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ACDIS/AHIMA Query Escalation Policies Released

Tue, 04 Jun 2013 15:48:00 GMT

In the April edition of the CDI Journal, ACDIS published the joint ACDIS/AHIMA practice brief on “Guidelines for Achieving a Compliant Query Practice.” The intent of this practice brief is to maintain the integrity of the coded healthcare data. The purpose of the query process outlined is to ensure appropriate documentation appears in the health record. Additional policies may need to be implemented when questions arise regarding the clinical validity in practitioner documentation.

The ACDIS/AHIMA-developed Internal Escalation Policy includes sample policies that require a CDI specialist or coder to escalate issues regarding clinical documentation validity to a manager or steering committee.

One example of an escalation policy would route these types of cases to the manager of coding or CDI. It would be the responsibility of the coder or CDI specialist to refer any clinical validity questions to their manager, who would then determine if the case would need to be referred to an appropriate administrative representative. In another example, a multi-disciplinary committee would be implemented and tasked with reviewing the cases in which clinical validity of documentation is in question. This committee would be responsible for providing guidance and next steps depending on each case reviewed.

The below Internal Escalation Policy samples are to be viewed as guidance only and not a mandatory practice unless the facility or entity institutes such a policy.

Internal Escalation Policy

When the question of clinical validity is identified in practitioner documentation, the facility may wish to follow their internal escalation policy rather than requiring the CDI specialist/coder to query the practitioner. Sample escalation polices are outlined below.

Sample 1

When the question of clinical validity is found in practitioner documentation, the case should first be referred to the CDI manager/coding manager for review.

a. The CDI manager/coding manager determines if the case should be referred to the appropriate administrative representative (whether a physician advisor/physician champion, CPO, VPMA, Medical Director, corporate compliance officer or designated designee) for further review.

i. The administrative representative notifies CDI manager/coding manager of their concurrence with practitioner.

ii. The administrative representative does not agree with the existing documentation and discusses the case with the practitioner. The practitioner provides clarifying documentation when indicated.

iii. If significant disagreement cannot be resolved by the administrative representative, the case escalates to the appropriate medical staff or administrative physician leader for further review.

b. Steps in the escalation process are tracked for internal compliance purposes, such as in a query tracking log, or CDI worksheet/internal coding worksheet communication.

Sample 2

An organization may wish to implement a multi-disciplinary committee (consisting of physicians, quality, compliance, and HIM staff) to review cases submitted by CDI and coding when diagnoses are inconsistent with the patient’s clinical picture, or the clinical picture is inconsistent with the diagnoses. The committee can provide guidance on the best course of action on a case-by-case basis.

June, so soon?

Fri, 24 May 2013 04:00:00 GMT

As we break for a long weekend and the unofficial start of summer, I want to tell you about a couple of items on the Credentialing Resource Center roster.

First, we’ll be offering you the chance to weigh in on a benchmarking report on fluoroscopy privileging policies. This benchmarking report will distill information from you—MSPs and credentialing experts—to provide data about how organizations comparable to yours delineate privileges for fluoroscopy. Survey questions ask, “What’s going on at your facility now?” and break down the information in various ways, such as by number of beds, facility type, medical staff size, number of procedures performed annually and by which specialists, and more. Your responses will form the benchmarking report to illustrate broad, up-to-date privileging trends. Healthcare organizations, and in particular MSPs, can use the data to determine where they stand in comparison to similar facilities. The link to this benchmarking survey will be posted soon.

Second, look for “Effective Peer Review: The Complete Guide to Physician Performance Improvement, Third Edition,” by Robert J. Marder, MD, which is slated to be available in early June. (I, for one, can’t believe June starts next week!) You can get more information or order a copy here.

Thank you for reading! Please email your questions and comments to mstevens@hcpro.com.

