surgeons being on vacation
• Physicians being unresponsive to Coder and Clinical Documentation Specialist queries
• An increase in CMI may be reflective of:
• Tracheostomy procedures that have an extremely high Relative Weight
• Ventilator patients
• Open Heart Procedures
• Improved Physician Documentation
• Improved Physician response rate to queries resulting in an improved CC / MCC capture rate

Realizing the Importance of every Medical Professional’s role in the success of a hospital’s DRG program:

• The Physician’s Role: Is to provide complete and accurate documentation of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status in the medical record.

• The Clinical Documentation Specialist’s Role: Is to perform concurrent medical record reviews and ask queries whether verbal or written when indicated.

• The Coder’s Role: May be concurrent medical record review or a retrospective review after discharge; also ask queries when indicated.

The American Health Information Management Association (AHIMA) published a practice brief “Managing an Effective Query Process” in October 2008. The AHIMA brief states that “Providers should be queried whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant reportable condition or procedure” or if “additional information is needed for correct assignment of the POA indicator.”

Further, AHIMA suggests querying when documentation in the patient’s record fails to meet one of the following five criteria:

• Legibility
• Completeness (e.g. abnormal test results without notation of clinical significance)
• Clarity (e.g. diagnosis without statement of cause or suspected cause)
• Consistency (e.g. conflicting documentation)
• Precision (e.g. greater specificity)

The entire brief can be found at AHIMA's Managing an Effective Query Process.

So, how do you know if your patients are sicker?

Internally, hospitals can:

• Work with their Decision Support staff to develop CMI reports by facility and by individual physicians.
• Perform root-cause-analysis when you see fluctuations in the CMI rate.
• Use CMI reports to compare Physicians in like specialties to each other.

External Resource for hospitals:

MMP, Inc’s sister company RealTime Medical Data (RTMD) affords hospitals the unique ability to finally compare their CMI rates to other hospitals within their defined market as well as statewide. RTMD uses real Medicare paid claims data and reports are based on the total market – all residents, all physicians, and all hospitals within Alabama, Mississippi, Tennessee, Georgia, Florida, Louisiana, Arkansas, Delaware, District of Columbia, Maryland, New Jersey, North Carolina, Oklahoma, Pennsylvania, South Carolina and Texas.

RTMD reports that can help a hospital and physician’s answer this question include:

• CMI Detail Reports
• Provider CMI Details by DRG with Statewide CMI: This report represents CMI for the Provider with DRG details and includes Statewide CMI for all providers.
• Provider CMI Details by Physician: This report represents CMI for the Provider with Physician Details.

A successful DRG program is dependent on accurate documentation. Addressing issues that can impact CMI will enable you to capture the most accurate severity of illness, have a positive impact on reimbursement and support the medical necessity of inpatient admissions.

As a new Hospital Case Manager in the 1990’s, I performed the job duties that I was taught in orientation but often wondered why we did some of the things that we did. Why did we have a quarterly Utilization Review Committee meeting? Why did we give our patients a patient choice list of Home Health Agencies, Skilled Nursing Facilities and Hospice Agencies? What I have learned and continue to learn is that there is a lot more to Case Management and Discharge Planning than “looking at charts” all day and to be compliant you need to understand the “why” of what you do as much as the “how you do it.”

CMS has indicated that the CoPs “health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries.”

The Social Security Act (the Act) Sections 1861(e)(1) through (8) indicates that hospitals that participate in the Medicare program must meet specific requirements. Section 1861(e)(9) of the Act further specifies that “a hospital must meet such other requirements as the Secretary finds necessary in the interest of the health and safety of individuals furnished services in the institution.” (Federal Register / Vol. 76, No. 205 / Monday, October 24, 2011 / Proposed Rules / page 65892)

This is where the Conditions of Participation (CoP) enter into the “why” of it. CoPs for health care organizations, simply put, are the guidance that must be met to be able to start and continue to participate in the Medicare and Medicaid programs. According to the Centers for Medicare and Medicaid Services (CMS) “these health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries.” (https://www.cms.gov/CFCsAndCoPs)

