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If you have ever audited electronic healthcare medical records, you have likely seen patients that are the same one day as another – exactly the same – no, I mean EXACTLY the same - the exact same wording of the patient’s condition, patient statements, treatment plan and/or other documentation elements. This is the result of “copy and paste” within an electronic medical record.

There are benefits and risks associated with the use of “copy and paste” within EHRs as described by the Partnership for Health IT Patient Safety. Benefits include time savings and a more efficient way to capture complex information which may result in improved tracking of multiple problems and improved continuity of care. It can also reduce transcription errors and omissions of important information. However, the outdated, inaccurate, irrelevant, and misleading information that can result from “copy and paste” erodes confidence in the record, may have medico-legal implications, and can result in more queries and work to determine if the information is correct. Charts and notes can become overwhelmingly long and effective communication is compromised because important findings and problems are intertwined with normal patient information, making it difficult to decipher what is important or current.

In response to safety concerns, the Partnership for Health IT Patient Safety developed a Toolkit for the Safe Use of Copy and Paste. Although the focus of the toolkit is patient safety, other concerns associated with “copy and paste” include billing and compliance issues and potential malpractice implications.

The recommendations provided in the toolkit and listed below are not intended to impair usability of EHR systems or impede workflow. Their goal is to allow providers the opportunity to evaluate the best ways to see the information that is being reused and to take steps toward the safe use of “copy and paste.”

Recommendation A: Provide a mechanism to make copy and paste material easily identifiable.

• Allows verification of accuracy and facilitates review for edits
• Potential Actions: Create policies and procedures; block certain areas of documentation from copying; have a different appearance for copied material (italics, different color, etc.)

Recommendation B: Ensure that the provenance of copy and paste material is readily available.

• Helps verify that the information is appropriate and accurate and increases the potential to defend the record and achieve billing compliance
• Potential Actions: Identify original source of information and track changes and authors

Recommendation C: Ensure adequate staff training and education regarding the appropriate and safe use of copy and paste.

• Helps providers understand their liability and the potential patient safety and compliance risks of copy and paste
• Potential Actions: Provide regular training and feedback; identify methods to verify current and correct information

Recommendation D: Ensure that copy and paste practices are regularly monitored, measured, and assessed.

• Ensures the integrity of the clinical record, the quality and safety of care rendered, and compliance with state and federal regulations
• Potential Actions: Create auditing policy; perform regular audits and report findings and provide feedback

I personally think this toolkit offers excellent recommendations for the safe use of a “copy and paste” function. As explained in the Toolkit, some of the recommendations will take time to implement, particularly those that require technology changes by developers and workflow changes for providers. However, there are some steps that hospitals could implement now to improve the use “copy and paste.” A realization of the associated risks of “copy and paste” is one first step.

Dilemma:

A patient was recently admitted to an acute care hospital diagnosed with an infection from a vascular access device.  The patient was then discharged from the acute care hospital and admitted to a long-term acute care hospital (LTACH) to continue antibiotics for the infection.  What 7th character would be assigned for the principal diagnosis to the LTACH, initial encounter (A) or subsequent encounter (D)?

Solution:
The principal diagnosis for the LTACH admission is (T82.7XXA) for Infection/Inflammatory Reaction due to Other Cardiac/Vascular Device, Initial Encounter.  The patient is still receiving active treatment for the infection of the vascular device so the 7th character is an A.  Examples of active treatment are:  surgical treatment, emergency department encounter, and evaluation and continuing treatment by the same or a different physician. 
Information Source(s):

• ICD-10-CM Official Guidelines for Coding and Reporting, Chapter 19,  Application of 7th Characters
• 1Q, Coding Clinic, 2015, under the heading, Applying the 7th Character for Continued Treatment in Other Care Settings

When I was first introduced to the concept of Case Mix Index (CMI) in the late 90’s, documentation in the medical record was handwritten. And I can remember understanding that CMI depends on the physician’s pen.