Best regards,

Mary Stevens

Managing Editor, Credentialing Resource Center Insider

Note from the instructor: Manual medical review by Recovery Auditors of outpatient therapy claims begins April 1

Tue, 02 Apr 2013 14:05:00 GMT

This week’s note from the instructor is written by Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

During the last quarter of 2012, hospital outpatient departments temporarily fell under the therapy caps and manual medical review provisions as required under the Middle Class Tax Relief and Job Creation Act. On January 2, 2013, the American Taxpayer Relief Act revised those provisions that impacted outpatient therapy services, including those provided in hospital outpatient departments for services furnished between January 1 and December 31, 2013.

For CY 2013, the therapy payment caps were set at $1,900 for physical therapy (PT) and speech language pathology (SLP) combined and $1,900 for occupational therapy (OT). The payment cap will accrue for claims with dates of service from January 1 through December 31, 2013. The therapy cap applies to all Part B outpatient therapy settings and providers including:

Private therapy practices and physician offices;
Part B Skilled Nursing Facilities;
Home Health Agencies (TOB 034X);
Outpatient Rehabilitation Facilities (ORFs) and Comprehensive Outpatient Rehabilitation Facilities (CORFs);
Hospital Outpatient Departments (TOB 013X including TOB 012X); excluding CAHs.

Critical access hospitals (CAHs) will not be included in applying the payments caps to their outpatient therapy services or reporting the –KX modifier; however, the therapy visits provided at a CAH will count towards all other providers’ therapy payment caps. In other words, if a patient is seen at a CAH and receives physical therapy that Medicare pays $1,000 for, those services will count toward another hospital’s payment cap if the patient transfers care or starts a new episode of care at another facility in the same calendar year. Of interest is that the CMS representative on the recent March Rural Health Open Door Forum stated that CAHs will be considered for inclusion in the therapy caps in 2014 through the proposed rule making process.

The manual medical review provision of the law affects therapy claims that exceed $3,700 threshold cap for PT and SLP services combined and a separate one for OT services. Although the manual medical review provision has been in place with dates of service beginning January 1, 2013, some MACs put this process on hold until further notice. CMS has announced that effective April 1, 2013, Recovery Auditors (RA) will review all therapy claims which have exceeded the $3,700 threshold cap for the year. Although PT and SLP services are combined for triggering the threshold, the medical review will be conducted separately for each discipline.

Recovery Auditors will conduct both prepayment and post payment reviews when services exceed the threshold cap.

Recovery Audit Prepayment Review Demonstration will be conducted in eleven states -FL, CA, MI, TX, NY, LA, IL, PA, OH, NC, and MO. The claims will be reviewed and compared to the medical record before the claim is processed for payment whenever the $3,700 threshold cap is met.

The ADR will be sent to the provider by the MAC with instructions to send the records to the RA who will then have 10 business days after receiving the medical record to conduct the prepayment review. The provider will receive a review results letter describing the RA’s findings and their determination.

The remaining states will fall under post payment review by RAs for all therapy claims that reach the $3,700 threshold cap. The request for medical records will occur immediately after the claim has been processed for payment.

CMS did not indicate a separate timeframe for completion of the post payment review outside of the current RA process; however, if the RA determines than an improper payment has been made, a demand letter will be sent to the provider from the MAC who will initiate the take back.

For both prepayment and post payment reviews, the current medical record request limits will not apply to therapy services since they are based on a payment cap. All therapy claims that hit the cap will fall into review outside of the usual RA ADR limits.

Keep in mind that all providers must report the National Provider Identifier (NPI) on the claim form of the physician or non-physician practitioner who is responsible for reviewing the therapy plan of care to prevent claims from being rejected and further delaying payment. Additional guidance on the therapy payment cap and manual medical review can be found on the CMS Therapy Cap web page.

Note from the instructor: Details released on Part A to B rebilling ruling

Tue, 26 Mar 2013 13:13:00 GMT

Editor’s note: Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc., is the author of this week’s note from the instructor.

Providers were glad to see CMS’ ruling (CMS-1455-R) released on March 13 (published in the Federal Register on March 18) which allows full Part B payment for inpatient stays that had been denied as not reasonable and necessary. The ruling had very few details on how the process would work, but on March 22 CMS published a transmittal R1203OTN instructing contractors and providers on the details.

