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This seems to be the year for some big changes from Medicare. As providers are wondering what will happen with the major revisions to OPPS, Medicare finalized two policies relating to patient status in the final IPPS rule that are equally dramatic. The two interrelated policies are designed to reduce the frequency of inappropriate extended observation care and provide appropriate payment for necessary inpatient services. Next week, we will address the revisions concerning the admission and medical review criteria for hospital inpatient admissions. This week we examine the Part B Inpatient Billing requirements.

In the 2014 IPPS final rule, CMS finalized the requirements of the proposed rule for Part B inpatient billing when an inpatient admission is determined to not be medically necessary. When this rule becomes effective on October 1, 2013, it replaces the current Part A to B rebilling regulations under the Ruling that was published on March 13, 2013. The major significant differences of the Final Rule from the Ruling concern the allowance of Part B inpatient billing as the result of a hospital self-audit and the application of timely filing.

Here is a summary of the requirements of the Final Rule. For complete information, please refer to the IPPS final rule which is scheduled to be published in the Federal Registry on August 19th. Until that time a display copy can be viewed at 2014 IPPS Final Rule display copy.

If a hospital inpatient admission is determined to not be medically necessary after a patient’s discharge, the hospital may decide to submit a Part B inpatient claim for all services provided to the patient during the admission.

Who makes the determination the admission is not medically necessary?

• This decision could be made by CMS or a Medicare contractor as a denial, upon medical review of the inpatient claim. In this case, the hospital may decide to appeal the Part A denial or submit a Part B inpatient claim (a 12x type of bill).
• The decision could be made by the hospital as part of a utilization review “self-audit” in accordance with the Medicare Conditions of Participation UR guidelines. If the hospital determines an inpatient admission is not medically necessary after the patient’s discharge, the hospital may bill for Part B inpatient services.

What type of hospitals can submit Part B inpatient claims?

• All hospitals billing Part A services are eligible to bill Part B inpatient services, including short-term acute care hospitals paid under IPPS, hospitals paid under OPPS, LTCHs, IPFs, IRFs, CAHs, children’s hospitals, cancer hospitals, and Maryland waiver hospitals.

What services can be included on the Part B inpatient claim?

• All hospital services that were furnished to an inpatient (after the order for inpatient admission) and would have been reasonable and necessary if the patient had been treated as an outpatient, except for those services specifically requiring an outpatient status. The excluded outpatient services are diabetes self-management training services (DSMT), outpatient visits including ED visits, and observation services. Outpatient services provided prior to the admission order may be billed on a Part B outpatient claim (see below for more information).
• In the proposed rule, rehabilitative therapy services (physical therapy, occupational therapy, and speech language pathology services) were proposed to be excluded as strictly “outpatient” services. This proposal was not finalized; providers may continue to include therapy services on Part B inpatient claims. However, these therapy services will be subject to the Part B therapy caps, the therapy caps exception process, the manual medical review process, and all other requirements for payment and coverage of therapy services under Part B such as functional status reporting requirements.

When can outpatient services furnished during the 3-day (1-day for non-IPPS hospitals) payment window be billed separately?

• When there is no Part A coverage for the inpatient stay, services provided to the patient prior to admission may be separately billed to Part B as outpatient services (13x type of bill). This includes any outpatient visits or observation services provided prior to the admission order.

When can Part B inpatient claims be submitted?

• The “expanded” Part B inpatient services can only be billed when payment cannot be made under Part A because the inpatient admission was not reasonable and necessary. This new policy does not apply to other circumstances when there is no Part A payment, such as when a beneficiary exhausts or is not entitled to Part A benefits.
• A Part B inpatient claim cannot be submitted if there is a current Part A claim. Any corresponding Part A claims must be canceled by the provider or denied by Medicare and any pending appeals must be withdrawn by the provider. A Part A “no pay/provider liable” claim must be submitted first if the decision to bill Part B inpatient claim is made as part of a hospital “self-audit”. Once the Part A claim denial is posted in the claims history, the Part B claim(s) can be submitted.
• The final rule applies timely filing requirements for services with dates of admission on and after October 1, 2013. Both Part B inpatient and outpatient claims must be filed within one calendar year after the date of service.
• Medicare allowed an extension of the Ruling time frames - hospitals may follow the Part B billing timeframes established in the Ruling after the effective date of the final rule, provided (1) the Part A claim denial was one to which the Ruling originally applied; or (2) the Part A inpatient claims has a date of admission before October 1, 2013, and is denied after September 30, 2013 on the grounds that although the medical care was reasonable and necessary, the inpatient admission was not.