Flash forward to 2016 and the electronic health record. It is now fair to say that it all begins with the click of a button. I am not sure if it is due to the fact that I wrote my college term papers on a Brother Typewriter or from auditing electronic records remotely, the “click of the button,” has not improved the telling of the patient’s story which is at the heart of what needs to happen.

In fact, it seems to me that it is harder than ever to find proof that your “patients are sicker.” Understanding CMI is a good way to answer the question of “how do I know my patients are sicker.” 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 comorbidities 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 (CC) 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 (CC) 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. 
• 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.
• A patient with a history of chronic obstructive pulmonary disease undergoes surgery and develops post-op respiratory failure.
  

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.

Case Mix Index (CMI) is defined by CMS as representing “the average diagnosis-related group (DRG) relative weight for the hospital. It is calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges.”

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

30 ÷ 10 = 3.0 GPA

Case Mix Index Example A:

Formula for Case Mix Index: Sum of Relative Weights ÷ Total Number of DRGs Coded = CMIExample A CMI: 3.7688 ÷ 4 = 0.9422 Case Mix IndexExample B: The Potential Impact Physician Queries can have on DRG Assignment

Example B CMI: 4.5823 ÷ 4 = 1.1456 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: Optum 360 2016 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.

In 2013, the American Health Information Management Association (AHIMA) published the practice brief Guidelines for Achieving a Compliant Query Practice. The AHIMA brief states that “A query is a communication tool used to clarify documentation in the health record for accurate code assignment. 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.”

ICD-10-CM/PCS and CMI

We are now six months post ICD-10-CM/PCS implementation. Has this transition impacted CMI? To answer this question I analyzed paid claims data from our sister company RealTime Medicare Data (RTMD). The following tables compare CMI data from October through December of 2014 compared to 2015.

Figure 1: Alabama CMI Compare Pre and Post ICD-10-CM/PCS Implementation

Figure 2: South Carolina CMI Compare Pre and Post ICD-10-CM/PCS Implementation

Figure 3: Texas CMI Compare Pre and Post ICD-10-CM/PCS Implementation

So far, it appears that the transition has not had a negative impact on CMI but it is still early and MMP, Inc. will continue to keep an eye on the trends and report key findings to our readers. In the meantime, remember that 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.

A common mnemonic device to aid memory is to come up with a short sentence or phrase using the first letters of what you are trying to remember. Since it is spring and we are planning our vegetable garden, for PGATO I came up with “please gather all the okra.” If you have never grown okra, you may not realize the gathering demands of okra in the miserably hot, sultry days of late summer. The reward however is the delicious, Southern dish of fried okra. For Medicare services, rewards are two-fold – one is helping patients to recover or improve and two is the Medicare reimbursement you receive if you have followed all of Medicare’s requirements for billing, coding, and documentation. Like okra plants can be prickly, so can Medicare requirements.

PGATO is my memory tool for remembering all of the components for proper documentation to support billing of psychotherapy - plan, goals, activity, time, and outcomes. CPT codes 90832-90838 represent insight oriented, behavior modifying, supportive, and/or interactive psychotherapy. Reviews by the Comprehensive Error Rate Testing (CERT) contractors have identified issues with missing documentation.

Plan and Goals

A recent CERT review (see Cahaba Article Psychotherapy Codes) has identified errors in outpatient psychotherapy CPT codes 90832 and 90834, Type of Bill 13X. The primary issue identified on review was the absence of a signed, individualized plan of care for the services billed.

The individualized treatment plan must state the type, amount, frequency and duration of the services to be furnished and indicate the diagnoses and anticipated goals. Treatment goals should be measurable and objective. Documentation should include specific therapeutic interventions planned and an estimated duration of treatment.

