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This month MMP will focus on some of the important changes and guidelines covering Chapter One “Certain Infectious and Parasitic Diseases”.

Chapter 1 is divided into 22 separate blocks covering two alpha characters A00-B99 and includes:

• Diseases generally recognized as communicable or transmissible as well as a few diseases of unknown but possibly infectious origin.

Type I Excludes:

• Certain localized infections – refer to body system related chapters.
• Influenza and other acute respiratory infections (J00-J22)

Type 2 Excludes:

• Carrier or suspected carrier of infectious disease (Z22.-)

A separate subchapter was created for “Infections with a Predominantly Sexual Mode of Transmission” (A50-A64) to appropriately group these type diseases together:

• Human Immunodeficiency Virus (HIV) is excluded in this range of codes.

For cases with infections shown to have an associated drug resistance, code Z16 should be assigned in addition to the infection code to show the associated drug resistance.                      

• Coding Guideline I.C 1.c. – Infections Resistant to Antibiotics:  Many bacterial infections are resistant to current antibiotics. It is necessary to identify all infections documented as antibiotic resistant.

Streptococcal Sore Throat has been relocated from Chapter 1 to Chapter 10 – Diseases of the Respiratory System.

Tuberculosis (TB):  

• ICD-10-CM will not ask for information denoting how the disease was identified.
• The codes for Tuberculosis have been restructured and consolidated. Assignment is now based on anatomical site or type.

Intestinal Infections:

• Codes will now identify type of infection.
• Viral
• Bacterial
• Fungal or parasitic/amebic
• Options available for “Other “ and “Unspecified”

Categories B95.0-B99.9 are supplementary codes to identify the infectious agent(s) in diseases classified elsewhere in which there is no organism identified as part of the infection code.

• Refer to Coding Guideline I.C.1.b.

Human Immunodeficiency Virus (HIV) Infections

HIV is the virus that can lead to AIDS (Acquired Immunodeficiency Syndrome).   People with this illness are much more vulnerable to infections due to the attack and alteration to their immune system. This is prone to get worse as the disease progresses. The human body is not capable of fighting off this virus. Once a person is infected with HIV, it is an affliction for the rest of their life.

HIV is found in the body fluids of an infected person and can be transmitted:

• From one person to another through blood-to-blood and/or sexual contact.
• Newborn infants can acquire HIV:
• During pregnancy
• Through delivery
• Through breast feeding
• Blood transfusion
• Sharing hypodermic needles

There is a subcategory and four codes to classify the HIV virus in ICD-10-CM.

B20 - Human Immunodeficiency Virus (HIV) disease

Assign code B20 as the principal diagnosis when a patient is admitted with an HIV-related condition. An additional diagnosis code should be used to identify all reported manifestations of HIV infection.

• Refer to Coding Guideline I.C.1.a.2.a.
• Code only confirmed cases of HIV infection.
• Confirmation does not require a positive serology or culture for HIV. The physician’s diagnostic statement is sufficient.
• Refer to Coding Guideline I.C. 1.a.1.
• People with HIV can acquire many infections that are called “Opportunistic Infections” or OIs.

Includes:

• Acquired Immune Deficiency Syndrome (AIDS)
• AIDS-related Complex (ARC)
• HIV Infection, Symptomatic

Excludes Type 1:

• Asymptomatic Human Immunodeficiency Virus (HIV) Infection Status (Z21)
• Exposure to HIV virus (Z20.6)
• Inconclusive Serologic Evidence of HIV (R75)

Z21 - Asymptomatic Human Immunodeficiency Virus (HIV) Infection Status

Code Z21 is used for reporting a patient diagnosed with a positive HIV status but has never been diagnosed with any type of manifestation or OI.

• Includes HIV positive NOS
• Once a patient has developed an HIV-related OI, the patient should always be assigned code B20 for any future admission/encounter.
• Code Z21 should never be assigned again for a patient diagnosed with HIV/AIDS even if there is no infection or HIV related condition during that present admission.
• Codes B20 and Z21 should never be assigned together during the same admission.

R75 - Inconclusive laboratory evidence of Human Immunodeficiency Virus (HIV)

• An inconclusive serology test, but no definitive diagnosis or manifestation of the HIV infection.

