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

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

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

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

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

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

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

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

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

§482.13 Condition of Participation: Patient’s rights

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

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

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

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

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

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

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

Utilization Review requirements for Medicare and Medicaid

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

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

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

Survey Procedures for evaluating the Standards include:

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

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

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

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

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

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

§482.43 Condition of Participation: Discharge Planning

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

Medicare Resources

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

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

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

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

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

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

 

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

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

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

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

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

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

 

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

Coding Issues

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

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

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

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

Billing Issues

Outpatient within Inpatient Stay

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

Inappropriate Hospital Admissions

Respiratory Conditions

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

DRG 581, Other Skin, Subcutaneous Tissue and Breast Procedures

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

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

Case Mix Index

Question:

What is Case Mix Index (CMI)?

Answer:

CMI is the sum of the relative weights of all DRGs assigned to Medicare inpatient cases, billed by the hospital in a given time-frame, divided by the total number of cases.

Formula for CMI:Total Relative Weights ÷ Total DRGs Coded = CMI

CMI:

•Measures the cost or resources needed to treat patients

•Calculated from billed data

•Reveals how sick your patients really are

•The higher the CMI the more complex the patients are, indicating that they have utilized costly and/or complex resources

 

How many times have you heard someone say that complete and accurate medical record documentation and quality improvement efforts are vitally important because they impact what is being publically reported about your hospital? Well, it’s true. But who exactly is looking at you?

The Centers for Medicare and Medicaid Services (CMS) has provided an educational tool for hospitals titled Contractor Entities At A Glance: Who May Contact You About Specific Centers for Medicare & Medicaid Services (CMS)

• Program Integrity Contractors (i.e. Recovery Auditors, Zone Program Integrity Contractors (ZPICs), Comprehensive Error Rate Testing Review Contractor (CERT RC) and Medicaid Integrity Contractors (MICs)),
• Quality Contractors (i.e. Quality Improvement Organizations (QIOs)),
• Specialized Work Contractors (i.e. Medicare Coordination of Benefits Contractor (COBC)),
• Claims Administrative Contractors (i.e. MACs, DME MACs); and
• Appeals Contractors and Entities (i.e. Qualified Independent Contractors (QIC) and Administrative Law Judge (ALJ).

While this is a great tool for hospitals to understand who may contact them, what sources are available for the public to use to select a physician, a hospital, a nursing home, etc.?

In June of 2011 the Robert Wood Johnson Foundation launched a

National Directory that is a compilation of state, federal, hospital and health plan quality data from across the country. The Foundation indicates that “our directory provides access to publicly available, free reports with information about the process of delivery care (for example, did patients get all the recommended care?), actual outcome for patients (for example, did patients die or have to return to the hospital?), what patients said in surveys about their experience with physicians or hospitals, and/or cost.” In the 16 months since the Directory was launched the list of public reports has increased from 224 separate sites to 258.

Below is a much smaller list of sites compiled by MMP, Inc. to provide you with an idea of who is publicly reporting data about your hospital and information about each report.

 

We believe that focused efforts on complete and accurate medical record documentation, quality improvements efforts and understanding what is being publicly reported about your efforts are positive steps towards clients embracing the shift in health care away from the traditional Fee-for-Service model towards payment for Quality Care as evidenced by current initiatives such as the 30 Day Readmission Reduction Program, Value-Based Purchasing and Accountable Care Organizations.

Clarification of Thoracentesis CPT Codes 32421 and 32422

Question:

When reporting CPT code 32422 “thoracentesis with insertion of tube including water seal when performed”, is this referring to a chest tube that is left in place after the thoracentesis is completed?

Answer:

The key to answering this question is to look back at the November 2003 CPT Assistant addressing coding guidelines for CPT codes 32000 and 32002. (In 2008, these CPT codes were revised to 32421 and 32422, respectively. The code descriptions remained the same, but the codes were renumbered in CPT.)

In the article, it is noted that CPT code 32002 (now 32422) “thoracentesis with insertion of tube including water seal when performed” represents a procedure where tube is removed at the end of the thoracentesis.