Hospital CoPs can be found in the Electronic Code of Federal Regulations under Title 42: Public Health, Part 482 – Conditions of Participation for Hospitals. “The CoPs are organized according to the types of services a hospital may offer, and include specific, process oriented requirements for each hospital service or department. The purposes of these conditions are to protect patient health and safety and to ensure that quality care is furnished to all patients in Medicare-participating hospitals.” (Federal Register / Vol. 76, No. 205 / Monday, October 24, 2011 / Proposed Rules / page 65892)

Section 1864 of the Act indicates that State Surveyors assess the compliance of facilities to determine whether or not they qualify to participate in the Medicare program. Per Section 1865 of the Act, “hospitals can elect to be reviewed instead by private accreditation organizations approved by CMS as having standards and survey procedures that are at least equivalent to those used by CMS and State surveyors.” (Federal Register / Vol. 76, No. 205 / Monday, October 24, 2011 / Proposed Rules / page 65892) In December of 2011, CMS updated the Approved Accreditation Organization Contact Information. The Joint Commission is an approved Accreditation Organization.

The three Hospital CoPs that Case Managers and Discharge Planners should become familiar with. These CoPs are:

• §482.13 Condition of Participation: Patient’s rights,
• §482.30 Condition of Participation: Utilization Review; and
• §482.43 Condition of Participation: Discharge Planning.

Understanding these specific CoPs will lay the groundwork for Case Managers and Discharge Planners in understanding the “why” of the duties they perform in their job every day.

§482.13 Condition of Participation: Patient’s rights

Standard §482.13(a)(1) “A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible.”

“In part as a result of the Weichardt v Leavitt lawsuit, CMS published final regulations on November 27, 2006, that established revised requirements for how hospitals must notify Medicare beneficiaries who are hospital inpatients about their discharge appeal rights.”

Embedded within the guidance of this standard are details regarding providing Medicare Beneficiaries with the standardized notice, “An Important Message from Medicare” (IM). Case Management and Discharge Planning became involved in this process on July 2, 2007 when participating hospitals were required to begin not only providing an IM to Beneficiaries on Admission but to provide a second IM prior to but not more than two days before discharge.

CMS provided Questions and Answers on April 3, 2007 related to this new process. One of the Q&A’s explained how in part this new process was the result of a lawsuit. The IM form advises Beneficiaries about their Medicare Discharge Rights and that hospital staff will work with them to plan for a safe discharge, arranging for any post-acute care services that they may need. The IM also advises the Beneficiary that when they no longer need inpatient services that the doctor or hospital staff will make them aware of a planned discharge date.

In 2009 the American Case Management Society (ACMA) Public Policy Committee surveyed Case Management Professionals about their experience with providing the IM second notice. L. Greg Cunningham, ACMA CEO, shared the responses with a group of CMS administrators at the agency headquarters in Baltimore. Following this meeting, CMS requested that the ACMA submit a prioritized list of issues and concerns regarding the IM second notice. The outcome of this proactive endeavor by ACMA was that CMS provided FAQ Documentation Addressing Case Managers Concerns and that the current IM form was modified to include a place to time when the form was signed. This updated form went into effect on April 1, 2011.

§482.30 Condition of Participation: Utilization Review (for Medicare Beneficiaries)

“The hospital must have in effect a utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid program.”

Utilization Review requirements for Medicare and Medicaid

§482.30 Condition of Participation: Utilization Review (for Medicare Beneficiaries) “The hospital must have in effect a utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid program.”

The State Operations Manual - Appendix A, Interpretive Guidelines for §482.30 indicate that “the Utilization Review CoP is not a part of the deemed program for hospitals, per 42 CFR 488.5. As such, State Survey Agencies have jurisdiction over the UR CoP for accredited and non-accredited hospitals.”