Z20.6 - Exposure to HIV Virus

This code is assigned only when a patient has been exposed or may have come in contact with the HIV virus.

Some Common HIV Infections:   (this list is not all or inclusive)

• Pneumocystis pneumonia (PCP) - Serious infection which causes inflammation and fluid buildup in the lungs.
• Cytomegalovirus - An opportunistic infection which takes advantage of a patient’s weakened immune system.
• Tuberculosis (TB) - Leading cause of death for people infected with HIV.
• Mycobacterium Avium Complex (MAC) - Usually happens only after a patient has been diagnosed with AIDS and when their CD4 cell counts drop below 50.
• Dementia - AIDS dementia is caused by the HIV virus itself, not by the opportunistic infections.
• AIDS Wasting Syndrome - Occurs when a patient with AIDS has lost at least 10% of their body weight -- especially muscle. The patient could experience at least 30 days of diarrhea, extreme weakness and fever that's not related to an infection.
• Non-Hodgkin’s Lymphoma - As a result of a weakened immune system, a patient is prone to develop certain cancers.
• Lipodystrophy - Also known as “fat redistribution”.   This is when the body has problems in the way it produces, uses, and stores fat.
• Kaposi’s Sarcoma (KS) - Type of cancer affecting mainly the skin, mouth, and lymph nodes (infection-fighting glands). Other organs such as the lungs and gastrointestinal tract can be affected as well.

A list of Meds currently available in the US

‍Note: When coding the HIV Disease and Sepsis, it is very important to read and familiarize yourself with the Coding Guidelines. 

The Office of Inspector General (OIG) recently released the report Medicare Incorrectly Paid Hospitals for Beneficiaries Who Had Not Received 96 or More Hours of Mechanical Ventilation. In fact, the report indicates that in the calendar years 2009 – 2011, Medicare overpaid hospitals $7.7 million.

Background

The OIG has done prior hospital compliance reviews of claims with MS-DRGs requiring 96 or more hours of mechanical ventilation. In past reviews the OIG found erroneous claims and as such this review was performed to determine whether payments made to hospitals for MS-DRGs requiring 96 or more hours of mechanical ventilation were correct. Hospitals use procedure code 96.72 (Continuous invasive mechanical ventilation for 96 consecutive hours or more) to identify these patients. This review focused specifically on two MS-DRGs:

• MS-DRG 207: Respiratory System Diagnosis with Ventilator Support 96+ Hours and
• MS-DRG 870: Septicemia or Severe Sepsis with Mechanical Ventilation 96+ Hours.

Audit by the Numbers

• $12,764,239: The amount of Medicare Part A payments covered in this audit.
• 290: The number of hospitals included in this audit.
• 377: The number of inpatient claims that were selected as at risk for billing errors.
• 4 days or less: This audit reviewed claims where the length of stay was 4 days or less.
• 14: The number of records where the Medicare payment was correct.
• 363: The number of records where the Medicare payment was incorrect due to the beneficiary not receiving 96 or more hours of mechanical ventilation.
• $7,714,825: The overpayments made by Medicare to the hospitals

As part of the audit process the OIG had the hospitals conduct an internal review of the claims to determine if the services had been billed correctly. The OIG also requested that the hospital provide them with the “itemized bills and medical record documentation, including timelog for the mechanical ventilation and summary of the inpatient stay to determine whether the beneficiaries had received 96 or more hours of mechanical ventilation.”

The report indicates that “the hospitals confirmed that these claims were incorrectly billed and generally attributed the errors to incorrectly counting the number of hours that beneficiaries had received mechanical ventilation or to clerical errors in selecting the appropriate procedure code.”

Centers for Medicare and Medicaid Services (CMS) Response and Action Plan

The OIG found that CMS did not have controls in place to identify the incorrectly paid claims. Since this review, CMS “implemented a new length-of-stay edit for continuous invasive mechanical ventilation for 96 consecutive hours or more. With this edit, effective October 1, 2012, claims found to have procedure code 96.72 and a length of stay fewer than 4 days are returned to the provider for validation and resubmission.”

Is Correct Coding of Ventilator Hours still on the Radar?