Inpatient cases that have been denied as not reasonable and necessary, including those where the provider has pending appeals, are rebilled on at least two and possibly three separate claims depending on when the services are rendered. First, the provider will submit a type of bill (TOB) 11X (presumably TOB 110) no pay inpatient claim (sometimes referred to as a “provider liable” claim). Then services after the inpatient order, which continue to be considered inpatient services, are billable on a TOB 12X Part B inpatient claim. Services prior to the inpatient order, included on the original Part A claim because of the three day window, are billable on a TOB 13X Part B outpatient claim as standard outpatient services.

Denials subject to the ruling

The ruling only applies to Part A claims denied as not reasonable and necessary by a contractor:

After March 13^th
Prior to March 13^th, but the timeframe for appeal has not expired
Prior to March 13^th and an appeal is pending

The transmittal further notes that the ruling will only apply to denials while the ruling is in effect. Along with the ruling, CMS simultaneously published a proposed rule that once finalized would limit some of the policies in the ruling – most notably the exception from timely filing. Providers should expedite their rebilling under this ruling if they have denials subject to the ruling for which the original date of service is more than one year ago. To avoid processing problems, however, providers should wait until at least the implementation date of the transmittal (July 1, 2013) or they receive instructions from their contractor that systems are ready to receive, process and properly pay claims.

While timely filing exceptions are not proposed to be extended under the proposed rule on rebilling, CMS did propose to expand the policy to provider self-audit denials. This will emphasize the importance of providers conducting utilization review even after discharge to ensure the correct Part of Medicare (A or B) is billed prior to timely filing expiring.

Timeframe for rebilling

The Part B inpatient and Part B outpatient claims will be considered “timely” if the original Part A inpatient claim was timely. However, the Part B claims must be submitted within 180 days from the applicable denial, or in the case of an appeal, 180 days from the unfavorable appeal decision or order of dismissal if the provider elects to withdraw their appeal.

The timeframe will be counted from the date of the denial, decision or order and will be presumed to have been received by the provider five days following the date of each. The provider will report this date as noted below so that the system can determine they met the 180-day requirement under this policy.

Special considerations for pending appeals

The Office of Medicare Hearings and Appeals has information on their website about the ruling, as well as a form and instructions for providers wishing to request to withdraw a pending appeal. CMS has determined that appeals contractors and administrative law judges (ALJs) may only consider the originally billed Part A claim and may not consider potential coverage and payment under Part B. This will mean that rebilling under the ruling is currently the only way a provider can receive Part B payment for a denied Part A stay. Appeal contractors and ALJs will no longer be able to award payment based on the amount that might have been payable under Part B if the provider had billed a Part B claim.

Format of rebilling

According to the transmittal, providers must use a condition code and special remarks when rebilling under this ruling. CMS is requiring providers submit condition code W2 (“Duplicate of original bill”) on both the TOB 12X and 13X claims indicating they are a duplicate of the original Part A claim. By billing with condition code W2, the provider is attesting there is no pending Part A appeal (because of final determination or dismissal), that the Part A claim is not payable and they have refunded deductibles and coinsurance amounts to the beneficiary. Contractor will return to provider (RTP) any claims under the ruling without condition code W2.

Additionally, a “treatment authorization code” in the format of “ABREBILL” followed by the document control number (DCN) followed by the date of last adjudication will be required. This will be reported on the 837I in loop 2300 (as detailed in the transmittal) and in the direct data entry (DDE) system at 5/MAP1715. On paper claims its unclear if the entry will be in the FL 63 treatment authorization or FL 80 remarks. More detailed instructions or clarifications should follow, although paper claims are rarely used.

The fiscal intermediary shared system (FISS) will search the DCN reported to ensure that the Part A claim has been denied. If the denied claim can’t be found, the TOB 12X or 13X claim will be RTP’d to the provider. Additionally, contractors have been instructed not to pay the Part B claims if there is a pending Part A claim appeal.

The Part B inpatient claim should report all procedures as HCPCS codes using the standard revenue code assignments. The limitation on reportable revenue codes on a TOB 12X claim do not apply. Room and board charges should not be “converted” to observation hours because CMS has stated that inherently outpatient services such as clinic, ED and observation services may not be billed on the Part B inpatient claim.