Therefore, 32422 would not be appropriate for reporting a thoracentesis where a chest tube was left in after the procedure. This information is supported by a 2009 SIR article and a 2007 article from Chest Journal.

In most of the procedure reports seen by MMP, Inc., the physician indicates a thoracentesis was performed with drainage occurring through a “catheter” – with the catheter removed at the end of the procedure. CPT code 32422 is the appropriate CPT code for this procedure.

*********

Question:

When should CPT code 32421 be used (thoracentesis, puncture of pleural cavity for aspiration)?

Answer:

CPT code 32421 describes a procedure where a needle is inserted and a smaller amount of fluid is aspirated, usually for diagnostic purposes (whereas CPT code 32422 is for therapeutic purposes). Again, in 32421, the needle is removed at the end of the aspiration procedure. SIR 2009 indicates the difference between CPT code 32421 and 32422 is -32421 is thoracentesis performed with a needle, usually for diagnostic purposes to obtain pleural fluid for analysis and diagnosis

-32422 is thoracentesis performed via catheter, usually for therapeutic purposes of relieving a pleural effusion. Pleural fluid may also be submitted for analysis.

Edits for outpatient ESRD dialysis HCPCS code G0257 went into effect October 1, 2012. See MLN Matters Article MM7762. Claims will be returned if G0257 is reported on a Type of Bill (TOB) other than 13x or 85x.

 

• HCPCS code G0257 should only be reported for dialysis performed on hospital outpatients who have ESRD (TOB 13X or 85X) that meet the criteria as described in the Medicare Claims Processing manual, chapter 4, section 200.2.
• CPT code 90935 is reported for:
• Part B services (TOB 12x) for dialysis for hospital inpatients (with or without ESRD) who do not have Part A coverage, and for
• hemodialysis performed on non-ESRD hospital outpatients (TOB 13x or 85x).

The OIG “is an independent and objective oversight organization that promotes economy, and effectiveness in the programs and operations of the U.S. Department of Health and Human Services (HHS or the Department).” In 1997 the Health Care Fraud and Abuse Control (HCFAC) was created. Since HCFAC’s creation “approximately 80 percent of OIG’s annual funding and workload have been dedicated exclusively to oversight and enforcement activities with respect to health care fraud and abuse in the Medicare and Medicaid Programs” (Source: Fiscal Year 2013 Office of Inspector General Justification for Estimates for Appropriations Committees)

Did you know?

• The OIG has been on the forefront of the Nation’s fight against waste, fraud and abuse in Medicare, Medicare and over 300 other HHS programs since 1976?
• In 2011 the OIG launched a “Most Wanted Fugitives” list seeking over 170 fugitives on charges for healthcare fraud and abuse.
• In 2011 the OIG announced that during the first half of 2007 Medicare spent $95 million on claims for power wheelchairs that were either medically unnecessary or there was insufficient documentation to determine medical necessity.
• The OIG has a Compliance 101 web page offering “free educational resources to help health care providers,practitioners, and suppliers understand the health care fraud and abuse laws and the consequences of violating them.”
• When settling Federal health care program investigations the OIG will negotiate Corporate Integrity Agreements (CIA) with providers and in exchange the OIG agrees to not seek provider exclusion from participation in Medicare, Medicaid, or other Federal health care programs.
• In 2012 the OIG introduced a “Most Wanted” list of Deadbeat Parents
• In the Semiannual Report to Congress for October 1, 2011 – March 31, 2012 the Inspector General, Daniel R. Levinson indicated that:
• “Over the past 6 months, OIG has stepped up our focus on data analytics as a critical tool for enhanced fraud, waste, and abuse activities.”
• “OIG’s data warehouse is a key component of our strategic use of information technologies. Among other things, the warehouse integrates data from Medicare Parts A, B, and D so we can develop a more comprehensive picture of beneficiaries’ histories of medical care and providers’ billing patterns.”
• In the first half of Fiscal Year 2012 the OIG reported expected recoveries of about $483.1 million in audit receivables.