Services must reasonably be expected to improve the patient’s condition. The treatment must be designed to reduce or control the patient’s psychiatric symptoms so as to prevent relapse or hospitalization, and improve or maintain the patient’s level of functioning. Psychotherapy services are not covered for severe and profound intellectual disabilities. Also, psychotherapy services are not covered for dementia patients when documentation indicates that dementia has produced a severe enough cognitive defect to prevent psychotherapy from being effective. When a patient has dementia, the capacity to meaningfully benefit from psychotherapy must be documented in the medical record.

Activity and Time

Another CERT review as described in MLN Matters Article SE1407 identified the main error as not clearly documenting the amount of time spent only on psychotherapy services.

The medical record must indicate the time spent in the psychotherapy encounter and the therapeutic maneuvers, such as behavior modification, supportive or interpretive interactions that were applied to produce a therapeutic change. Behavior modification is not a separate service, but is an adjunctive measure in psychotherapy.

A variety of techniques are recognized for coverage under the psychotherapy codes; however, the services must be performed by persons authorized by their state to render psychotherapy services (such as physicians, clinical psychologists, registered nurses with special training, and clinical social workers). Medicare coverage of procedure codes 90832-90838 does not include teaching grooming skills, monitoring activities of daily living, recreational therapy (dance, art, play) or social interaction.

Psychotherapy codes 90832-90838 are timed codes and the documentation must support the time billed as a psychotherapy encounter. The time associated with these codes is for face-to-face services only with the patient (or patient and family). In general, providers should select the code that most closely matches the actual time spent performing psychotherapy. CPT® provides flexibility by identifying time ranges that may be associated with each of the three codes:

• Code 90832 (or + 90833) 30 minutes: 16 to 37 minutes
• Code 90834 (or + 90836) 45 minutes: 38 to 52 minutes, or
• Code 90837 (or + 90838) 60 minutes: 53 minutes or longer

Do not bill psychotherapy codes for sessions lasting less than 16 minutes.

CPT codes 90833, 90836, and 90838 are add-on codes for psychotherapy services provided with an evaluation and management (E&M) service. Both services are payable if they are significant and separately identifiable and billed using the correct codes. Time spent for the E&M service is separate from the time spent providing psychotherapy and time spent providing psychotherapy cannot be used to meet criteria for the E&M service. Because time is indicated in the code descriptor for the psychotherapy CPT codes, it is important for providers to clearly document in the patient’s medical record the time spent providing the psychotherapy service rather than entering one time period including the E&M service.

Outcomes

A periodic summary of goals, progress toward goals and an updated treatment plan must be included in the medical record. The general expectation is that the treatment plan will be updated at least every three months.

There are no specific limits on the length of time that services may be covered, but the duration of a course of psychotherapy must be individualized for each patient. As long as the evidence shows that the patient continues to show improvement in accordance with their individualized treatment plan, and the frequency of services is within the norms of practice, coverage may be continued. However, prolonged periods of psychotherapy must be well-supported in the medical record and include a description of the necessity for ongoing treatment.

You may want to come up with your own memory tool for remembering to include all the required documentation components of psychotherapy. However you choose to remember, meeting Medicare’s prickly requirements will help guarantee appropriate payments.

“I don’t know why my brain has kept all the words to the Gilligan’s Island theme song and has deleted everything about triangles.”- Jeff Foxworthy

This month CMS appears to have stuck with their “theme” from past transmittals as a lot of the newly released transmittals are periodic updates of different CMS edits and systems. In contrast, this month, we are broadening our “theme” of bringing you monthly transmittal updates by making this an “all inclusive” Medicare Updates article (i.e., Transmittals, Conditions of Participation, Code of Federal Regulations).

Transmittals

April 2016 Integrated Outpatient Code Editor (I/OCE) Specifications Version 17.1

• Transmittal 3477, Change Request 9553, MLN Matters MM9553
• Issued March 22, 2016; Effective: April 1, 2016; Implementation date April 4, 2016
• Affects providers who submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospices (HH+H) MACs, for services provided to Medicare beneficiaries
• Updates Chapter 4, section 40.1; Medicare Claims Processing Manual

Summary of Changes: This notification providers the Integrated OCE instructions and specifications for the Integrated OCE that will be effective April 1, 2016.