The Part B outpatient claim should include all outpatient services originally “moved” to and billed on the Part A inpatient claim, including everything before the inpatient order. This would include any clinic, ED or observation hours. Although CMS notes these can’t be billed on the Part B inpatient claim, they are appropriate on the Part B outpatient claim. Additionally, the provider would not include condition code 51 (“Attestation of unrelated outpatient nondiagnostic service”) because there is no covered Part A stay to trigger the three-day window which would require this condition code.

Rebilling under the new ruling is complex, but providers should take advantage of the exception from timely filing to file Part B claims where appropriate while the exception exists because CMS has proposed not to continue this policy once their final rule on this topic is published – which could be within 60-90 days. This is especially true for any appeal where the provider appealed with the hope of getting Part B payment if they did not succeed with the appeal of the Part A claim.

CMS issues proposed changes to Part B inpatient billing in hospitals

Mon, 18 Mar 2013 04:00:00 GMT

On March 13, CMS issued a notice of ruling that establishes a policy that revises the current policy on Part B billing following the denial of a Part A inpatient hospital claim that a Medicare review contractor deemed to be not reasonable or necessary. The revisions are intended as an interim measure until CMS can finalize an official policy to address the issues raised by the Administrative Law Judge and Medicare Appeals Council decisions going forward.

This temporary ruling is effective until CMS finalizes the accompanying proposed rule, which proposes a permanent policy that would apply on a prospective basis. Specifically, CMS is proposing the following:

When a Part A claim for inpatient hospital services is denied because the inpatient admission was deemed not to be reasonable or necessary, or when a hospital determines under § 482.30(d) or § 485.641 after a beneficiary is discharged that his or her inpatient admission was not reasonable and necessary, the hospital may be paid for all the Part B services (except for services that specifically require an outpatient status) that would have been reasonable and necessary had the beneficiary been treated as a hospital outpatient rather than admitted as an inpatient, if the beneficiary is enrolled in Medicare Part B.

While the CMS ruling acquiesces to the current ALJ and Appeals Council rulings to award Part B payment as timely if the original Part A claim was timely, the proposed rule would reverse this ruling and require inpatient Part B claims be filed within the one-year timely filing period. Providers should comment to CMS on the impact of this policy and the operational difficulty that it may present. In the meantime, they should take every opportunity to avail themselves of the CMS Ruling before it is superseded by a final rule that again requires inpatient Part B claims to be submitted within timely filing.

HIPAA Q&A

Sun, 17 Mar 2013 15:07:00 GMT

Q. I work at a teaching hospital affiliated with one of the nation's top universities and medical schools.

Our emergency department staff forgot to return a patient's insurance card and mailed it to the patient via regular first-class mail without notifying her that they were doing so. A few days later, the patient was traveling when she discovered that the insurance card was missing. She called our emergency department and was told the card had been mailed to her home address.

The patient said she understands that mistakes happen occasionally, but that she was far more upset by our failure to contact her and ask her preference for returning the card than by our initial failure to return it while she was at the hospital. The patient said that had we called her, she would have come to the hospital to retrieve it and that she would have done so promptly because of her imminent travel plans.

Did we do the right thing by sending the insurance card via regular first-class mail without calling the patient first? Should we have sent it via certified mail or in some other manner that required a signature confirming receipt?

Also, should our privacy policy address situations like this?

A. This amounts to a violation of patient preference versus a violation of the privacy or security of the patient's information. There is no regulatory requirement to contact the patient before sending back a left-behind insurance card. First-class mail is protected by federal mail tampering laws, so intercepting and fraudulently using another individual's insurance card would amount to a criminal act.

There is no need to change your privacy policy in an effort to comply with state or federal law. HIPAA represents the privacy and security floor-you need to at least comply with HIPAA. You may implement more stringent privacy practices if you wish, and this could include a procedure that requires a call to the patient before sending that left-behind insurance card back. Implementing such a procedure would probably lead to a happier patient, but it's not legally required.

