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It has been just over three years since the Affordable Care Act (ACA) was signed into law on March 23, 2010. This slide provided by the Kaiser Family Foundation Health Tracking Polls, polled people on their view of the health reform bill based on what they know about it. As you can see, there are very mixed views.

To test what you know about the health reform law you can go to the Kaiser Health Reform quiz at this link: http://healthreform.kff.org/quizzes/health-reform-quiz.aspx

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On March 13, 2013, CMS released a ruling (Ruling 1455-R) with a HUGE impact for hospitals. This ruling is in light of the numerous recent appeal decisions by Administrative Law Judges (ALJs) and the Medicare Appeals Council to allow payment for Part B services when an inpatient admission is determined to not be medically necessary. This interim ruling is effective immediately and remains in effect until the corresponding proposed CMS rule entitled, "Medicare Program; Part B Billing in Hospitals" is finalized. Note that there are differences in the requirements of the ruling versus the proposed rule. This article discusses the currently effective Ruling only.

The Ruling allows hospitals to bill and receive payment for all reasonable and necessary Part B services provided to a hospital inpatient when a Medicare review contractor denies the Part A inpatient admission as not reasonable and necessary.

On Friday, March 22, 2013, CMS released Transmittal 1203 (CR 8185) which details the claims requirements for Part B rebilling. Although this transmittal is effective March 13, 2013, the implementation date is not until July 1, 2013. Therefore, hospitals cannot bill under the instructions of CR 8185 until July 2013. Further instructions from Medicare regarding billing in the interim are expected to be released soon. As indicated in our Extra newsletter yesterday, if you have a denied claim that has not been appealed and is approaching the end of the appeal timeframe, you should appeal the claim now in order to reserve your right to request a dismissal and bill under Part B once the billing instructions are released.

The key points from the Ruling are: 

• The ruling applies to
• Inpatient denials on or after the date of this ruling (March 13, 2013),
• Prior inpatient denials still within the appeal timeframe or
• Prior inpatient denials with an appeal pending.
• The ruling does not apply to
• Prior inpatient denials if the timeframe to appeal has expired, or
• Inpatient admissions determined by the hospital to not be medically necessary, such as during UR or other internal review.
• Hospital may submit a Part B inpatient claim for all reasonable and necessary Part B services that would have been payable if the patient had been treated as an outpatient –
• It is not limited to “Part B only” services described in Medicare Benefit Policy Manual, Chapter 6, Section 10. Prior to this ruling, a hospital could only bill selected services on a 12x type of bill when an inpatient admission was not allowed. These services are referred to as “Part B only” services, are listed in the policy manual referenced above, and include mostly laboratory tests and imaging studies. They did not include therapeutic services such as drug administrations, surgery, or therapeutic coronary or peripheral interventions. Under the Ruling, these types of services will be allowed to be billed on the Part B inpatient claim if the Part A stay was denied as not medically necessary by a Medicare contractor.
• Outpatient services that require an outpatient status, such as outpatient visits, ER services, and observation services may not be submitted on the Part B inpatient claim. These types of services may occur immediately prior to the inpatient admission and can be billed on an outpatient claim (see next bullet point regarding the 3-day window). Only Part B services occurring during the inpatient admission (i.e. after an inpatient admission order) would be included on the Part B Inpatient claim.
• Reasonable and necessary outpatient services provided during the 3-day payment window prior to inpatient admission may be billed separately on an outpatient claim if the inpatient admission is denied as not medically necessary. This ruling allows billing of this outpatient claim beyond the usual timely filing restrictions in accordance with the time frames listed below.
• The hospital may not have simultaneous requests for both Part A and Part B payment:
• The hospital must withdraw any Part A appeals in order to submit Part B claims for the same services.
• The hospital may not initiate a Part A appeal after submitting a Part B claim for the same services.
• The Part B billing may occur past normal timely filing limitations as long as it is:
• Within 180 days from the date of receipt of an appeal dismissal notice or,
• Within 180 days from the date of receipt of a final denial decision or,
• Within 180 days from the from the date of receipt of the initial or revised determination on the Part A inpatient claim (that is, the date of the remittance advice).