Is your Hospital prepared for an On-Site OIG Compliance Audit?

Medicare compliance reviews are listed in the 2012 OIG Work Plan as a new aspect of the plan under “Medicare Inpatient and Outpatient Payments to Acute Care Hospitals.” The first of these audits began in 2011 and have continued in earnest in 2012. The OIG is required to make all hospital audit results publically available at http://oig.hhs.gov. The OIG has indicated that the objective of these audits is “to determine whether the Hospital complied with Medicare requirements for billing inpatient and outpatient services on selected claims.” The good news is that it is possible that the OIG will complete a review and make no recommendations as was the case with the review of Regional Medical Center at Memphis for calendar years 2009 and 2010. The bad news is that they can also find just over $1 million in overpayments as was the case in the review of Boston Medical Center for calendar years 2009 and 2010. Common items in all of these audit reports include:

OIG Examples of Risk Areas:

• Inpatient short stays,
• Inpatient same-day discharges and readmissions,
• Inpatient claims billed with high severity level DRG codes,
• Inpatient and outpatient claims paid in excess of charges,
• Inpatient hospital-acquired conditions and present on admission indicator reporting,
• Inpatient and outpatient manufacturer credits for replaced medical devices,
• Outpatient claims billed for Lupron injections,
• Outpatient claims billed with evaluation and management (E&M) services,
• Outpatient claims billed with modifiers, and
• Outpatient claims billed on the date of an inpatient admission.

OIG Audit Methodology:

• Review applicable Federal laws, regulations and guidance,
• Extract Hospital inpatient and outpatient paid claim data from CMS’s National Claims History File for the time period of the review,
• Use computer matching, data mining, and analysis techniques to identify claims potentially at risk for noncompliance with selected Medicare billing requirements,
• Select a judgmental sample for detailed review,
• Review available data from CMS’s Common Working File for sampled claims to determine whether or not the claims had been cancelled or adjusted,
• Review itemized bills and medical record documentation provided by the Hospital to support the paid claims,
• Request the Hospital conduct its own review of the sampled claims to determine whether or not the services were billed correctly,
• Utilize Medicare contractor medical review staff to determine whether a limited selection for sampled claims met medical necessity requirements,
• Review Hospital procedure for assigning HCPCS codes and submitting Medicare claims,
• Discuss incorrectly billed claims with Hospital personnel to determine the underlying causes of noncompliance with Medicare requirements,
• Calculate the correct payments for those claims requiring adjustment; and
• Discuss the results of the review with Hospital officials.

Billing Errors Associated with Inpatient Claims:

• Billing Medicare Part A for stays that should have been billed as outpatient or outpatient with observation services.
• Billing Medicare separately for related discharges and readmissions within the same day.
• Billing Medicare for incorrect DRG codes.
• Hospitals reporting medical device credit for a replaced device from a manufacturer without adjusting its inpatient claims with the proper value and condition codes to reduce payment as required.

Billing Errors Associated with Outpatient Claims:

• Drug injections
• Billing incorrect number of units of service
• Billing incorrect HCPCS codes

• Billing Medicare for E&M services that arepart of the usual preoperative and postoperative care associated with aprocedure.
• Incorrect use of the -59 and -91 Modifiers
• Billing for services without sufficient documentation in the medical record to support the service.

OIG Recommendations:

• Refund to the Medicare contractor identified overpayments, and
• Strengthen controls to ensure full compliance with Medicare requirements.

At the end of each audit is an Appendix that include the Hospital’s comments regarding the report.

Next steps for Hospitals:

• Review your PEPPER Reports for any outlier areasspecific to Inpatient Short Stays and Medical and Surgical DRGs with CC andMCC.
• Consider Emergency Department Case Management to assist Physicians 7 days a week.
• Provide Coding staff with continuing education opportunities and the resources (i.e. Coding Clinic and the most current ICD Official Guidelines for Coding and Reporting) needed to remain current in
  coding updates and revisions. This will be especially important with the transition to ICD-10-CM/PCS on October 1, 2014.
• Verify that outpatient drugs are billed with the correct HCPCS codes and units.
• Educate staff on the correct application of modifiers.
• Work with physicians and ancillary departments to obtain complete documentation to support the services provided and billed.