Since this review focused on 2009 through 2011 calendar year claims and an edit was put in place as a control to identify incorrectly paid claims, you may be thinking that this should no longer be an issue. However, other Contractors continue to review and or monitor correct coding of ventilator hours. Before we walk through a timeline of who is reviewing this issue it is important to note that most reviewers have expanded their efforts beyond MS-DRGs 207 and 870 to also include the following MS-DRGs:

• MS-DRG 003: Ecmo or Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R.
• MS-DRG 004: Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck without Major O.R.
• MS-DRG 927:Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours with Skin Graft
• MS-DRG 933: Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours without Skin Graft

Timeline of Review Efforts around Correct Coding of Ventilator Hours:

• Medicare Quarterly Compliance Newsletter October 2011: In the Volume 2, Issue 1 - October 2011 newsletter the CMS reported that Recovery Auditors reviewed MS-DRGs 003, 004, 207, 870, 927 and 933 due to Providers not adding the correct number of Ventilator hours during an inpatient admission. This Newsletter provides examples of their findings and education resources for hospitals.

• Cahaba GBA, the Medicare Administrative Contractor (MAC) for Alabama, Georgia and Tennessee completed a widespread probe review of MS-DRG 270 and posted the findings to their website on November 14, 2011. Their focus was on coding accuracy and medical necessity for acute inpatient hospitalization. One issue identified was that “documentation did not confirm 96 consecutive hours on ventilator support.” They took no further action as a result of this review but continue to monitor utilization through data analysis to see if further reviews are needed.

• The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is now into their 12th Edition of the Short-Term Acute Care Hospitalizations Users Guide. Ventilator Support has been an at risk target since their 6th Edition Users Guide. Internally, providers can view their report to see if they are an outlier and follow the audit recommendations in the report.

• In the 2013 OIG Work Plan, the OIG indicated that “We will review Medicare payments for mechanical ventilation to determine whether the DRG assignments and resultant payments were appropriate. We will review selected Medicare payments to determine whether patients received fewer than 96 hours of mechanical ventilation. Mechanical ventilation is the use of a ventilator or respirator to take over active breathing for a patient. CMS requires that claims be completed accurately to be processed correctly and promptly. For certain DRG payments to qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation.”

As you can see this is certainly not a new issue and hospitals need to remain vigilant in their efforts to correctly code ventilator hours.

The hardest part of Medicare’s new guidance is understanding all of the details and nuances of the rules. For example, there were some surprising guidelines in the temporary instructions for the implementation of the final rule for Part A to B billing of denied hospital inpatient claims that could have a financial impact on hospitals. Drug administrations and nebulizer treatments are some of the more frequent Part B services provided to inpatients and now Medicare is saying these services are not billable on a Part B inpatient claim. I understand these services are included in the room and board charge for inpatients, but how is a hospital to recoup the cost of these services when billing under Part B if these services are not separately billable and there is no inpatient Part A payment?

The temporary instructions were published September 16th in MLN Matters article (SE1333).   A lot of the guidance in this article simply reaffirms the instructions from the final rule. MMP presented that information several weeks ago in an article titled “If ‘A’ Doesn’t Work, Try ‘B’”. 

As a reminder, the basic rule for admissions on or after October 1, 2013 is:

“When an inpatient admission is found to be not reasonable and necessary, the Centers for Medicare & Medicaid Services (CMS) will allow payment of all hospital services that were furnished and would have been reasonable and necessary if the beneficiary had been treated as an outpatient, rather than admitted to the hospital as an inpatient, except for those services that specifically require an outpatient status such as outpatient visits, emergency department visits, and observation services, that are, by definition, provided to hospital outpatients and not inpatients.”

So this week, I would like to point out a few items from the temporary instructions that are new or clarified guidance.