Quarterly Update to the Correct Coding Initiative (CCI) Edits, Version 22.2, Effective July 1, 2016

• Transmittal 3482, Change Request 9516, MLN Matters MM9516
• Issued March 18, 2016; Effective: July 1, 2016; Implementation date July 5, 2016
• Affects providers submitting claims to MACs for services provided to Medicare beneficiaries
• Updates Chapter 23, section 20.9; Medicare Claims Processing Manual

Summary of Changes: This is the normal update to the CCI procedure to procedure edits.

April 2016 Update of the Ambulatory Surgical Center (ASC) Payment System

• Transmittal 3478, Change Request 9557, MLN Matters MM9577
• Issued March 11, 2016; Effective: April 1, 2016; Implementation date April 4, 2016
• Affects Ambulatory Surgical Centers (ASCs) who submit claims to MACs
• Updates Chapter 14, section 10; Medicare Claims Processing Manual

Summary of Changes: This Recurring Update Notification describes changes to billing instructions for various payment policies implemented in the April 2016 ASC payment system update. As appropriate, this notification also includes updates to the Healthcare Common Procedure Coding System (HCPCS).

Telehealth Services

• Transmittal 221, Change Request 9428, MLN Matters MM9428
• Issued March 11, 2016; Effective: January 1, 2015; Implementation date April 11, 2016
• Affects providers submitting claims to MACs for telehealth services provided to Medicare beneficiaries
• Updates telehealth language has been removed from the Medicare Benefit Policy Manual, Chapter 15, Section 270 and a reference added in text to see the Medicare Claims Processing Manual, Chapter 12, section 190 for further information regarding telehealth services (see related Transmittal 3476)

Summary of Changes: The purpose of this change request is to display the list of telehealth services that were once available through the manual updates to now be displayed via a web-link going forward. CMS is also adding CRNAs to the list of Medicare practitioners who may bill for covered telehealth services.

July Quarterly Update to 2016 Annual Update of HCPCS Codes Used for Skilled Nursing Facility (SNF) Consolidated Billing (CB) Enforcement

• Transmittal 3473, Change Request 9561, MLN Matters MM9561
• Issued March 4, 2016; Effective: January 1, 2016; Implementation date July 5, 2016
• Affects providers submitting claims to MACs for services provided to Medicare beneficiaries during a SNF stay.
• Changes to CPT/HCPCS codes and Medicare Physician Fee Schedule designations will be used to revise Common Working File (CWF) edits to allow MACs to make appropriate payments in accordance with policy for SNF consolidated billing in Chapter 6, section 20.6; Medicare Claims Processing Manual

Summary: This notification provides updates to the lists of Healthcare Common Procedure Coding System (HCPCS) codes that are subject to the consolidated billing provision of the SNF Prospective Payment System (PPS).

April 2016 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Transmittal 3471, Change Request 9549, MLN Matters MM9549
• Issued February 26, 2016; Effective: April 1, 2016; Implementation date April 4, 2016
• Affects providers who submit claims to MACs for services provided to Medicare beneficiaries paid under the OPPS.
• Updates Chapter 4, section 50.8; Medicare Claims Processing Manual

Summary: This Recurring Update Notification describes changes to and billing instructions for various payment policies implemented in the April 2016 OPPS update.

Coding Revisions to National Coverage Determinations

• Transmittal 1630, Change Request 9540
• Issued February 26, 2016; Effective: July 1, 2016; Implementation date July 5, 2016

Summary of Changes: This is the 6th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs). The majority of the NCDs included are a result of feedback received from previous ICD-10 NCD CR7818, CR8109, CR8197, CR8691, CR9087, and CR9252. Some are the result of revisions required to other NCD-related CRs released separately.