I remember from my days in Hospital Compliance that one of the most difficult issues was billing the correct drug units. This evidently continues to be a challenge for facilities based on the ongoing reminders from CMS and the numerous OIG audits that find errors in the billing of drug units.

Some of the issues that make this such a challenging area are:

• Drug HCPCS codes must be billed based on the amount, such as milligrams (mgs) in the HCPCS code description, not on standard usage or packaging amounts.
• Most hospitals accomplish this by using a “multiplier” in their charge description master (CDM), which presents the challenges of making sure all drugs that need a multiplier have one, there are no errors or typos in the multiplier amounts, and the multipliers are kept updated with code description changes.
• CMS often changes drug HCPCS codes and/or the HCPCS description. This is especiallychallenging when the amount in the description changes.
• Medical record documentation should include the dosage amount in the physician’s order and in the administration record.
• If the dose administered does not match the dosage amount the physician ordered, a corrected order should be obtained from the ordering physician.
• If the drug dose is based on the patient’s weight, there should be documentation in the medical record of the patient’s weight.
• Medicare does not allow providers to bill for wastage of multi-dose vials.
• When billing for wastage associated with single-dose vials, there should be documentation in the medical record of the dose given and the amount wasted.
• Medicare is applying Medically Unlikely Edits (MUEs) to a number of drug quantities. Although there are no published MUEs for drugs (HCPCS “J” codes), it is the understanding of MMP, Inc. that the quantity limitations are based on manufacturer package inserts. Providers should carefully review Medicare remittances to determine which drugs are being denied for MUEs and the likely MUE quantity.

Recent OIG audits have identified some drugs that have had repeated billing errors by multiple facilities. The first has to do with the billing of the drug Herceptin (J9355- Injection, trastuzumab, 10 mg). It is the understanding of MMP, Inc. that Herceptin is only available in a multi-dose vial of 440 mg (44 units). There have been problems with a number of facilities billing for entire vials of Herceptin instead of the dosage administered to the patient. Since Herceptin is a multi-dose vial, it is not appropriate to bill for drug wastage. MMP, Inc. recommends that providers review any claims with Herceptin units in multiples of 44 (such as 44, 88, etc.) and verify that the units billed match the dosage administered to the patient. Note that in addition to the OIG audits, this issue is also targeted by Recovery Auditors (RAs) and Medicare Administrative Contractor (MAC) pre-payment audits.

Another interesting drug issue has to do with the drug Lupron. There are two HCPCS codes for Lupron Depot –

• HCPCS code J1950 injection, leuporlide acetate (for depot suspension), per 3.75 mg)
• FDA approved specifically for uterine disorders
• Medicare ASP payment rate July 2012 of $653.299
• HCPCS code J9217 (Leuporlide acetate (for depot suspension), 7.5mg).
• FDA approved solely for advanced prostatic cancer
• Medicare ASP paymentrate July 2012 of $216.750

Since the payment amount for the smaller dosage amount is over 3 times the amount of the payment for the larger dosage, using the incorrect HCPCS code can result in significant over or under-payment. Reference OIG report A-04-11-03069 for further discussion.

Other drugs that have been noted in recent OIG reports for incorrect units include:

• adenosine
• alpha 1–proteinase inhibitor
• baclofen
• bortezomib
• cetuximab
• doxorubicin HCl liposome
• epoetin alfa
• immune globulin
• paclitaxel
• pemetrexed
• rituximab

MMP, Inc. encourages providers to be diligent in your reporting of the correct drug units by staying up to date on HCPCS code descriptions and changes, verifying correct multipliers in your CDM and by reviewing OIG, RA, and MAC audits to be aware of problem-prone drugs. For MMP, Inc. clients, note that we data-mine your 835 files for possible errors with high-risk, high-dollar drug units. Please contact MMP, Inc. if you have further questions concerning the billing of drug units.