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MMP, Inc. Presents “Pain Points”

 Case Mix Index (CMI): It all begins with the Physician’s Pen

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:

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

“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 hospital's 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 and Arkansas.

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.

Effective April 1, 2011, for services furnished on and after January 1, 2011, providers should report HCPCS code G0010 for administration of Hepatitis B vaccine in an outpatient facility setting instead of CPT codes 90471 and 90472. This will ensure that cost-sharing waivers for Preventive Services are correctly applied to the vaccine administrations.

Here is the complete CMS announcement:

"Please note that a correction has been issued by CMS to the Preventive Services Table (via Change Request #7012), with specific regard to CPT codes 90471 and 90472.  Beginning Friday, April 1, for services that were or are furnished on or after Saturday, January 1, 2011, when providers are furnishing Hepatitis B Vaccines in outpatient  facility settings they must report HCPCS code G0010 (Administration of Hepatitis B vaccine) rather than CPT code 90471 or 90472.  This is in order to ensure that cost-sharing waivers are correctly applied to vaccine administration.  As of Friday, April 1, CR 7012 will no longer recognize CPT codes 90471 and 90472 for applying cost-sharing waivers on claims submitted for preventive services."

Link to Transmittal 864 (CR 7012)

Question:
What is the correct way to bill for myocardial perfusion studies that are performed over multiple days, for example the resting portion of the study is done one day and the stress portion is performed the next day?

Answer:
Even if performed on two separate dates of service, MMP, Inc. recommends billing only CPT code 78452 or CPT code 78454 (with a quantity of 1) representing myocardial perfusion imaging “multiple studies”, at rest and/or stress and/or redistribution and/or rest injection.

Do not use the single study CPT codes 78451 or 78453 (even with a reduced service modifier) to charge separately for each day. This would be considered unbundling.

References to support this recommendation include:

• Society of Nuclear Medicine and MedLearn, Nuclear Medicine & PET Coder, 2010, page 87; and
• Dr. Z, Diagnostic & Interventional Cardiovascular Coding Reference, 2011, page 484, coding instruction #5.

It has been brought to the attention of MMP, Inc. by one of our clients that Alabama Medicaid is still applying a unit restriction of one (1) for CPT code 97598. The descriptions of CPT codes 97597 and 97598 changed in 2011 – prior to 2011, CPT 97597 was for selective debridement of total wound(s) less than or equal to 20 sq cm and CPT 97598 was for selective debridement of total wound(s) greater than 20 sq cm. In 2011, CPT 97597 is for the first 20 sq cm debrided and CPT 97598 is an add-on code for each additional 20 sq cm, or part thereof, debrided.

MMP, Inc. also notes that the Medicare January 2011 published MUE list also has a quantity of 1 for CPT code 97598 and hospital CCI edits effective for the first quarter of 2011 do not allow the billing of 97597 and 97598 together, even with a modifier. Physician CCI edits have deleted this edit effective December 31, 2010, but since hospital CCI edits are a quarter behind physician edits, this edit change will not be effective for hospitals until April 2011. We have not heard of any problems with Medicare processing of multiple units of CPT 97598 or the billing of CPT 97597 and 97598 for the same date of service, but would appreciate notification if anyone encounters such issues.

Per correspondence to our client facility, Alabama Medicaid recommended holding claims with CPT code 97598 until they are able to address the quantity issue. Due to the above noted Medicaid quantity issue and the Medicare MUE and CCI edits, MMP, Inc. recommends hospital providers, upon administrative approval, consider the option of holding Medicaid and Medicare claims with CPT code 97598 until April 1, 2011.

We will provide further updates on this issue as we become aware of new information.

Question:
What discharge disposition code is assigned for a patient that is discharged from an Acute-Care Hospital to an Assisted Living Facility?

Answer:
Assign disposition code “04” (Discharged/transferred to a Facility that Provides Custodial or Supportive Care) for patients discharged to an Assisted Living Facility.

Per the latest NUBC revisions (effective 10/1/09): 

            04--Discharged/transferred to a Facility that Provides Custodial or Supportive Care

Usage Note – Includes:  Intermediate Care Facilities (ICFs) if specifically designated at the state level.  Also, used to designate patients that are discharged/transferred to a nursing facility with neither Medicare nor Medicaid certification AND for discharge/transfers to Assisted Living Facilities.