Edits to ICD-10 and other coding updates specific to NCDs will be included in subsequent, quarterly releases as needed. No policy-related changes are included with these updates. Any policy-related changes to NCDs continue to be implemented via the current, long-standing NCD process.

Conditions of Participation (CoPs)    

Advance Copy – Interpretive Guidelines for the Organ Transplant CoPs at 42 Code of Federal Regulations (CFR) §§ 482.68 through 482.104

• Memo # 16-10-Transplant
• Posting Date March 11, 2016

Summary: CMS has updated the Organ Transplant Interpretive Guidelines to incorporate previously-published changes, clarify certain areas, and address feedback received based on previously-released drafts. New Appendix X Interpretive Guidelines supersede all previous versions and will be published in a new Appendix X of the State Operations Manual (SOM).

When medical emergencies occur in public places, such as restaurants, movie theaters, or on airplanes, we often hear “is there a doctor in the house?” For certain diagnostic outpatient hospital procedures, Medicare wants to know if there is a doctor in the room. Descriptions of Medicare physician supervision requirements for both diagnostic and non-diagnostic services can be found in the Medicare Benefits Policy Manual, Chapter 6, sections 20.4 and 20.5.

Therapeutic Services

In 2010, CMS caused quite a ruckus when they “clarified” the physician supervision requirements for hospital therapeutic services. After several more clarifications, the final Medicare guidelines, from 2011 forward, for most hospital outpatient non-diagnostic services is “direct supervision” which means the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure. The physician does not have to be in the room, on the campus, or within any other physical boundary as long as he or she is immediately available. Other factors for “direct supervision” of therapeutic services are:

• In addition to physicians and clinical psychologists, licensed clinical social workers, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives may furnish the required supervision of hospital outpatient therapeutic services that they may personally furnish in accordance with State law and all additional rules governing the provision of their services.
• Immediate availability requires the immediate physical presence of the supervisory physician or non-physician practitioner.
• The supervisory physician or non-physician practitioner may not be performing another procedure or service that he or she could not interrupt.
• The supervisory physician or non-physician practitioner must have, within his or her State scope of practice and hospital-granted privileges, the knowledge, skills, ability, and privileges to perform the service or procedure.

Diagnostic Services

The type of supervision required for diagnostic services furnished in an outpatient hospital setting is determined by the supervision levels listed in the quarterly updated Medicare Physician Fee Schedule (PFS) Relative Value File which can be found at PFS Relative Value Files. Select the appropriate year and quarter (A correlates to 1st quarter, B to 2nd quarter, etc.). You will want to select the spreadsheet that starts with PPRRVU. The pdf document in the folder explains the various designations within the file. For example, some of the definitions related to Physician Supervision of Diagnostic Procedures are:

• 01 = Procedure must be performed under the general supervision of a physician.
• 02 = Procedure must be performed under the direct supervision of a physician.
• 03 = Procedure must be performed under the personal supervision of physician.
• 09 = Concept does not apply.

See the complete document for explanations of all the assignments.

General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Direct supervision for outpatient hospital diagnostic services has the same requirements that are described above for direct supervision of therapeutic services except that diagnostic services require supervision by a physician. Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

As stated above, diagnostic services require supervision by a physician and in general may not be supervised by non-physician practitioners. There are exceptions that allow some diagnostic tests furnished by certain non-physician practitioners to be furnished without physician supervision. When these non-physician practitioners personally perform a diagnostic service they must meet only the physician supervision requirements for that type of practitioner when they directly provide a service. For example, nurse practitioners must work in collaboration with a physician, and assistants must practice under the general supervision of a physician. Non-physician practitioners, including physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse midwives, cannot provide the required physician supervision when other hospital staff are performing diagnostic tests.