Specific Standards within this CoP are: the Composition of the UR Committee, the Scope and Frequency of Reviews, determination regarding admissions or continued stays, extended stay reviews and the review of professional services.

Survey Procedures for evaluating the Standards include:

• Determine that a hospital has a UR Plan for services provided to Medicare and Medicaid patients by a hospital and its medical staff.
• Verify that UR activities are being performed as outlined in the Hospital’s UR Plan.
• Review UR Committee meeting minutes to verify that they include dates, members present, extended stay reviews with approval or disapproval noted and a report of any actions taken.
• Determine the composition of the UR Committee.
• The Committee must have at a minimum 2 Doctors or Medicine or Osteopathy.
• Determine that the UR Committee has received authority and responsibility to carry out its function by the hospital’s governing body.
• For small hospitals where it is not practical to have a staff committee, verify that the hospital delegated the UR function to an outside group.
• Verify that UR Committee members do not have ownership of 5 percent or greater in the hospital and were not involved in the planning or carrying out of the patient’s treatment plan.
• Review the UR Plan and other documents to confirm that medical necessity is reviewed for admissions, continued stays and professional services furnished.
• For Inpatient Prospective Payment System (IPPS) Hospitals verify that outlier cases and professional services in outlier cases are reviewed.

Title 42 – Public Health - Part 456 – Utilization Control - Subpart C – Utilization Control: Hospitals (for Medicaid Recipients)

A key standard within this section is that hospitals need to be aware of is the Medical Care Evaluation Studies as detailed in §456.141 - §456.145. “The purpose of medical care evaluation studies is to promote the most effective and efficient use of available health facilities and services consistent with patient needs and professionally recognized standards of health care.”

Hospitals must at a minimum have one Medical Care Evaluation study in progress at any time and complete one study each calendar year. §456.145

§456.143 details what must occur in a Medical Care Evaluation Study and includes:

• Identify and analyze medical or administrative factors related to the hospital’s patient care;
• In the analysis the minimum to be included are: Admissions, Durations of Stay, Ancillary services furnished (including drugs and biological, Professional services performed in the hospital and if indicated should contain recommendations for changes beneficial to the patient, hospital staff, hospital and the community.

§482.43 Condition of Participation: Discharge Planning

Interpretive Guidelines in the State Operations Manual – Appendix A, indicate that “this CoP applies to all types of hospitals and requires all hospitals to conduct appropriate discharge planning activities for all inpatients.” The Guidelines go on to indicate that “adequate discharge planning is essential to the health and safety of all patients. Patients may suffer health consequences upon discharge without benefit of appropriate planning. Such planning is vital to mapping a course of treatment aimed at minimizing the likelihood of having any patient rehospitalized for reasons that could have been prevented.”

With the 30 Day Readmission Reduction Program set to begin October 1, 2012, Discharge Planning is more important than ever and is a first step to providing smooth transitions of care for our patients. A good evaluation begins with assessing a patient’s functional status, their cognitive ability and their family support.

“The Hospital must inform the patient or family as to their freedom to choose among providers of post-hospital care.”

- Interpretive Guideline of §482.43(b)(4)

This CoP answers the question of why we provide patient choice lists for Home Health Agencies (HHA), Skilled Nursing Facilities (SNF) and Hospice agencies.

The State Operations Manual – Appendix A - Interpretive Guidelines expectation is that hospitals “provide a list of Hospice, HHAs or SNFs that are available to the patient, that participate in the Medicare program, and that serve the geographic area that the patient requests.” The expectation is that the hospital will document in the medical record that a list had been provided to the patient or the person acting on the patient’s behalf. Hospitals have been allowed the flexibility to develop and maintain their own lists. It is important to note that hospitals are prohibited from steering patients to a particular agency and must disclose when the hospital has a financial interest in the agency.