• One of the most significant clarifications concerns the billing of infusions and injections and nebulizer treatments on the Part B inpatient claim. The article clarifies that routine services generally captured in the room and board rate are not separately billable Inpatient Part B services. This includes IV infusions and injections, blood administrations, and nebulizer treatments provided by the floor nurse.
• In the case of UR self-audit determination that the stay was not medically necessary, the hospital must submit a no-pay, provider liable Part A claim and receive a denial before submitting the Part B inpatient claim (12x type of bill). Provider liability is indicated by the inclusion of Occurrence Span Code “M1” and the inpatient admission Dates of Service on the no-pay inpatient claim. If a Part A claim for payment has already been submitted, the hospital must cancel that claim, submit the no-pay claim, and receive a denial prior to billing Part B.
• Services provided prior to the admission order are billed on a 13x outpatient claim; services provided after the admission order are billed on the 12x Part B inpatient claim. This means “inpatient-only” services (such as procedures on the inpatient only list) provided prior to the admission may not be reported on the inpatient claim even though they are not payable on the outpatient claim. Also if observation services are continued after the admission order is written, they are not billable on the inpatient claim since they are exclusively “outpatient” services.
• The article includes a listing of revenue codes not covered under inpatient Part B medical necessity denials. However, note that when a revenue code can be sometimes covered and sometimes not covered, providers should use the HCPCS code to determine if the service is covered.
• The article encourages providers to remember the medical necessity requirements for outpatient services, specifically those outlined in local coverage determinations (LCDs), and to include all diagnosis codes to support these medical necessity requirements on both the Part B inpatient and outpatient claims.
• Billing of limited Part B services still applies when there is no Part A payment because the beneficiary is not entitled to Part A benefits or has exhausted Part A benefits.

Please refer to the article for complete information including the specific claim requirements for the Part A provider liable claim and the Part B inpatient claim.

For continuing to provide quality patient care while dealing with Medicare’s ever-increasing requirements, MMP applauds the providers of all types of rehabilitative therapy services, with a special recognition of physical therapy providers during October, Physical Therapy Month. We hope our articles on therapy issues help therapists to understand and better implement Medicare’s rules. With that in mind, I would like to address the requirements for the use of the Advance Beneficiary Notice (ABN) for outpatient therapy services.

Prior to January 2013, therapy services provided to a patient that exceeded the therapy cap and were not medically necessary were denied as a benefit category denial. That meant the patient was liable for payment and although encouraged, a notification of liability did not have be given to the patient. The American Tax Relief Act changed denials above the therapy cap amount to be provider liable unless the patient is issued an ABN. Since therapy services below the cap have always required an ABN for patient liability, this change provides more consistency. Now, all therapy services that are not medically necessary, above or below the therapy cap amount, require that an ABN be issued to the patient so that the patient can choose whether to obtain the services and accept financial responsibility for them.

So practically, when would a therapist provide medically unnecessary services? The scenario that requires an ABN be given that I have seen most often is when patients have been receiving therapy services for a condition for a while. The patient’s progress plateaus or reaches its maximum potential for that patient in the therapist’s opinion. Sometimes such patients do not want to discontinue therapy services but the therapy is no longer “medically necessary” according to Medicare requirements. This is an appropriate time to issue an ABN to the patient. The challenge here is explaining the situation to the patient so that he or she understands the Medicare regulations and their impending liability. Just another one of the challenges therapists face beyond their clinical duties!

See the last two pages of MLN Matters Article MM8404 for more information on outpatient therapy services use of an ABN.

We are now into the second day of the Centers for Medicare and Medicaid Services (CMS) 2014 Fiscal Year. For those that were unable to listen to the CMS Special Open Door Forum (ODF) this past Thursday September 26th, CMS appeared to have heard and has responded to the medical community’s concerns around the education and implementation of the new 2-Midnight Benchmark for inpatient admissions and the Physician Certification of all inpatient admissions.

Clarification of CMS Inpatient Hospital Policy, Why Now?

On the same day as the ODF, CMS also released a letter to the American Hospital Association (AHA). In both this letter and during the ODF, CMS indicated that they have been facing “pressures” that include:

• “An increase in the average length of observation stays;
• An increase in the Comprehensive Error Rate Testing (CERT) error rate for short inpatient stays;
• An increase in the number of inpatient appeals; and
• Requests from the hospital industry requesting clarification on inpatient review policy.”

The two year conversation around these “pressures” between CMS and the hospital industry are what prompted the implementation of the 2-Midnight Benchmark and Physician Certification process. CMS announced that the next three months (October 1, 2013 – December 13, 2013) will be a transition period where they will monitor the impact of the changes to ensure that they result in the best interest for Medicare beneficiaries. Further, they announced a New Probe and Education Program.