What information must be included on the Part B claims?

• The hospital must furnish information as may be necessary in order to determine the amounts due for the services billed on the Part B outpatient or inpatient claims.
• This means re-coding to itemize the outpatient services provided with HCPCS codes as required and diagnosis coding for the time period of the claim. Providers will need to consider appropriate coding to support the medical necessity of the Part B services furnished.

What if the hospital determines the inpatient admission is not medically necessary prior to the patient’s discharge?

• This new policy does not change the existing regulations concerning changing a patient’s status from inpatient to outpatient following the condition code 44 requirements.

Does the patient’s status change if a Part B inpatient claim is submitted and how does this affect utilization days and the skilled nursing facility (SNF) 3-day qualifying stay?

• The patient’s status remains inpatient because there is no provision to change a patient’s status after he or she is discharged from the hospital.
• Medicare will not deduct the days associated with the inpatient hospital stays billed under Part B from a beneficiary’s 150 utilization days when no Part A payment is made for that inpatient hospital stay.
• The 3-day inpatient hospital stay which qualifies a beneficiary for “post-hospital” SNF benefits does not have to be covered by Medicare, as long as it is does not represent a “substantial departure from normal medical practice”. This means that most denied hospital inpatient stays will meet the requirements to qualify the patient for SNF coverage because the care was medically necessary, although the admission was not. An exception would be if the admission was solely for the purpose of qualifying the beneficiary for the SNF stay and therefore was a substantial departure from normal medical practice.

What is the patient’s liability and must hospitals bill the patient for their liability?

• If a Part A admission is denied as not reasonable and necessary and the patient is not liable under section 1879 of the Act, the hospital must refund Part A deductible and co-payment amounts paid by the patient and other insurers.
• The patient (Medicare beneficiary) is responsible for applicable deductible and co-payment amounts for covered Part B services and the cost of services excluded from coverage such as self-administered drugs.
• If the beneficiary is not enrolled in Part B, hospitals should bill Part B to ensure the claim enters the coordination of benefits cross-over process in the event the beneficiary has coverage under a supplemental or secondary insurance plan.
• The issue of whether hospitals are required to bill the beneficiaries for their Part B liabilities is governed by the beneficiary inducement and anti-kickback laws and falls under the jurisdiction of the OIG.

May appeals adjudicators require payment under Part B if a Part A denial is upheld?

• No, appeals adjudicators may only consider the claim that is before them and may not order payment for items or services that have not yet been billed.

I realize this is a lot of information to absorb. You may want to print this article to use as a resource for future questions. MMP plans to present a webinar prior to October 1st to address both the Part B inpatient billing and the new admission criteria. Be on the lookout in the Wednesday@One for> announcements about this upcoming webinar.

 

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

CMS, Members of Congress and others have been expressing concerns about observation stays and short inpatient stays for Medicare beneficiaries. Three main concerns being voiced include:

• Beneficiaries paying more for long observation stays than if they had been an inpatient,
• Beneficiaries not meeting the three day qualifying inpatient stay requirement for skilled nursing facility care; and
• Improper payment for short inpatient stays when the beneficiaries could have been treated in a lesser level of care such as outpatient.

The Office of Inspector General (OIG) recently released a report in response to these concerns based on 2012 claims data. To help our clients better understand the potential payment differenced in patient status we have provided the following comparison of outpatient stays and short inpatient stays.

‍Report Drill Down:

 

Observation Stays:

• Medicare paid $2.6 billion which averages $1,741 per stay.
• Beneficiaries paid $606 million which averages $410 per stay.
• The top 10 most common reasons for observation stays should not be a surprise to anyone and include chest pain, digestive disorders, fainting, signs & symptoms, nutritional disorders, dizziness, irregular heartbeat, circulatory disorders, respiratory signs & symptoms and medical back problems.
• Observation stays typically begin with treatment in the emergency department.
• The most common operating procedure was coronary stent insertion.

Long Outpatient Stays (stays lasting at least 1 night but had no observation services coded):

• Some of these stays did include observation services that were not coded by the hospital as they are not always paid a separate amount for coding claims as observation stays.
• This set of beneficiaries had similar characteristics to the observation stays i.e. most stays began in the emergency department and beneficiaries were most commonly treated for chest pain and digestive disorders.