The Conditions of Participation provide guidance for Hospitals that participate in the Medicare and Medicaid programs. There are three specific CoPs that provide an answer to why Case Managers and Discharge Planners provide the second Important Message from Medicare to Beneficiaries, why you have a Utilization Review Plan and Committee Meetings and why you provide discharge planning for all patients in the inpatient setting. More importantly, these CoPs support the ACMAs definition of Case Management in that “Case Management in Hospital/Health Care Systems is a collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The Case Management Process encompasses communication and facilitates care along the continuum through effective resource coordination. The goals of Case Management include the achievement of optimal health, access to care and appropriate utilization of resources, balanced with the patient’s right to self determination.”

References

The Federal Register / Vol. 76, No. 205 / Monday, October 24, 2011 / Proposed Rules / page 65892. Retrieved March 29, 2012, from http://www.gpo.gov/fdsys/pkg/FR-2011-10-24/pdf/2011-27175.pdf

CMS webpage overview of the Conditions of Participation (CoPs) Retrieved March 29, 2012 from https://www.cms.gov/CFCsAndCoPs

Electronic Code of Federal Regulations Retrieved March 29, 2012 from http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=%2Findex.tpl

CMS-Approved Accredited Organization Contact Information Retrieved March 29, 2012 from https://www.cms.gov/SurveyCertificationGenInfo/Downloads/AOContactInformation.pdf

Final Rule: Notification of Hospital Discharge Appeal Rights (CMS-4105-F) Qs AND As (April 3, 2007) Retrieved March 29, 2012 from https://www.cms.gov/BNI/Downloads/CMS4105FINALRULEQsandAs2007.pdf

CMS Provides ACMA with FAQ Document Addressing Case Managers’ Concerns Surrounding the IM Second Notice Retrieved March 29, 2012 from http://www.acmaweb.org/forms/IM_FAQ.pdf

State Operations Manual – Appendix A – Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 81,03-23-12) Retrieved March 29, 2012 from http://www.cms.gov/manuals/Downloads/som107ap_a_hospitals.pdf

American Case Management Society of America (ACMA) definition of Case Management Retrieved March 29, 2012 from http://www.acmaweb.org/section.asp?sID=4&mn=mn1&sn=sn1&wpg=mh

We all know about the cloning of genetic material (remember Dolly the sheep), but are you aware of the risks associated with the cloning of medical record documentation? This type of “cloning” occurs when each entry in the medical record for a patient or patients is worded exactly alike or similar to previous entries. It is also known as “cut and paste” or “carrying forward” and generally occurs with using a preprinted template or an electronic health record (EHR).

Templates and electronic records offer many benefits, such as increased documentation speed and efficiency, but there are potential risks. The Office of Inspector General (OIG) and several Medicare Administrative Contractors (MACs) have published articles about the use of cloned documentation. Their concerns are that “cloned” documentation can lead to fabricated information, improper payments and corrupted patient records. Several MACs state that “this ‘cloned documentation’ does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter.” See the references at the end of this article for specific excerpts from government agencies and contractors.

So, as a hospital, how should you identify “cloned” documentation and what should you do about it?

• It is likely that your medical record coders, clinical documentation improvement staff, and/or case managers can tell you if there are instances of cloned documentation in your medical records.
• To identify problems with repetitive documentation look for contradictory information in the medical record associated with such entries, progress notes that do not change from day to day, and the repetition of typographical errors from note to note.
• Develop a policy addressing the use and controls for carry forward documentation and documentation templates
• Educate physicians and practitioners about the appropriate use of EHR tools and the importance of verifying accurate and complete documentation
• Audit medical records for inappropriate “cloning” and have processes in place to address abuses.

Two excellent articles that address this topic are a reprint of a Report on Medicare Compliance article by AISHealth and an AHIMA article on Documentation Bad Habits.

Medicare Resources

OIG Top Management and Performance Challenges: Integrity and Security of Health Information Systems and Data“Finally, EHRs should facilitate more accurate billing and support better quality of care but, when misused, may promote fraudulent billing or inappropriate care. For example, cut-and-paste features and auto-fill templates can reduce paperwork burdens, but can also be misused to fabricate information, generating improper payments and corrupting patients' records with inaccurate and potentially dangerous information. Similarly, well-designed decision support tools can help physicians select the best care for their patients, but inappropriately designed decision support tools can promote waste and inappropriate care."