New Probe and Education Program

This new program will begin with dates of admission on or after October 1, 2013 through December 31, 2013. Specific instructions for Contractors include the following:

• Medicare Administrative Contractors (MACs)
• MACs will shift their pre-payment focus to admissions on or after October 1st through December 31st with “0” or “1” midnight lengths of stay.
• The focus of these reviews will be to “determine the medical necessity of the patient status in accordance with the two midnight benchmark.”
• The Pre-payment Probe limit has been set at 10-25 claims per hospital.
• If a MAC completes a probe and finds no issues they will “cease further such reviews for that hospital from October – December 2013, unless there are significant changes in billing patterns for admissions.”
• If a MAC does identify issues, education will be provided to the hospital and then the MAC will conduct further follow-up as necessary.
• Since these will be pre-payment reviews, a hospital could re-bill any denied claims in accordance with the Part A to Part B rebilling Final Rule.
• MACs will use their review findings to determine a hospital’s compliance with the new inpatient rules and provide feedback to CMS for development of joint education and guidance.

• Recovery Auditors (RAs)
• During this same 90 days, “CMS will not permit Recovery Auditors to review inpatient admissions of one midnight or less that begin on or after October 1, 2013.”
• The RA Pre-payment Demonstration will be suspended during the 90 day period for the 11 states that are participating in this demonstration (FL, CA, MI, TX, NY, LA, IL, PA, OH, NC, and MO).
• RAs will continue pre-payment reviews for Therapy Caps.

• Caution:
• CMS reminds providers that “physicians should make inpatient admission decisions in accordance with the 2 midnight provisions in the final rule. If at any time there is evidence of systematic gaming, abuse or delays in the provision of care in an attempt to surpass the 2-midnight presumption could warrant medical review.”
• During this transition period MACs can continue to perform coding validation reviews.
• The CERT contractor, Zone Program Integrity Contractors (ZPICs), Office of Inspector General (OIG), etc. are not limited by this 90 day time period and can continue to pick any claims for review.
• Contractor reviews specifically supporting the medical necessity of a surgery (i.e. total knee replacement) and correct coding reviews can continue during this time.

Dress Rehearsal

Moving forward, CMS has set up an Inpatient Hospital Reviews webpage on their website under Medical Review and Education and encourages hospitals to check this site frequently for updates.

Hospitals should take this time to use the next three months as a dress rehearsal to continue with staff education, proceed with your plans to be compliant with the 2-Midnight Benchmark and develop processes to ensure completion of the Physician Certifications prior to beneficiaries being discharged.

2014 IPPS Final Rule Resources:

Link to the Final Rule:  http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf

Link to September 5, 2013 Guidance - Hospital Inpatient Admission Order and Certification:  http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-09-05-13.pdf

Link to MLN Matters: SE1333 – Temporary Instructions for Implementation of Final Rule 1599-F for Part A to Part B Billing of Denied Hospital Inpatient Claims

 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1333.pdf

Link to CMS Open Door Forums webpage:  http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/ODFSpecialODF.html

‍

Hospitals are facing significant changes with the implementation of the 2014 IPPS Final Rule. Beyond medical necessity guidance, physician certification and recertification for a Part A inpatient admission and the Part A to Part B rebilling, the National Uniform Billing Committee (NUBC) developed and approved new discharge status codes that were finalized for use in the Final Rule.

An interesting twist is that these codes are to be used specifically for DRG 280 (Acute Myocardial Infarction, Discharged Alive with MCC), DRG 281 (Acute Myocardial Infarction, Discharged Alive with CC), DRG 282 (Acute Myocardial Infarction, Discharged Alive without CC/MCC) and DRG 789 (Neonates, Died or Transferred to Another Acute Care Facility).

DRGs 280, 281 and 282:

The finalized rule added one new code for this DRG group.

• New Code: 69 - Discharged/transferred to a designated disaster alternative care site
• Purpose: “Is to identify those patients diagnosed with an acute myocardial infarction (AMI) who were discharged/transferred to a designated disaster alternative care site alive.”
• Final Rule Comments: Most people that commented on this proposal were supportive of adding this new code and anticipate that it will be used infrequently.

The 15 remaining discharge status codes were proposed and finalized to identify planned readmissions after an AMI index admission. The new codes will replace codes already in place. In response to a comment CMS clarified that “at this time, these new discharge status codes are not related in any way to the Hospital Readmission Reduction Program and will not be taken into account in the readmission measures for that program.” The following table is a crosswalk from the current code to the new code. (This table can be found in the Final Rule on pages 50533 – 50534).