Short Inpatient Stays (stays lasting less than 2 nights):

• This group of beneficiaries on average was more costly to Medicare and the Beneficiary.

1. Medicare paid $5.9 billion which averages to $5,142 per stay.
2. Beneficiaries paid $831 million which averages to $725 per stay.

• Ninety percent of this group spent 1 night in the hospital while the remaining 10% spent less than 1 night in the hospital.
• Similar to the other two stay types, these stays began in the emergency department, were most commonly treated for chest pain and 6 of the 10 most common reasons for a short inpatient stay were also among the 10 most common reasons for observation stays (chest pain, digestive disorders, fainting, nutritional disorders, irregular heartbeat and circulatory disorders).

Concerns and Report Conclusions:

Concern: Beneficiaries paying more for long observation stays than if they had been an inpatient

• Short Inpatient Stays in 2012 were more costly to the beneficiary when being treated for the same reason.
• Two exceptions where the cost was more for an observation stay were for coronary stent insertions and circulatory disorders.
• Six percent of all observation stays paid more than the inpatient deductible with a smaller subset paying more than two times the inpatient deductible.

Concern: Beneficiaries not meeting the three day qualifying inpatient stay requirement for skilled nursing facility care

• There were 617,702 hospital stays that lasted at least 3 nights that did not include 3 inpatient nights and therefore did not qualify for SNF services.
• While not mentioned in this report, a point of interest is that similar legislation has recently been introduced in the House (H.R. 1179) and the Senate (S.569) which would amend the law to allow for time beneficiaries spent in the hospital under observation services to count toward the required three-day hospital stay for coverage of skilled nursing facility (SNF) care.

Concern: Improper payment for short inpatient stays when the beneficiaries could have been treated in a lesser level of care such as outpatient.

• Short inpatient stays in 2012 were more costly to Medicare than observation stays. This validates the concern that there is improper payment for short inpatient stays when the beneficiaries could have been treated in a lesser level of care such as outpatient.
• Use of short inpatient stays varied widely among hospitals.

Moving Forward:

Proposed Changes to Payment Policies for Inpatient and Outpatient Stays

This report touches on two payment issues that occurred earlier this year. The first issue was announced in April when CMS made a proposal through a Notice of Proposed Rulemaking (NPRM) that would have a tremendous effect on how hospitals bill for observation and short inpatient stays. If implemented, “CMS contractors would presume that inpatient hospital stays lasting 2 nights or longer were reasonable and necessary and would qualify for patient as inpatient stays. Conversely, CMS contractors would presume that stays lasting less than 2 nights would not qualify for payment as inpatient stays and instead would be paid for as outpatient stays.” The OIG believes that their report findings may be useful as “our results further indicated that, under the policies proposed in the NPRM, some hospitals would likely follow the previsions and continue to bill these as outpatient stays; other hospitals – given strong financial incentives and few barriers – would likely not follow the provision and would admit beneficiaries as inpatients as soon as possible to meet the 2-night presumption.”

In March the second issue announced was that “CMS revised its Part B inpatient billing policy to allow for all hospital services that were provided and would have been reasonable and necessary if the beneficiary had been treated as an outpatient.”

Since the release of this OIG report, CMS released the fiscal year 2014 IPPS Final Rule last Friday August 2nd. Both proposals are now implemented in the Final Rule. We will be addressing the IPPS changes in the coming weeks

The findings in this report also “raise concerns about SNF services” and the OIG advises that “CMS should consider how to ensure that beneficiaries with similar post-hospital care needs have the same access to and cost-sharing for SNF services.”

On a final note, you should be aware that the OIG plans to “refer to CMS in a separate memorandum the SNFs that received $255 million in inappropriate payments so that CMS can look into recoupment.” Unfortunately, beneficiaries could be receiving unexpected bills for SNF services at some point in the not too distant future. The entire report can be accessed at http://oig.hhs.gov/oei/reports/oei-02-12-00040.pdf.

One of the frustrations of dealing with the overwhelming volume of reviews by Medicare contractors is often the lack of guidance from Medicare on how to handle a particular issue. In June, CMS released several MLN Matters SE articles concerning some of the findings of CERT and Recovery Auditors. These articles describe the issue and the corrective actions necessary for providers to resolve the issue. Although some of these are obvious resolutions – such as, only one cataract removal per eye – I wanted to point out the information on Mohs surgery and also make you aware of some of the other issues that are addressed.