Palmetto GBA: Medical Record Cloning“The word 'cloning' refers to documentation that is worded exactly like previous entries. This may also be referred to as 'cut and paste' or 'carried forward.' Cloned documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic Health Record (EHR). While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter. Cloned documentation does not meet medical necessity requirements for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”

Cahaba GBA: FAQ Medical Reviewregarding cloning“The medical necessity of services preformed must be documented in the medical record and Cahaba GBA would expect to see documentation that supports reasonable and medically necessary services and any changes and or differences in the documentation of the History of Present Illness, Review of System and Physical Examination. The medical record must be authenticated by the provider of services. CMS acceptable signature methods are hand written and electronic signatures. Stamp signatures are not acceptable.”

CGS: Electronic Medical Records Tips“Cloning occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. This "cloned documentation" does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”

First Coast: Cloning of Medical Notes“Cloning of Medical Notes: Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”

Noridian: Documentation Software Templates“NAS Part B MR has noted that some Electronic Medical Record (EMR) software programs auto-populate certain aspects of the medical record with information that is not patient specific. This issue is more profound in the HPI when discussing the context of a certain illness and/or co-morbidity. Documentation to support services rendered needs to be patient specific and date of service specific. These auto-populated paragraphs provide useful information such as the etiology, standards of practice, and general goals of a particular diagnosis. However, they are generalizations and do not support medically necessary information that correlates to the management of the particular patient. Part B MR is seeing the same auto-populated paragraphs in the HPI’s of different patients. Credit cannot be granted for information that is not patient specific and date of service specific."

On November 8, 2012, CMS released MLN Matters Article SE1232 with a series of frequently asked questions and answers about the 3-day payment window. However, these are the same FAQs that CMS published in June of this year. information in the August 15, 2012 Wed@One – search the client section of our www.mmplusinc.com ) using the word “window” to review this article). Also, CMS finally updated the manual instructions for the 3-day payment window in August of this year in Transmittal R2539CP concerning the 2013 IPPS changes. So, even though this information is not exactly new, the 3-day payment window regulations are so complex that another review of the more difficult aspects of this rule never hurts.

Since it is a 3-day rule (not 72 hours), I like to break the rule down into three separate components so I can better understand it.

1. All services on the day of inpatient admission must be bundled into the inpatient claim.
2. All diagnostic services within the payment window (3 days for IPPS hospitals), must be bundled into the inpatient claim, whether related or not.
3. A service is “diagnostic” if it is an examination or procedure to which you subject the patient, or which you perform on materials derived from a hospital outpatient, to obtain information to aid in your assessment of a medical condition or to identify a disease.
4. For this provision, diagnostic services are defined by the presence on the bill of the particular revenue and/or CPT codes specified in the Medicare Claims Processing Manual, Chapter 3, Section 40.3.
5. All non-diagnostic services within the payment window that are related to the reason for inpatient admission must be bundled into the inpatient claim.
6. It is the responsibility of the hospital to determine if non-diagnostic services are clinically related to the inpatient admission. Hospitals should carefully consider how and who to best accomplish this determination and communicate that to billing.
7. Non-diagnostic services within the payment window that are not related may be submitted on a separate outpatient claim. Hospitals attest that these services are unrelated by adding condition code 51 on the outpatient claim.