‍DRG 789:

Three new discharge status codes have been added to this DRG “to identify neonates that are transferred to a designated facility with a planned acute care hospital inpatient readmission.” The new codes can be found on page 50538 of the final rule and include:

Suggestions to prepare for the new discharge status codes:

• Work with your IT Department to ensure that your systems have been updated to reflect these changes,
• Provide physician education to help ensure that there is clear documentation in the Index admission that he/she is planning on readmitting the patient; and
• Educate HIM and Case Management staff.

The Medicare Hospital Conditions of Participation (CoPs) allow stamped signatures but Medicare conditions of payment do not allow stamped signatures and now there is an exception to the conditions of payment that does allow stamped signatures. Are you confused yet? Let’s see if we can sort this out.

Section 3.3.2.4 of the Medicare Program Integrity Manual addresses signature requirements for Medicare medical review purposes. This section states:

“For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable.” (emphasis added)

This means that for services to be approved for payment by Medicare, they must contain a legible handwritten or electronic signature. Stamped signatures are generally not acceptable for Medicare payment purposes. However, under the Rehabilitation Act of 1973 a stamped signature will be accepted in the case of an author with a physical disability.

Change Request 8219 (MLN Matters Article MM8219) clarifies that CMS will permit the use of a rubber stamp for signature when the author has a disability that prevents him/her from physically signing documentation. These providers must be able to provide proof to the Medicare contractor of their inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document. So if your hospital has a provider that uses a rubber stamp due to a physical disability remember to include the required proof of their inability to sign when you submit medical records containing their stamped signature to a Medicare review contractor.

Question:

If there is no stop time for an infusion, how is this to be reported?

Answer:

If there is no stop time for an infusion, it should be reported as an IV push.

However, be sure to look for other documentation that might support the duration of the infusion service, such as:

• Periodic drug titrations
• Nurse’s notes that the infusion is still in progress
• Nurse’s notes that the infusion continued at the time of transfer
• Documentation of the total hours infused (the most recent guidelines from Cahaba GBA indicate they will accept documentation of “total hours infused”)

Remember, the time the IV is discontinued or removed is not necessarily the same as the infusion stop time.

 

One thing that we all continue to hear about the transition to ICD-10-CM is the increased specificity of the codes. Asthma is one example of the increased specificity with ICD-10-CM. ICD-9-CM used an older classification for Asthma that is no longer relevant for treatment. Over the years the guidelines and classifications of Asthma have been revised. The latest update was released in 2007 by the National Asthma Education and Prevention Program which is coordinated by the National Heart, Lung and Blood Institute (NHLBI). ICD-10-CM has incorporated the classifications listed below into the new code set.

• Mild Intermittent Asthma (J45.2_)
• Symptoms occur less than two days per week and no interference with regular activities.
• Fewer than 2 days a month of night time symptoms
• Lung Function Tests (LFTs) are normal when they are not having an asthma attack
•  Mild Persistent Asthma(J45.3_)
• Symptoms occur more than 2 days per week, but not every day and there is interference of daily activities.
• Three to four times a month of night time symptom occurrences
• LFTs are normal when not having an asthma attack
•  Moderate Persistent Asthma (J45.4_)
• Symptoms occur daily requiring inhaled asthma medication and may restrict physical activity
• Night time symptoms occur more than once a week, but not every day
• Abnormal LFTs
• Severe Persistent Asthma (J45. 5_)
• Symptoms occur throughout the day with frequent severe attacks limiting the ability to breathe and perform physical activities
• Night time symptoms sometimes occur every night
• Abnormal LFTs

It is interesting to note that in ICD-9-CM Extrinsic Asthma codes to 493.0x and Intrinsic Asthma codes to 493.1x. However, in ICD-10-CM both Extrinsic/Intrinsic (allergic and nonallergic) are assigned to J45.909, Unspecified Asthma.

A discussion needs to take place with your physicians who treat Asthma patients to make them aware of the updated classifications so their documentation will reflect the medical complexity of their patients. Talking to your physicians now will hopefully reduce the amount of queries in the future.