The correct billing of Mohs Micrographic Surgical (MMS) services affects both hospitals and physicians and recent Recovery Auditor reviews have revealed errors in the billing of MMS. Medicare will only reimburse for MMS services when the Mohs surgeon acts as both surgeon and pathologist. Providers should not bill Medicare for these procedures if preparation or interpretation of pathology slides is performed by a physician other than the Mohs surgeon.

Mohs surgery is a two-step process where the tumor is removed in stages with histologic evaluation after each stage until all margins are clear. The performing physician serves as both surgeon and pathologist, performing both the excision and histologic evaluation of the specimen. The CPT codes for MMS (CPTs 17311-17315) should not be billed with separate CPT codes for the histologic evaluation of the tumor tissue removed. If the histology is performed by another physician, the excision should be billed with the standard malignant tissue excision codes (CPT 11600-11646) and the histologic evaluation with the surgical pathology code (CPT 88305).

Other Medicare requirements for coverage of Mohs surgery include:

• The surgery must be of a higher degree of complexity that most skin cancers, such as poorly defined borders, possible deep invasion, prior irradiation or when maximum conservation of tumor-free tissue is important.
• Only physicians (MDs or DOs) specifically trained and highly skilled in MMS techniques and pathological identification may perform Mohs surgery.
• Medical record documentation should support the medical necessity of the procedure including the location, number and size of the lesions; the number of stages; the number of specimens per stage; and a detailed description of the histology of the specimens.

For complete information, please read MLN Matters Article SE1318.

Issues addressed by other MLN Matters SE articles include:

• Appending modifiers to duplicate services billed for the same patient on the same date – SE1314.
• Billing the correct drug units by converting dosage of drugs given (such as milligrams) to units based on HCPCS description – SE1316.
• Billing cataract removal only once per eye – SE1319.
• Being sure to include the code for the primary service when billing add-on codes – SE1320.
• Appropriate bundling of outpatient services onto the inpatient claim under the 3-day window billing rule – SE3124.

Last month we wrote about Saint Thomas Hospital in Nashville, TN being the first hospital that the Office of Inspector General (OIG) extrapolated their Medicare Compliance Review findings. Since then they have done it again. This time Baptist Medical Center South in Montgomery, Alabama was subjected to extrapolation. This resulted in an increase in their amount to be refunded from an initial $242,514 to $1,784,982.  

OIG Medicare Compliance Reviews by the Numbers:

In addition to extrapolating findings what else is occurring in these Medicare Compliance Reviews?

After completing an extensive review of all reviews to date, here is a list of interesting facts by the numbers:

• One: The number of hospitals with no identified overpayments during a review
• Regional Medical Center at Memphis, Tennessee
• One: The number of hospitals where the OIG identified overpayments as well as potential underpayments to the hospital during the review.
• University of Alabama Hospital at Birmingham, Alabama
• Two: The number of hospitals who have now had their Medicare Compliance Review Findings extrapolated.
• Saint Thomas Hospital in Nashville, Tennessee, and;
• Baptist Medical Center South in Montgomery, Alabama
• Three: The number of hospitals that have been revisited for additional reviews by the OIG.
• Fletcher Allen Health Care, Inc. in Burlington, Vermont,
• Boston Medical Center in Boston, Massachusetts; and
• Tufts Medical Center in Boston, Massachusetts.
• Eleven: The highest number of hospitals within a single state to undergo an OIG Medicare Compliance Review (Massachusetts).
• Twenty-Six: Number of states that have had at least one hospital subject to an OIG Medicare Compliance Review.

• Sixty-Three: The total number of Medicare Compliance Reviews completed and reported on the OIG website as of July 17, 2013.
• Eight in 2011, Thirty-Nine in 2012 and Sixteen thru July 17 of 2013
• $12,222: The lowest overpayment amount identified to date was at Sanford University of South Dakota Medical Center.
• $2,244,649: The highest overpayment amount identified to date was at Cedars Sinai Medical Center. Note, this amount was not an extrapolated amount.
• $26,979,529: The amount identified as overpayments for all hospitals to date requiring payback to the Contractor without extrapolation being applied.
• $29,420,885: The amount identified as overpayments for all hospitals to date requiring payback to the Contractor with extrapolation being applied to Saint Thomas and Baptist Medical Center South.

Has Your Hospital Been Subject to an OIG Medicare Compliance Review?

Clicking the link below will show a table of all Medicare Compliance Reviews displayed on the OIG website to date. This table includes a link to the OIG reports, the “risk areas” looked at in the audit and the amount the OIG recommended the hospital refund.