Other, more challenging, aspects of the 3-day payment window regulations include:

• The 3-day rule does not apply if there is no Part A coverage for the inpatient admission. This means that if an inpatient admission does not meet inpatient criteria and is billed as a no-pay inpatient claim or is denied as not medically necessary, the 3-day rule does not apply. Outpatient services prior to such inpatient admissions can be billed separately on an outpatient claim.
• Services furnished more than 3 days preceding the date of the inpatient admission are not part of the payment window, even when furnished during a single, continuous outpatient encounter. Services prior to the 3 calendar days should not be bundled into the inpatient claim, but should be billed separately on an outpatient claim.
• The 3-day payment window applies to physicians’ practices and other entities that are wholly-owned or operated by the hospital where the patient is admitted. Guidance on combining these services can be found in the Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Sections 90.7 and 90.7.1.
• Hospitals must include on a Medicare claim for a beneficiary’s inpatient stay the diagnoses, procedures, and charges for all services bundled under the 3-day payment window rule. This will require the coordination of billing and coding to combine charges, include and appropriately sequence diagnosis codes for the combined outpatient/inpatient services, and convert combined outpatient procedures to ICD-9-CM procedure codes for the inpatient claim.

And one final very scary thought on the 3-day payment window – in this year’s Office of Inspector General’s (OIG) Work Plan , the OIG states they will “analyze claims data to determine how much CMS could save if it bundled outpatient services delivered up to 14 days prior to an inpatient hospital admission into the diagnosis related group (DRG) payment. OIG work has also concluded that CMS could realize significant savings if the DRG window was expanded from 3 days to 14 days.”

CMS’s Medicare Learning Network publishes quarterly Medicare Compliance Newsletters to address the findings from reviews by Medicare contractors such as MACs, RAs (formerly RACs), ZPICs, CERT and the OIG. A cursory look at the October 2012 newsletter might lead you to believe it is the same old issues with the same old information. But a more thorough reading of the details reveals education and guidance on coding / billing issues and examples of services provided in an inappropriate level of care. And of course the usual information is there also – but in these days of seemingly never-ending recoupment, one more reminder doesn’t hurt.

Coding Issues

Inappropriate secondary diagnosis with major joint replacements that resulted in inappropriate DRG assignment:

• “Moderate protein nutrition” should only be assigned code 263.0, Malnutrition of moderate degree, because this code category includes protein-calorie malnutrition. Code 260, Kwashiorkor, is not appropriate since this condition was not specifically documented. (Coding Clinic: Third Quarter, 2009)
• Code 416.2 was created in October 2009 to describe chronic pulmonary embolism to distinguish these from acute pulmonary emboli. Use this code if the patient did not have an acute PE during the current admission, instead of reporting code 415.19. (Coding Clinic, Fourth Quarter, 2009)

Sequencing errors related to the principal diagnosis with cardiac procedures that resulted in inappropriate DRG assignment.

• Code acute myocardial infarction (410.xx) as the principal diagnosis rather than CAD (414.01) for patients who present with an acute MI and are successfully treated with angioplasty. (Coding Clinic, 4th Quarter 2005 and Coding Clinic, 2nd Quarter, 2001)

Billing Issues

Outpatient within Inpatient Stay

• A separate claim for laboratory services by the same hospital during the time frame of an inpatient admission.
• A separate claim by another hospital for ERCP services during an inpatient admission. If an outside entity provides services to an inpatient, those services are part of the inpatient admission. The inpatient hospital should make arrangements with the outside entity to ensure that a separate outpatient claim is not submitted to Medicare.

Inappropriate Hospital Admissions

Respiratory Conditions

• Patient with mild COPD 2 and costochondritis who presented with chest pain and successfully treated with IV ketorolac; discharged next day. Per Medicare reviewers, services should have been provided at outpatient level of care.
• Patient with wheezing and hypoxemia post EGD; successfully treated with IV Solu-Medrol and IV Protonix and discharged home the next day. Per Medicare reviewers, services should have been provided at outpatient level of care.

DRG 581, Other Skin, Subcutaneous Tissue and Breast Procedures

• Two examples of uncomplicated mastectomies, discharged home the next day. Per Medicare reviewers, services should have been provided at outpatient level of care.

Please read the October 2012 Medicare Quarterly Compliance Newsletter to see the complete examples and other helpful information.