Hospitals need to be aware of the supervision requirements for diagnostic services, particularly those services that require personal supervision where the physician must be in the room during the performance of the procedure. There are over 200 CPT codes in the 2016 PFS RVU file that require personal supervision, with almost 150 of those being radiology procedures in the 70010-79999 CPT code range. This includes radiology procedures such as myelography, arthrography, angiography and venography, among others. Medicare allows payment for diagnostic services only when those services are furnished under the appropriate level of supervision.

Hospitals need to ensure that venograms, arthrograms and other relevant radiology services are only performed when a physician is in the room. Lack of appropriate supervision can result in an inappropriate Medicare payment. When personal supervision is required, there must be “a doctor in the room.”

The month of March is National Nutrition Month and March 9, 2016 was Registered Dietitian Nutritionist Day.   According to the Academy of Nutrition and Dietetics website - “As the nation’s food and nutrition experts, registered dietitian nutritionists are committed to improving the health of their patients and community.” We at MMP, Inc. would like to acknowledge dietitians, nutritionists, and all those who work in the field of nutrition and thank them for their commitment to helping hospital patients. We also want to take this opportunity to look at some guidelines and information related to hospital dietitian services allowed and covered by Medicare.

Ordering Therapeutic Diets

Several years ago, a deficiency report released by CMS identified 147 deficiencies for hospitals related to dietary standards. In response to these deficiencies and to minimize regulatory requirements for hospitals, CMS revised the Hospital Conditions of Participation at section 482.28(b)(2) effective July 11, 2014 as follows:

§482.28(b)(2) -All patient diets, including therapeutic diets, must be ordered by a practitioner responsible for the care of the patient, or by a qualified dietitian or qualified nutrition professional as authorized by the medical staff and in accordance with State law governing dietitians and nutrition professionals.

The final rule can be read at Federal Register Final Rule May 12, 2014

The revision allows registered dietitians to order patient diets independently, which they are trained to do, without requiring the supervision or approval of a physician or other practitioner, if allowed by State law and hospital privileging.

CMS made the following comments related to this change:

“[T]he addition of ordering privileges enhances the ability that RDNs already have to provide timely, cost-effective, and evidence-based nutrition services as the recognized nutrition experts on a hospital interdisciplinary team.”

“We believe that the greater flexibility for hospitals and medical staffs to enlist the services of non-physician practitioners to carry out the patient care duties for which they are trained and licensed will allow them to meet the needs of their patients most efficiently and effectively.”

The problem many hospitals may face with the revised rule relates to State law. Another

link from the Academy of Nutrition and Dietetics website shows the status of State laws for allowing therapeutic diet orders by dietitians, including a color-coded map. Therefore hospitals and dietitians must be familiar with the laws for their particular State before seeking hospital privileging for RDNs to order patient diets. For example, Alabama State law states in section 420-5-7-.14 (3)(a): "Therapeutic diets shall be prescribed by the practitioner or practitioners responsible for the care of the patients." The Academy of Nutrition and Dietetics will be working with affiliate leaders to remove existing impediments through statutory or regulatory changes.

Medical Nutrition Therapy (MNT) Services

Medicare covers medical nutrition therapy (MNT) upon physician referral for beneficiaries with diabetes or renal disease when furnished by a registered dietitian or nutrition professional meeting certain requirements. Basic coverage includes initial assessment visit, follow-up visits for interventions, and reassessments within the year for a total of 3 hours for the first calendar year of a diagnosis of diabetes or renal disease and 2 hours for subsequent years for a renal disease diagnosis.

Important points about MNT services include:

• The treating physician must make a referral and indicate a diagnosis of diabetes or renal disease.
• Renal disease means chronic renal insufficiency (not severe enough to require dialysis or a transplant; GFR of 13-50) or successful renal transplant within the last 36 months.
• Diabetes Self Management Training (DSMT) and MNT can be provided within the same time period, but not on the same day.
• The number of hours covered in an episode of care may not be exceeded unless a second referral is received from the treating physician.
• Additional covered hours of MNT services may be covered beyond the number of hours typically covered under an episode of care when the treating physician determines there is a change of diagnosis or medical condition within such episode of care that makes a change in diet necessary.
• Hours may not be carried over into the following calendar year.
• MNT can be provided individually (one-to-one) or in a group setting.