OIG Medicare Compliance Reviews as of July 17, 2013

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

Medicare’s Recovery Audit program affords a variety of ways for hospitals to lose money. But it makes it harder to accept when you don’t have a process to deal with the issues. In this article we look at an inpatient issue that offers such challenges.

When we think of Recovery Auditor reviews of hospital inpatient records, we normally think of DRG Validation reviews and the ever-so-popular Medical Necessity reviews. But the Recovery Auditors also review inpatient records for other issues.

The topic addressed here is actually several different issues, all dealing with the correct assignment of the patient’s discharge disposition status. These include:

• reviews of acute care hospital to hospital transfers receiving an overpayment due to the assignment of an incorrect discharge status code,
• reviews of overpayments when a patient receives post-acute care but is coded as a discharge to home, and
• underpayment reviews for patients coded as a transfer to a post-acute care setting who never actually receive post-acute care.

Some of the errors may be the result of an error in code assignment, but a lot of these are due to either incomplete documentation concerning the patient’s post-discharge plans or circumstances that change after the patient is discharged.

So what can a hospital do to prevent receiving an improper payment, either over or under? First make sure physicians, case managers and discharge planners document clearly in the medical record the plans for the patient post-discharge. Also develop an avenue for coders to follow up on discharge status if the documentation in the record is unclear or conflicting. Now the harder part is how to address those patients that do not end up where they were planned to go. Some hospitals have implemented systems to verify the actual post-discharge care the patient receives. Examples of this would be contacting patients scheduled to begin home health care after discharge to see if this actually occurred or contacting skilled nursing facility to see if the patient was actually admitted. Medicare recently addressed post-acute care transfer underpayments in an MLN Matters article, SE1317.

This can be a difficult issue and contains financial risks for hospitals. Hopefully, being aware of what the issues are, understanding the regulations and having a plan in place will help reduce risks for hospitals.

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

Saint Thomas Hospital in Nashville, TN has the unique or unfortunate distinction of being the first hospital that the Office of Inspector General (OIG) has extrapolated their Medicare Compliance Review findings. Through extrapolation the payback amount to the Medicare Administrative Contractor increased from $293,359 for the actual records reviewed to an extrapolated amount of $1,092,248.

Background of OIG Medicare Compliance Reviews:

The mission of the OIG is mandated by Public Law and “is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of beneficiaries served by the programs. This statutory mission is carried out through a nationwide network of audits, investigations, and inspections conducted by” the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations and Office of Counsel to the Inspector General.

Hospital specific Medicare Compliance Reviews are performed to review Medicare payments to hospitals for selected claims for inpatient and outpatient services.

The OIG has indicated that they identify claims at risk for noncompliance through computer matching, data mining, and analysis techniques. Examples of risk areas include:

• Inpatient short stays,
• Inpatient claims billed with high severity level DRG codes,
• Inpatient claims pain in excess of charges,
• Inpatient same-day discharges and readmissions,
• Inpatient and outpatient manufacturer credits for replaced medical devices, and
• Outpatient claims with payments greater than $25,000.

Saint Thomas Compliance Review Findings and Recommendations:

In this review, the OIG found that the Hospital complied with Medicare billing requirements for 206 of 250 claims reviewed and that the remaining 44 claims resulted in $293,359 in overpayments to the Hospital. Reasons identified resulting in overpayments included the following:

• Billing claims as Medicare Part A that should have been billed as outpatient or outpatient with observation services,
• Incorrect DRG code assignment,
• Incorrect reporting of medical device credits,
• Billing separately for related discharges and readmissions on the same day; and
• Incorrect HCPCS code assignment.

Complete details can be found in the Medicare Compliance Review of Saint Thomas Hospital for Calendar Years 2009 and 2010.

The OIG made two recommendations:

• First, that the Hospital refund $1,092,248 in estimated overpayments; and
• Second that the Hospital strengthen controls to ensure complete compliance with Medicare billing requirements.

 

Saint Thomas Says:

Saint Thomas indicated that they were not made aware until “towards the end of the audit process that the sample was statistical and the findings would be estimated.”

Saint Thomas disagreed with the recommendation to refund the $1,092,248 in estimated overpayments and indicated in their comments that “in reviewing the Medicare Compliance Reviews audit reports the OIG has issued in the past two years, all of them were based on a “judgmental” sampling methodology. In some cases, it was noted that some hospitals had no extrapolation even though their overpayment audit results appeared to exceed those of STH.”