Per a direct email MMPI received from the AHA/NUBC on 2/3/10—“There was a time when one of the FAQs (that has since been deleted – FAQ #41 effective 10/1/09) indicated that if a Nursing Facility was the permanent residence that 01 could be appropriate.  Now, no discharge to any facility is 01.”

Transmittal 796 (CR7142) clarifies the payment window for outpatient services treated as inpatient services by adding a new condition code to report when non-diagnostic (therapeutic) services are not related to the inpatient admission. Starting April 1, 2011, providers may add condition code 51 (Attestation of Unrelated Outpatient Non-diagnostic Services) for services on and after June 25, 2010 that they determine to be unrelated to the reason for admission.

The transmittal does not provide much (if any) additional guidance on how to determine if services are related or not – the definition of unrelated in the transmittal is “clinically distinct or independent from the reason for the beneficiary’s admission.”  In previous comments, CMS has maintained that the determination of related versus unrelated is to be made by the hospital and the use of condition code 51 is the hospital’s attestation that the services are unrelated.

Other points from the article include:

• Ambulance and renal dialysis maintenance services are exempt from the payment window rule - (that is, they do not have to be combined with the inpatient admission).
• All services provided the day of admission (except ambulance and dialysis services) must be combined to the inpatient claim for all types of hospitals.
• The payment window is 3 calendar days for IPPS hospitals (first, second and third calendar day preceding the admission) and 1 calendar day for non-IPPS hospitals.
• All diagnostic services provided within the payment window must be combined to the inpatient claim. (See section 40.3 (B) of Chapter 3 of the Medicare Claims Processing Manual (Pub 100-04) for a list of diagnostic revenue codes and HCPCS codes.)
• Outpatient non-diagnostic services provided within the payment window are deemed related and must be combined unless the hospital determines and attests that the services are not related to the reason for the patient’s admission. This applies to all types of therapeutic services (other than ambulance and dialysis services) including outpatient physical, occupational and speech therapy.
• A hospital must include on the claim for a beneficiary’s inpatient stay, the diagnoses, procedures, and charges for all outpatient diagnostic services and admission-related outpatient non-diagnostic services provided during the payment window.
• The payment window applies to the hospital and all entities that are wholly owned or wholly operated by the hospital.

Outpatient claims with a date of service on or after June 25, 2010, that did not contain condition code 51 received prior to April, 1, 2011, will need to be adjusted by the provider if they were rejected by FISS or CWF.

For more information, read the CMS Transmittal at the link above or MLN Matters Article MM7142.

The 2011 Medicare Physician Fee Schedule (MPFS) final rule, which was released by CMS earlier this week, contains two rules that affect hospitals.

The first concerns the application of a multiple procedure payment reduction for therapy services. Specifically, beginning CY 2011, CMS will apply a 25% payment reduction to the practice expense (PE) component of the Physician Fee Schedule (PFS) payment rate for the second and subsequent "always therapy" services that are furnished to a single patient by a single provider on one date of service. Note that this will not be a reduction of 25% to the total payment amount for the additional multiple services, but only a reduction to one of three components used to calculate the payment rate. The “always therapy” service with the highest PE component will pay at 100% of the payment rate and other “always therapy” services provided the same day will be paid at a reduced rate calculated using the reduced PE component. Without final payment rates and component ratios, we are unable to determine what the final impact will be; we also note that the percent reduction will vary based on the number and combination of services furnished. When the final PFS rates are available, MMP, Inc. will provide some example reduction scenarios.

This policy applies to:

• services provided to the same patient, by the same provider, on the same day of service;
• multiple units of the same therapy service, as well as to multiple different services;
• all settings where outpatient therapy services are paid under Part B at PFS rates, which includes hospital outpatient therapy services;
• services furnished in different sessions on the same day by the same provider; and
• services provided by different therapy disciplines, such as physical therapy, occupational therapy and/or speech therapy.

The “always therapy” CPT codes to which the policy applies are: 92506, 92507, 92508, 92526, 92597, 92607, 92609, 96125, 97001, 97002, 97003, 97004, 97012, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97110, 97112, 97113, 97116, 97124, 97140, 97150, 97530, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97762, G0281, G0283, and G0329. The policy does not apply to add-on, bundled, or contractor-priced codes.