Below are the links that contain the clinical information and updated guidelines for Asthma.

 http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf

 http://www.webmd.com/asthma/tc/classification-of-asthma-topic-overview

With just 40 days until the 2014 Final Rule goes into effect, there are significant changes for hospitals to digest and develop a plan to educate key stakeholders. Ongoing improper payments for short-stay hospital claims prompted two of the biggest changes. These two changes are the Two-midnight Benchmark and the Two-midnight Presumption Medical Review Policies.

Two-midnight Benchmark: Patient Status Guidance for Admitting Physicians

Historically, the decision to admit a beneficiary as an inpatient was based on a 24 hour benchmark. In the Final Rule CMS specifies “that the 24 hours relevant to inpatient admission decisions are those encapsulated by 2 midnights. This distinction is consistent with our application of Medicare utilization days, which are based on the number of midnights crossed.”

The two-midnight benchmark is intended as guidance for Physicians in identifying those patients that are appropriate for inpatient admissions. Specific 2 midnight guidance includes:

• There are two indications for a Physician to write an inpatient admission order:
• If the Physician has the expectation that a beneficiary’s length of stay (LOS) will be longer than 2 midnights.
• If the beneficiary undergoes an inpatient only procedure. In this instance, CMS acknowledges that there are times when a beneficiary would not require a two-midnight stay after an inpatient only procedure and they indicate “that procedures on the OPPS inpatient-only list are always appropriately inpatient, regardless of the actual time expected at the hospital so long as the procedure is medically necessary and performed pursuant to a physician order and formal admission.”
   
• The decision to write an inpatient admission order should be based on:
• The Physician expectation that the beneficiary will require medical care beyond 2 midnights.
• Factors leading a Physician to write an inpatient admission order need to be clearly and completely documented in the medical record. Supportive documentation would include “complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.”
• Note: Factors that could result in an inconvenience to the beneficiary and/or family are NOT justification for an inpatient admission.
  
  
• Timing for the two-Midnight Benchmark:
• If the Physician does not expect that a beneficiary will need medical services beyond 2 midnights then the beneficiary should be placed in outpatient with observation services. “As new information becomes available, the physician must then reassess the beneficiary to determine if discharge is possible or if it is evident that an inpatient stay is required.”
• After one midnight has past, “the decision to admit becomes easier as the time approaches the second midnight, and beneficiaries in medically necessary hospitalizations should not pass a second midnight prior to the admission order being written.”
• Currently, the inpatient admission starts at the date and time that the admission order is written. This will continue to apply on or after October 1st.
  
  However, final rule guidance directs that the decision to admit is based on all of the time a beneficiary is in the hospital, including any initial outpatient services. “In other words, if the physician makes the decision to admit after the beneficiary arrived at the hospital and began receiving services, he or she should consider the time already spent receiving those services in estimating the beneficiary’s total expected length of stay.”
  
  Services that are to be considered toward the 2 midnight expectation include observation services, treatment in the emergency department and procedures performed in the operating room or other treatment areas.
  
  
• Example: A beneficiary spends one midnight as an outpatient observation or has routine recovery following an outpatient surgery. The following day the physician reassesses the beneficiary and expects that he will need another midnight of medical services. At this point the physician should take the time spent in outpatient observation or routine outpatient surgery recovery into consideration that the 2 midnight benchmark will be met and an inpatient admission order should be written.
  
  
• Potential Exceptions when Inpatient Admission May Not span two-midnights: 
• When a physician has an expectation that a beneficiary will remain in the hospital beyond 2 midnights and “the beneficiary improved more rapidly than the physician’s reasonable, documented expectation. Such unexpected improvement may be provided and billed as inpatient care, as the regulation is framed upon a reasonable and supportable expectation, not the actual length of care, in defining when hospital care is appropriate for inpatient payment.”
• “If an unforeseen circumstance, such as beneficiary death or transfer, results in a shorter beneficiary stay than the physician’s expectation of at least 2 midnights, the patient may be considered to be appropriately treated on an inpatient basis, and the hospital inpatient payment may be made under Medicare Part A.”

2-midnight Presumption: Guidance for Medical Reviewers

The 2-midnight presumption “directs medical reviewers to select claims for review under a presumption that the occurrence of 2 midnights after admission appropriately signifies an inpatient status for a medically necessary claim.” Under this revised policy, the main focus of review efforts will now be on inpatient short stays with a LOS of 1 midnight or less.