Further complicating the OIG findings Saint Thomas found that their “sample frame included several claims that the Recovery Audit Contractors (RAC) had also reviewed. The Hospital believed that including RAC claims in our sample frame, especially claims that the Hospital had already repaid, would result in the Hospital repaying Medicare twice.”

Ultimately, Saint Thomas indicated that they did not agree with the sampling methodology but would make any final payment necessary as a result of the statistical sampling.

The OIG Says:

The OIG indicated “at our entrance conference on June 26, 2012, we informed the Hospital that we would use statistical sampling techniques to select claims for review. In addition, during the course of the audit, we discussed with a Hospital official our plans to “project” the sample results across the population.” Additionally, they indicated that “as this hospital compliance review initiative has matured, we have refined our audit methodologies. Some reviews are statistical sampling and estimation techniques to draw conclusions about a larger portion of a hospital’s claims while other reviews are judgmental sampling. Each hospital review is unique, and the sampling method used in each of these reviews will vary.”

The OIG indicated that they did identify claims in the sample under RAC or Department of Justice (DOJ) review and as such these claims were considered “non-errors.”

Ultimately, the OIG maintained that Saint Thomas should pay bay the $1,092,248 in estimated overpayments.

Key Takeaways for our Clients:

• Be involved with the OIG staff from the beginning of an audit to understand the sampling techniques that will be used,
• Be aware of the potential “risk areas” identified by the OIG and internally assess for potential break-downs in processes; and
• Be aware that the days of paying back overpayments for only the claims reviewed appears to no longer hold true.

 

 

 

Please share this article with the therapists at your facility.

In last week’s Wednesday@One, we discussed therapy documentation in the evaluation, re-evaluation, plan of care, and certification. This week we will note some potential areas of improvement for therapy documentation in the daily treatment notes, progress notes, and the discharge summary. Like last week, we encourage providers to review the

Daily Treatment Notes

• Daily notes should list each specific intervention/modality provided to the patient for both timed and untimed codes.
• Medicare requires that the treatment notes include the total treatment time in minutes (includes both timed and non-timed codes) and the total minutes of the timed codes. Therapists need to know which treatments are timed codes and which are non-timed codes.   Non-timed codes are reported as one unit per day while the total number of units allowed for timed codes is restricted by the total timed code treatment minutes. For example if a patient receives 10 minutes of therapeutic exercise, 10 minutes of neuromuscular re-education and 10 minutes of manual therapy, the total timed code minutes equals 30 minutes which is 2 units. This patient may have also received 20 minutes of unattended electrical stimulation; this is included in the total treatment time for a total of 50 minutes, but does not affect the calculation of timed code units since it is an untimed code.
• Units of timed codes are based on the following time scale:
• 8-22 minutes = 1 unit
• 23-37 minutes = 2 units
• 38-52 minutes = 3 units
• 53-67 minutes = 4 units, etc.
• The therapy professional(s) providing the treatment must sign the treatment note and include their credentials.
• Extra documentation in the daily notes, though not required, often helps to support medical necessity in case of a Medicare audit. This may include noting the patient’s response or any assistance / instruction the patient required. If pain is part of the patient’s functional deficit, a numeric evaluation or discussion of the patient’s pain is recommended.
• Some LCDs list specific requirements for certain therapy services. For example, Cahaba’s Physical Therapy LCD notes that the medication and dosage information is required for iontophoresis and, for manual therapy, the area(s) being treated and the soft tissue/mobilization technique used should be documented. Be sure to review your Medicare contractor’s coverage policies for any additional documentation requirements.

Interval Progress Notes

• After the evaluation, this is the most important documentation in supporting the medical necessity of the therapy services provided. Based on our reviews of therapy records, most progress reports consistently contain all of the required elements.
• These notes must include objective measurements that describe the patient’s current function. Note that under the new functional limitation reporting requirements, the patient’s function will be reported as a percentage of impairment which must be documented in the patient’s record.
• Progress notes that allow easy comparison of the patient’s initial status and the status at last progress interval to the current status make auditing the record easier. The original and any revised goals need to be listed or referenced by a numbering system and the patient’s progress toward each goal noted.
• The clinician must document an assessment of the patient’s progress or lack of progress. Clearly explain if the patient is on target, ahead of schedule or not progressing as expected including reasons, adjustments to treatments / goals and recommendation for continuation of treatment. Remember this is where the therapist makes his/her case for the medical necessity of continuing treatment.