(Note the date of receipt of an initial or revised determination, or an appeal decision or dismissal notice is presumed to be 5 days after the date of such notice or decision, unless there is evidence to the contrary.)

• For the Part B claims billed under this Ruling, the beneficiary's patient status remains inpatient as of the time of inpatient admission and is not changed to outpatient.
• The Part A to Part B Rebilling Demonstration is being terminated. CMS will inform participating hospitals that the Part A to Part B Rebilling Demonstration is being terminated and will provide the necessary instructions.
• The ruling clarifies Medicare appeals adjudicators’ scope of review. Administrative Law Judges (ALJs) may no longer award payment for Part B services when the Part A claim is denied. According to the Office of Medicare Hearings and Appeals (OMHA), “The Ruling explains that adjudicators may only consider the originally billed Part A inpatient admission denial. Adjudicators may not consider potential coverage under Part B because hospitals are solely responsible for determining whether to bill for services under Part A or Part B, and submitting the appropriate claims.”
• Beneficiaries will be responsible for their usual Part B financial obligations under the ruling. Part A copayments or the difference must be refunded to the patient if the Part A amount is greater than the Part B amount.

For more information, see the CMS Ruling and the MLN Matters Article MM8185 concerning Part B Inpatient Billing in Hospitals.

 

 

 

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I remember from my first year as a compliance officer, a hospital representative lecturing at a national compliance conference explained how her facility made unintentional errors in the assignment of Medicare patients’ discharge statuses that were interpreted by the government as fraudulent activity. Now she could have presented a skewed interpretation and I am, in no way, questioning the government’s conclusion of any of the cases below. I am just acknowledging that sometimes, different parties have differing interpretations of how certain activities are classified.

The Health Care Fraud and Abuse Control Program 2012 Annual Report, a collaboration between the Department of Health and Human Services and the Department of Justice, highlights the successes of the government’s program to identify, prosecute, and prevent healthcare fraud and abuse. Below is a summary of the issues that resulted in settlements by hospitals to resolve claims and allegations under the False Claim Act (FCA).

 

1. Two settlements (almost $25M) relating to inflated fees for services that resulted in inappropriate Medicare “outlier” payments. The report states that both hospitals manipulated their charge structures to make it appear as though their treatment of certain patients was unusually costly, when in fact it was not.
2. Four settlements (over $31M) resulting from medically unnecessary inpatient admissions for patients that could have been treated as hospital outpatients. These cases include patients receiving Gamma Knife stereotactic radiotherapy and patients having kyphoplasty, a minimally-invasive procedure used to treat certain spinal fractures, or other surgical procedures that could have been performed on an outpatient basis.
3. Four settlements (approximately $6.7M) for a variety of other issues including:
4. Medically unnecessary and dangerous endovascular procedures
5. Surgical services performed in an Ambulatory Surgery Center (ASC), but billed as hospital outpatient surgeries
6. The drug Lupron® billed with the wrong HCPCS code (note also that even after becoming aware of the issue, these hospitals never self-disclosed or attempted to pay back monies received in error)
7. Improper physician recruitment arrangements.

 

You can read the full report on the OIG website at HCFAC Report.

Over the years the American Health Information Management Association (AHIMA) has provided guidance on when and how to query for additional health record documentation in a compliant manner. They have recently published a new practice brief on “Guidelines for Achieving a Compliant Query Process” that augments and where applicable, supersedes prior AHIMA guidance on queries. MMP, Inc. encourages coders and clinical documentation specialists to read the AHIMA article for complete guidance and some excellent examples of compliant and non-compliant queries.

Key Points about Queries

The AHIMA article defines the purpose of a query as follows: “The desired outcome from a query is an update of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment.”