In addition to this shifted focus, CMS will also be monitoring for “evidence of systematic gaming, abuse or delays in the provision of care in an attempt to qualify for the 2-midnight presumption (that is, inpatient hospital admissions where medically necessary treatment was not provided on a continuous basis throughout the hospital stay and the services could have been furnished in a shorter timeframe).”

Reviews contractors will continue to assess claims that cross 2 midnights to ensure the medical necessity of services provided, that the hospitalization was medically necessary, to validate coding and documentation and when directed by the CERT Contractor or other governmental entity to do so.

• What Medicare Review Contractors are looking for in the Medical Record:
• A physician order for an inpatient admission to the hospital.
• Required elements of the physician certification.
• Medical documentation supporting that the decision to admit as an inpatient was reasonable and necessary.
• “Contractors will consider complex medical factors that support a reasonable expectation of the needed duration of the stay relative to the 2-midnight benchmark. Both the decision to keep the beneficiary at the hospital and the expectation of needed duration of the stay are based on such complex medical factors as beneficiary medical history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk (probability) of an adverse event occurring during the time period for which hospitalization is considered.”
  
  
• Certification and Recertification of the need for Inpatient Admission:
• The physician must certify and recertify that inpatient services are medically necessary. CMS clarified that the relationship between the physician order and physician certification by adding language to 42 CFR 412.3(c) that “the physician order also constitutes a required component of the physician certification of the medical necessity of hospital inpatient services under Part 424 of this chapter.”
• Physicians need to be mindful that the admission order and physician certification are not conclusive proof that an admission was medically necessary but two pieces of information to be considered along with documentation in the medical record.
• CMS is requiring that for inpatient admissions the certification has to be completed, signed and documented in the medical record before the beneficiary is discharged.
• Guidance on the certification requirements can be found in the Code of Federal Register (CFR) at §424.10, §424.11 and §424.
• Note: CMS indicated in an August 15, 2013 Open Door Forum that they will be providing further guidance in the near future on how to satisfy this requirement.
  
  
• Reasonable and Necessary Admissions:
• Commenter’s of the Final Rule requested additional guidance as to what criteria would support a reasonable and necessary admission.
  
  CMS Response:
  “Medicare review contractors must abide by CMS policies in conducting payment determinations, but are permitted to take into account evidence-based guidelines or commercial utilization tools that may aid such a decision. We also acknowledge that this type of information may be appropriately considered by the physician as part of the complex medical judgment that guides his or her decision to keep a beneficiary in the hospital and formulation of the expected length of stay. As we update our manuals and take additional steps to implement this rule, we anticipate using our usual processes to develop and release subregulatory guidance such as manual instructions and education materials, which may include open door forums, regional meetings, correspondence and other ongoing interactions with stakeholders; and that our contractors will continue to involve local entities as they implement these rules.”
  
  
• Beneficiary Status Order:
• “The order serves the unique purpose of initiating the inpatient admission and documenting the physician’s (or other qualified practitioner as provided in the regulations) intent to admit the patient, which impacted its required timing. Therefore, we are specifying in new paragraph (d) of §412.3 that ‘The Physician order must be furnished at or before the time of the inpatient admission”
• An order to “Admit to ICU” or to “Admit” is no longer sufficient for an inpatient status order. The order “must specify the admitting practitioner’s recommendation to admit “to inpatient,” “as an inpatient,” “for inpatient services,” or similar language specifying his or her recommendation for inpatient care.”
• If Physicians and Review Contractors can consider time spent in outpatient towards the inpatient admission does that mean that this time can count towards the 3 day requirement for Skilled Nursing Facility (SNF) services?
• Per CMS, “We reiterate that the physician order, the remaining elements of the physician certification, and formal inpatient admission remain the mandated means of inpatient admission. While outpatient time may be accounted for in application of the 2-midnight benchmark, it may not be retroactively included as inpatient for skilled nursing care eligibility or other benefit purposes. Inpatient status begins with the admission based on a physician order.”

CMS held an Open Door Forum this past Thursday August 15th regarding the Final Rule. After participating in this call, it appears that there are more questions than answers. In fact, CMS encourages everyone to send them questions at  IPPSAdmissions@cms.hhs.gov. They indicated that they will be providing further guidance in the near future. Be assured that as additional guidance is provided we will be sharing it with you.