Discharge Summary

• A discharge note or summary is required for each episode of outpatient treatment.
• It covers the period from the last progress note to the date of discharge.
• In the case of an unanticipated discharge, the therapist uses the daily treatment notes and verbal reports from the treating assistants to make judgments for the summary.
• The discharge note requires the same elements as an interval progress note and is the last opportunity to justify the medical necessity of the entire treatment episode in case the record is reviewed.

When documenting therapy services, remember that you are presenting a “story” to justify that

1. the patient has a condition for which therapy should be beneficial,
2. the services require the skills of a therapist, and
3. the services are appropriate for the individual needs of this particular patient.

On Friday May 17, 2013, the Centers for Medicare and Medicaid Services (CMS) released a memorandum to State Survey Agency Directors containing revisions to Appendix A – Interpretive Guidelines for 42 CFR 482.43, Discharge Planning. The memorandum instructs that the revisions are effective immediately.

Under §482.43 Condition of Participation: Discharge Planning the revisions indicate that “reducing the number of preventable hospital readmissions is a major priority for patient safety, and holding hospitals accountable for complying with the discharge planning CoP is one key element of an overall strategy for reducing readmissions.”

Within this 39-page document are Advisory Boxes that “display successful practices currently found throughout the industry in the area of care transitions.” The Advisory Boxes are not hospital compliance requirements rather suggestions for process improvement. One Advisory Box provides examples of patient discharge planning tools that includes the following links:

• Medicare’s “Your Discharge Planning Checklist” (available at http://www.medicare.gov/publications/pubs/pdf/11376.pdf,
• Agency for Healthcare, Research and Quality’s (AHRQ) “Taking Care of Myself: A Guide for When I Leave the Hospital” (available at http://www.ahrq.gov/patients-consumers/diagnosis-treatment/hospitals-clinics/goinghome/goinghomeguide.pdf; and
• Consumers Advancing Patient Safety (CAPS) “Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient Toolkit” (available at http://www.patientsafety.org/page/transtoolkit.

This memorandum also provides clarification for providing a patient list of available Home Health or Skilled Nursing Facilities. (See Survey Procedures §482.43(c)(6), §482.43(c)(7) & §482.43(c)(8):

• “Review a sample of cases of patients discharged to HHAs or SNFs to determine if, when applicable, the hospital provided the patient with lists of Medicare-participating HHAs or SNFs. In making this determination:
•  Is there documentation of a list of multiple HHAs or SNFs being provided (including electronically) to the patient? If not, is there documentation for an acceptable rationale for providing only one option, e.g., the patient’s home is included in the service area of only one Medicare-participating HHA that requested to be included on hospital lists, or there is only one Medicare-participating SNF in the area preferred by the patient?
• Ask to see examples of lists of HHAs and SNFs provided to patients prior to discharge.”

MMP, Inc. encourages Case Management and Discharge Planning Staff to review the entire memorandum at: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-32.pdf

 

Please share this article with the therapists at your facility.

With all of the new Medicare requirements for rehabilitative therapy, such as functional limitation reporting, cap amounts applied to hospital outpatient services, and manual medical review of therapy services exceeding the threshold, we thought now would be a good time to address therapy documentation. These Medicare requirements can be found in the Medicare Benefits Policy Manual, chapter 15, section 220.3. Also most Medicare Administrative Contractor shave local coverage determinations for therapy services that include additionald ocumentation requirements.

The Medicare Benefits Policy manual details the minimum documentation requirements for therapy services. They also list documentation elements that are “encouraged” though technically not “required.” But this is a catch 22 –therapy documentation must be sufficient to support the medical necessity of the services provided. The manual states, “It is encouraged but not required that narratives that specifically justify the medical necessity of services beincluded in order to support approval when those services are reviewed.” So, like Medicare, we encourage providers to cover their bases with the amount and type of therapy documentation.

We are not going to re-list all of the documentation elements that Medicare recommends to support therapy services. Most therapists are well aware of the documentation requirements but we recommend providers carefully review the Medicare Benefits Policy Manual and any therapy LCDs for their jurisdiction for complete documentation information. We are going to discuss a few elements we have identified during therapy audits that we believe have potential for improvement. This week we will address documentation in the therapy evaluation, re-evaluation, plan of care and certification.