Dietitians and nutritionists must meet the profession standards as described in Section 300.3 of the Medicare Claims Processing Manual, Chapter 4 and be enrolled as a provider in the Medicare program.

The following codes can be paid if submitted by a registered dietitian or nutrition professional who meets the specified requirements; or a hospital that has received reassigned benefits from a registered dietitian or nutritionist. Payment is only made for MNT services actually attended by the beneficiary and documented by the provider. MNT is not covered for inpatients of a hospital or skilled nursing facility.

• 97802 – MNT; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes (only for the initial visit)
• 97803 - Re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
• 97804 - Group (2 or more individual(s)), each 30 minutes
• G0270 - Medical Nutrition Therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, each 15 minutes
• G0271 - Medical Nutrition Therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition, or treatment regimen (including additional hours needed for renal disease) group (2 or more individuals), each 30 minutes

So here’s to eating right for everyone, but especially hospital patients, diabetic patients, and patients with renal disease. The knowledgeable advice and direction of a dietitian/nutritionist can make a critical difference.

“The secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming tasks into small manageable tasks, and then starting on the first one.”- Mark Twain

On January 26th, 2015 Health and Human Services Secretary Sylvia M. Burwell “announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.” This was the first time that CMS had set the following explicit goals for Alternative Payment Models (APMs) and Value Based Payment goals.

Alternative Payment Models Goal

By the end of 2016 have 30 percent of Medicare payments in alternative payment models.

By the end of 2018 have 50 percent of Medicare payments in alternative payment models.

Value Based Payments Goal

By 2016 have 85 percent of Medicare fee-for-service payments tied to quality of value.

By 2018 have 90 percent of Medicare fee-for-service payments tied to quality of value.

On March 3, 2016 CMS announced in a Fact Sheet that it estimates that the first target of 30 percent of Medicare payments being tied to APMs has been met 11 months ahead of schedule. CMS indicates that “when it comes to improving the way providers are paid, we aim to reward value and care coordination – rather than volume and care duplication.”

Alternative Payment Models by the Numbers

• $411 million is the amount that Medicare Accountable Care Organizations (ACOs) saved the program in 2014 alone through markedly improved quality and patient experience over previous years.
• $3,000 saved per Medicare beneficiary on average is what was saved in just one year through the Independence at Home Demonstration.
• 17% is the reduction from 2010 to 2014 in the number of hospital acquired conditions (HACs). This represents over 87,000 lives saved and $20 billion in cost savings.
• 565,000 is the estimated number of readmissions prevented across all conditions between April 2010 and May 2015.
• Medicare spent $315.9 billion less on personal healthcare expenses between 2009 and 2013 than what would have been spent if the 2000-2008 average growth rate had continued through 2013.

Health Care Payment Learning and Action Network

CMS created the Health Care Payment Learning and Action Network (LAN) March of 2015 “to help align the important work being done across the private, public, and non-profit sectors.”

CMS notes that this network has accelerated the transition to APMs by “fostering collaboration between Department of Health and Human Services (HHS), private payers, large employers, providers, consumers, and state and federal partners.”

Ready or not, the shift in payment is happening. To learn more about LAN you can visit the LAN web page at the CMS Innovation Center as well as the LAN website where you can join the network, view their Work Products, participate in webinars and sign up for the LAN e-newsletter.