• Queries should be used to clarify documentation in the medical record for accurate code assignment, such as when
• Information is ambiguous, incomplete, or conflicting,
• Clinical indicators are not related to a specific condition,
• Clinical indicators to support a documented diagnosis are missing, or
• Greater specificity is needed.
• All queries must be accompanied by the relevant clinical indicator(s) that justify the need for the query. These indicators should be derived from the specific patient’s current episode of care and may contain elements from any part of the current medical record.
• Verbal queries should contain the same information and be in the same format as written queries.
• Queries should not indicate the impact on reimbursement or provider profiles.
• Queries should not be leading. A leading query is one that is
• Not supported by clinical indicators in the medical record and/or
• Directs or “leads” a provider to a specific diagnosis or procedure.

Query Formats

Although open-ended queries are preferred, “yes/no” queries and multiple choice queries are acceptable under certain circumstances.

Yes/no queries:

• Are appropriate for example in
• determining if a documented condition was present on admission (POA),
• substantiating a diagnosis that is already present in the medical record,
• establishing a cause and effect relationship, or
• resolving conflicting documentation.
• Should include additional options besides “yes” and “no” such as “clinically undetermined”, “other”, and “not clinically significant”.
• Should not be used to document a condition/diagnosis that is not already documented in the medical record, i.e. a new diagnosis based on clinical indicators.

Multiple choice queries:

• Are appropriate for example to document greater specificity.
• Should include clinically significant and reasonable options as supported by the clinical indicators.
• Should include additional options such as such as “clinically undetermined”, “other”, and “not clinically significant”.
• Should allow the addition of free text by the provider.

Note: It is acceptable to include a new diagnosis as an option in a multiple choice list if supported by the clinical indicators, since other options including “other” and free text are also available.

Handling Missing Clinical Indicators

Is a query appropriate when a diagnosis is documented that does not appear to be supported by clinical indicators or should this type of conflict be addressed through the facility’s escalation policy? This is something your hospital will have to decide how to handle. CMS recommends that all facilities have an escalation policy that may include referral to a physician advisor, chief medical officer, or other administrative personnel. Even if you use queries in some of these situations, escalation will be needed for more complex situations, for unanswered queries and to address any concerns regarding queries. An example of a query from the brief that addresses documented conditions without clinical indicators is:

QUERY: “Please review the laboratory section of the present record to confirm your discharge diagnosis of hypernatremia. Laboratory findings indicate a serum sodium of 120 mmol/L.”

Should the Query Be Part of Your Medical Record?

Your facility should have internal policies that address query retention and whether the query is to be a part of the patient’s permanent medical record or stored as a separate business document. Either way, remember that the medical record should include the clinical rationale for all diagnoses. Also, capturing the content of the query and the provider’s response supports the sequence of events so that documentation does not appear out of context.

 

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

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

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

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

• J1050, Injection, medroxyprogesterone acetate, 1 mg

 

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

 

Contraceptive Use Restrictions (J1050-FP)

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

 

Non-contraceptive Use Restrictions (J1050-U1)

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

 

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

These requirements apply to both paper and electronic medical records.

Corrections to paper medical records require that:

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

Acceptable revisions in an electronic record must:

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

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

Background

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

General POA Requirements:

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

(Source: CMS POA Fact Sheet)

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

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

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

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

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

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

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

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

 

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

 

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

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

Background:

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

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

Assigning a DRG:

Principal Diagnosis:

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

Comorbidities and Complications (CCs and MCCs):

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

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

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

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

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

Example:

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

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

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

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

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

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

GPA Example:

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

 

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

21 ÷ 10 = 2.10 GPA

 

Case Mix Index Example A:

 

Formula for Case Mix Index:

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

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

 

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

 

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

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

(Source: Ingenix 2011 DRG Expert)

 

Challenges for Hospitals:

 

Understanding what can make your hospitals CMI fluctuate?

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

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

 

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

 

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

 

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

 

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

 

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

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

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

 

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

 

Internally, hospitals can:

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

External Resource for hospitals:

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

 

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

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

 

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