Evaluation

• Onset date – this is usually documented on the evaluation/certification form though the exact onset date is often hard to pin down. Our recommendation involves chronic conditionsa nd those conditions with an insidious onset. To support medical necessity, we recommend the evaluation answer these questions - If this condition has been going on for a while, why is therapy needed now? Has there been a recent decline in function, increase in pain or stiffness, increase in number of falls, or an exacerbation of the condition,etc.? Is the therapy intended to improve function or prevent further decline? Documentation that clearly addresses these questions helps to support the medical necessity of the therapy services.
• ADLs, ADLs, ADLs – The evaluation will include the patient’s functional deficit with objective measurements, but discussing the patient’s prior function and current limitations in terms of activities of daily living helps to support the medical necessity of the planned therapy. It is great to know the patient has limited mobility or restricted range of motion, but understanding the patient is unable to go grocery shopping or dress themselves is more dramatic and convincing of the need for treatment.

Plan of Care

• ADLs Again – In addition to the objective measures in the goals, linking the goals to improvement in a particular activity of daily living makes the goal more meaningful to the patient and to an outside reviewer.
• The functional impairments identified and expressed in the long term treatment goals must be consistent with those used in the claims-based functional reporting, using non-payable G-codes and severity modifiers.

Re-evaluation

• Continuous assessment of the patient's progress is a component of ongoing therapy services and is not payable as a re-evaluation.
• Re-evaluations are indicated when there are new clinical findings, a significant change in thepatient's condition, or failure to respond to the therapeutic interventionsoutlined in the plan of care.

Certification

• Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. Make sure the signature of the certifying practitioner is dated and be sure to include a copy of the signed certification when submitting records for external review. Medicare may deny services if a signed certification if not available in the medical records submitted for review.
• Let’s discuss timing of the certification -Certifications should be obtained as soon as possible after the plan of care is established or at least within 30 days of the initial treatment. Certifications are acceptable without justification for 30 days after they are due but certifications delayed beyond this time frame should include evidence to justify the delay.Evidence that the provider made immediate and on-going attempts to obtain the certification signature should be included in the record. Note however that delayed certifications are accepted by Medicare unless the contractor has reason to believe that there was no physician involved in the patient’s care, or treatment did not meet the patient’s need (and therefore, the certification was signed inappropriately).

Next week, we will look at daily treatment notes, progress notes, and the discharge summary.

 

CMS has released the April 2013 Medicare Quarterly Provider Compliance Newsletter. As a reminder, this newsletter is an educational product to assist providers in understanding audit findings identified by Contractors such as Medicare Administrative Contractors (MACs), Recovery Auditors (RAs), Comprehensive Error Rate Testing (CERT) contractors and the Office of Inspector General (OIG).

This edition of the newsletter addressed several findings related to the review of Inpatient hospital claims. Specifically, findings are provided for review of the following MS-DRGs:

• Neoplasm Surgery (MS-DRGs 826, 827, 828, 829, 830, 834, 835 and 836)
• Pancreas, Liver & Shunt Procedures (MS-DRGs 405, 406 and 407)
• Medical Necessity for respiratory neoplasms with a complication or co-morbidity (CC) (MS-DRG 181),
• Esophagitis, Gastroenteritis, and Miscellaneous Digestive Disorders with MCC (MS-DRG 391); and
• Acute Inpatient Hospitalization – Signs and Symptoms without MCC (MS-DRG 948)

 

Examples of review findings include:

• Incorrect selection of the Principal Diagnosis, reminding providers that “the circumstances of inpatient admission always govern the selection of principal diagnosis” and “is defined in the Uniform Hospital Discharge Data Set (UHDDS) as that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”
• High percentage of coding errors, reminding providers that “DRG validation requires that diagnostic and procedural information and the discharge status of the beneficiary, as coded and reported by the hospital on its claim, match both the attending physician description and the information contained in the beneficiary’s medical record.”
• Medically unnecessary inpatient hospitalizations, reminding providers that:

1. “Medicare pays for inpatient hospital services that are medically necessary for the setting billed. The Medicare Benefit Policy Manual, Chapter 1, Section 10, states that the physician or other practitioner responsible for a patient’s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient.”
2. “The Medicare Integrity Program Manual, Chapter 6, Section 6.5.2.A, states that inpatient care is required only if the patient’s medical condition, safety or health would be significantly and directly threatened if care were provided in a less intense setting.”

 

The following table is being provided to help you identify which MACs and RAs have currently targeted the MS-DRGs from this newsletter. A review of the specific examples and findings can afford you the proactive opportunity to ensure your records are coded accurately and that the hospitalizations were medically necessary.