“Mortality rates from sepsis are higher than heart attack, stroke, or trauma. Sepsis needs to be viewed with the same urgency as these other life-threatening conditions because we know early treatment can decrease mortality.”- Craig M. Coopersmith, MD, FCCM, Task Force Member and Immediate Past President of the Society for Critical Care Medicine (SCCM)

On February 22, 2016 the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) was released at SCCM’s 45th Critical Care Congress. The new recommendations are the result of extensive efforts by a Task Force of 19 leaders in the field of sepsis that was convened by the SCCM and the European Society of Intensive Care Medicine (ESICM). According to the SCCM announcement “the group’s recommendations have been endorsed by more than 30 medical societies from six continents, spanning disciplines from critical care and emergency medicine to infectious disease and family practice.”

Sepsis-3 Definitions

The Sepsis-3 definitions were published in the February 2016 issue of the Journal of American Medical Association (JAMA). “The task force recommended that its report be designated “Sepsis-3,” recognizing the two iterations to define sepsis (1991 and 2001) and signaling the need for future study.”  

Sepsis is now defined as “life threatening organ dysfunction due to a dysregulated host in response to infection.”

SOFA (Sequential [Sepsis-related] Organ Failure Assessment) is a tool to be used to clinically characterize the septic patient.

qSOFA (quick Sequential [Sepsis-Related] Organ Failure Assessment) is a new diagnostic tool that clinicians can conduct for patients outside a hospital, in an Emergency Department or General Hospital floor setting to identify patients at risk for sepsis. The three warning signs to assess for are:

• An alteration in mental status,
• A decrease in systolic blood pressure of less than 100mm Hg; and
• A respiration rate greater than 22 breaths/min.

Two or more of the warning signs increases the risk of a hospitalized patient having a longer length of stay in an ICU or to die in the hospital.

The task force stresses that SOFA and qSOFA are not intended to be used as a “stand alone definition of sepsis.”

Septic Shock is now defined as “a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities substantially increase mortality.” The task force identified the following two new criteria for diagnosing septic shock:

• “Persisting hypotension requiring vasopressors to maintain MAP ≥65 mm Hg;” and
• “Blood lactate level ≥2 mmol/L despite adequate volume resuscitation.”

Sepsis (lay definition) the recently published definition that “sepsis is a life-threatening condition that arises when the body’s response to infection injures its own tissues,” was endorsed by the task force as it is consistent with the new Sepsis-3 definition.

Severe Sepsis was deemed “redundant” by the task force, “as sepsis has a mortality rate of 10 percent or higher, making the condition already severe.”

Systemic Inflammatory Response Syndrome (SIRS) “The current use of 2 or more SIRS criteria to identify sepsis was unanimously considered by the task force to be unhelpful.”

While SIRS due to a localized infection can no longer be coded as sepsis in ICD-10, Coding and CDI Professionals need to be mindful that at this time the code set definitions of sepsis and severe sepsis remain the same.

Q:

Since payment for observation services has changed from a composite payment to a comprehensive APC payment (see MMP article Observation Payment for 2016), have the requirements for reporting observation hours changed?

A:

No. The reporting of observation services remains the same as described in the Medicare Claims Processing Manual, Chapter 4, section 290.2.2. Some of the key information from this manual is:

• Observation services are only covered when provided by the order of a physician or other individual authorized to admit patients or to order outpatient services.
• Observation services are generally reported with revenue code 762.
• Other ancillary services performed while the patient is receiving observation care are separately reported.
• Observation time is reported per hour, rounded up to the nearest hour.
• Observation time begins at the clock time documented when observation care is initiated in accordance with a physician’s order.
• Observation time ends when all medically necessary services related to observation care are completed.
• Although 8 or more hours of observation care are required for an observation payment, all hours of observation should be reported.
• Observation services should not be billed concurrently with diagnostic or therapeutic services for which active monitoring is a part of the procedure. This means providers may have to “carve out” procedure time from the total stay to calculate observation hours.
• Standing orders for observation services following outpatient surgery are not appropriate.
• When observation services span more than one day, all observation hours are reported as a single line item for the date observation care began.