The other rule effective for CY 2011 concerns signature requirements for laboratory requisitions. Previous guidance from CMS stated that a signature was not required on a laboratory requisition because the requisition was only “ministerial paperwork” and although a signature on a laboratory requisition was one way of documenting the treating physician ordered the test, it was not the only way. CMS believes this guidance was causing a lot of confusion about when signatures were and were not required. Providers were also having problems when Medicare reviewers, such as CERT, required them to produce a signed order to support payment if the requisition was not signed.   In the 2011 MPFS rule, CMS finalized their policy to require a physician’s or non-physician practitioner’s (NPP) signature on requisitions for clinical laboratory diagnostic tests paid under the Clinical Laboratory Fee Schedule (CLFS). Note that for hospitals paid under OPPS, diagnostic laboratory tests are paid under the CLFS (status indicator “A”). Physicians and NPPs may also continue to request laboratory tests by means other than a requisition, such as a written, signed order; a copy of annotated medical records; telephonically; or electronically. (Note: If an order is communicated via telephone, both the treating physician/practitioner, or his or her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records. Under the Hospital Conditions of Participation, verbal orders must be countersigned by the ordering physician/NPP within 48 hours.)

 

For more detail on both issues, see the complete 2011 MPFS Final Rule. The discussion concerning the therapy payment reduction is on pages 207-240 and the laboratory requisition signature requirements are discussed on pages 1021-1035.

Revenue code 0948, Pulmonary Rehabilitation services, has been added to the list of repetitive Part B services effective April 1, 2011. Institutional providers, such as hospitals, are required to bill repetitive services furnished to a single individual monthly or at the end of treatment. This updated information can be found in Transmittal 2092 or in MLN Matters Article MM7163.

CMS Transmittal 2091 explains requirements for the correct reporting of therapy modifiers (Modifiers GP, GO, and GN) on institutional claims. Only one modifier should be reported per line of service. Effective April 2011, Medicare is implementing new edits to return claims to the provider for correction if more than one of these modifiers is reported on the same line. Medicare also edits for the correct combination of modifier to revenue code as described below.

• Physical Therapy, modifier GP, revenue code 042X
• Occupational Therapy, modifier GO, revenue code 043X
• Speech Language Pathology, modifier GN, revenue code 044X

For more information, see MLN Matters Article MM7170.

In accordance with updates by the National Uniform Billing Committee (NUBC), CMS is implementing the following changes effective April 1, 2011 concerning Point of Origin codes:

• Point of Origin codes are no longer required on 14x bill types (used for non-patient laboratory specimens)
• Point of Origin code 9 – information not available – will be accepted on all bill types.

This information can be viewed in MLN Matters Article MM7144.

Question:
Can anything be billed to Medicare when a patient is DOA (dead on arrival)?

Answer:
Yes, services are covered until the patient is pronounced dead. If the patient is pronounced prior to arrival, there is no coverage.

Medicare Benefits Policy Manual, 100-02, Chapter 6, Section 20.2:

"Outpatient hospital services furnished in the emergency room to a patient classified as 'dead on arrival' are covered until pronouncement of death, if the hospital considers such patients as outpatients for record-keeping purposes and follows its usual outpatient billing practice for such services to all patients, both Medicare and non-Medicare. This coverage does not apply if the patient was pronounced dead prior to arrival at the hospital."

On September 24, 2010, CMS released Transmittal 776 (CR 7140) which clarifies the date for which CPT code 80101 is no longer valid for Medicare purposes. According to the transmittal, which has an implementation and effective date of October 26, 2010, CPT code 80101 is not valid for Medicare billing as of January 1, 2010. For dates of service on and after January 1, 2010, providers should use HCPCS code G0431 in place of 80101 (G0431QW in place of 80101QW for laboratories with a CLIA certificate of waiver). Claims with denials for CPT code 80101 from January 1, 2010 through June 30, 2010 should be resubmitted with HCPCS code G0431. Providers should not resubmit claims if they received payment for 80101.

The CPT/HCPCS descriptions for both 80101 and G0431 are identical: Drug screen, qualitative: single drug class method (e.g. immunoassay, enzyme assay), each drug class.

For more information, see MLN Matters Article MM7140 or Transmittal 776.