Q. Two patients with very similar names see the same primary care provider in our office. They are sisters-in-law whose names are Michele A. Smith and Michelle B. Smith.

Staff members often retrieve the wrong files for these patients, who become aware of the mistake when the physician asks Michele or Michelle a question that doesn't pertain to her but does pertain to her sister-in-law (e.g., a question about diabetes). The sisters-in-law have a friendly relationship and seem to be familiar with each other's health issues.

This has occurred more than once and with both patients. Do these recurring situations violate HIPAA?

A. Incidental disclosures of PHI do not represent a HIPAA Privacy Rule violation. On the other hand, repeatedly disclosing one patient's PHI to another patient would likely be seen as a violation. A better way to look at it is this: What would be the consequences of an ongoing mix-up if it involved two patients who did not know each other? It is important to implement controls to reasonably ensure Michele and Michelle's medical records are not mixed up.

Have a HIPAA question of your own? Please send your question to Editor James Carroll. (Editor's note: Due to the large volume of questions we receive, we are not able to answer all inquiries).

CMS releases fiscal year-end improper payment figures for Recovery Auditors

Fri, 07 Dec 2012 14:05:00 GMT

CMS releases Recovery Auditor overpayment and underpayment statistics at the close of each fiscal year (FY) quarter, and with the FY 2012 in the books, CMS has published its year-end improper payment figures. In FY2012, CMS more than doubled its total correction amount from the previous year.

In FY 2010, Recovery Auditors collected $75.4 million in overpayments and identified $16.9 million in underpayments for a total correction amount of $92.3 million. Last year, Recovery Auditors recouped $797.4 million in overpayments and reported $141.9 million in underpayments for a total correction amount of $939.9 million. In FY 2012, Recovery Auditors collected a total of $2.29 billion in overpayments and identified $109.4 million in underpayments for a total of $2.4 billion in corrections:

	FY 2010 Oct 2009-Sept 2010	FY 2011 Oct 2010– Sept 2011	FY 2012 Oct 2011– Dec 2012	Total national program
Overpayments collected	$75.4M	$797.4M	$2,291.3M	$3.16B
Underpayments returned	$16.9M	$141.9M	$109.4M	$268.2M
Total corrections	$92.3M	$939.M	$2,400.7M	$3.43B

What these figures show, despite the recent scrutiny of Recovery Auditors, is that Recovery Auditors are stronger than ever. The numbers show that CMS will still be able to justify audits, says Elizabeth Lamkin, MHA, CEO, Pace Healthcare Consulting, LLC, in Hilton Head, S.C.

“In the latest HealthLeaders Media magazine, an article on ‘Evaluating and Replacing Leaders’ ranks future skill sets for CEOs in five years with regulatory skill set from 26% today to 22% in five years,” she says. “There must be a new focus on how billing compliance and regulatory requirements affect the bottom line.”

She continues, “Finance, clinical operations, and medical staff must work as a team for medical necessity and billing compliance. The number one skill set named in this survey was cost containment and the regulatory issues around [Recovery Auditors] and billing must be a part of this.”

While audits are certainly justifiable, providers should view this report through a certain lens, says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc. in Danvers, Mass.

“The large jump in total recovery and the fact that three out of the four Recovery Auditors have identified the same top issue are both interesting pieces to take out of this, but, the fact that the report doesn’t truly reflect what was recouped after the appeals are done makes it somewhat incomplete,” she says. “It does, however, show that Recovery Auditors are not going away.”

Regional Recovery Auditor statistics and top issues

CMS’ report each quarter includes the top Recovery Auditor issue per region. For this past quarter, the issues remained the same:

Region A: Cardiovascular procedures
Region B: Cardiovascular procedures
Region C: Cardiovascular procedures
Region D: Minor surgery and other treatment billed as inpatient

CMS also provides a drilldown of total correction numbers for the past quarter for each Recovery Auditor region. Performant Recovery (Region A) and CGI (Region B) both saw their total quarter numbers dip slightly compared to the previous quarter, while Connolly (Region C) and HealthDataInsights (Region D) saw slight upticks. The following chart shows the overpayments, underpayments, and total corrections for the quarter and fiscal year to date, with figures provided in millions:

	Overpayments collected	Underpayments returned	Total quarter corrections	FY to date corrections
Region A	$142.0	$10.9	$152.9	$475.6
Region B	$42.1	$3.5	$45.6	$277.6
Region C	$225.7	$22.1	$247.8	$792.5
Region D	$238.2	$10.0	$248.2	$854.9
Nationwide totals	$648.0	$46.5	$694.5	$2,400.7

Denials and recoupment rates high, but so are appeals

For many reading this, the fact that the number of chart requests, denials, and the total dollar amount all went up does not come as a surprise. Perhaps the bigger story—and what will spill over into 2013—however, is the fact that overturn percentages continue to be quite high, says Ralph Wuebker, MD MBA, chief medical officer for Executive Health Resources (EHR) in Newtown Square, Pa.

“The cases overturned in the appeals process are higher than what CMS and Congress would expect and want—and that’s one of the big reasons there’s real call by Congress for additional oversight on the Medicare Auditors,” he says. “The two key areas [of the proposed legislation] are limited chart requests and more physician oversight and input in the auditors process.”

Concerning the record review limits, the proposed legislation includes a combined additional documentation request limit. It would establish annual limits that may not exceed 2% of all prepayment audit requests or complex postpayment audit requests in a year and 500 additional documentation requests during any 45-day period at a given facility.

The physician validation piece would require a physician to review each claim denial for medical necessity when the person who performed the review and issued the denial is not a physician. In particular, a physician reviewing a claim would make a determination whether:

The denial of the claim under the medical necessity review by the non-physician employee is appropriate
Sign and certify such determination
Append such signed and certified determination to the claim file

The next “Cardiovascular?”

Providers should also take notice of the fact that cardiovascular procedures were the top target in three of the four Recovery Auditor regions. Not necessarily because of the issue itself—which doesn’t surprise many—but the fact that in 2013, new trends and top targets could be making their way into these reports.

“Watch out for ortho[pedic procedures] in 2013. These procedures could turn into the new cardiac in the coming years given that a couple of these procedures came off of the inpatient-only list, and that could create a similar type target because they are costly, common and no longer on Inpatient Only list ,” says Wuebker.

Looking ahead to 2013

So the question everyone is asking, as a result, is ‘what happens next?’ The appeal process is clearly under a lot of pressure. Well, according to Wuebker, something is going to have to change with the appeal process, but for now, the best approach is to keep up with your current processes and stay compliant.

“I always think of a good front-end process overall to be like immunizations in the sense that there is no glory when they are effective. ” he says. “When an immunization works, nothing happens, and that is what you want. This is similar to how a strong front-end process works; solid documentation can help fend off a denial on the back-end. ” Unfortunately, like immunizations a solid front-end process does not prevent all denials.

A strong front-end process, coupled with the capacity and knowledge to appeal the proper cases, are fundamentals when it comes to maintaining a facility that is as “audit-proof” as it can be, says Wuebker.

“In response to providers that may not have the money [to appeal], I would argue that you can’t afford not to appeal the appropriate cases,” he says.

The “appropriate” cases for appeal, as stated, have solid clinical rationale and clear documentation of such. Denied cases should be vetted through the proper channels, which should include an audit coordinator and a physician who is a strong clinician, educated in the conditions of participation and the appeals process—essentially a physician that knows more than just how to “practice medicine,” according to Wuebker.

Focus on CAHs: 2013 OIG Work Plan

Wed, 28 Nov 2012 04:00:00 GMT

The Office of Inspector General (OIG) for the U.S. Department of Health & Human Services (HHS) released on October 2 its annual Work Plan, which highlights 25 projects that examine CMS payments to hospitals under Part A and Part B. Of these projects, 11 of them are new and two of them deal specifically with CAHs.

Work Plan highlights

Some of the new additions to the 2013 OIG work plan include reviews of payments for hospital transfers, DRG payment effect from FY 2008 to 2012, payment for cancelled surgeries, payment for mechanical ventilation, quality improvement organizations, provider-based status, the acquisition of ambulatory surgery centers, and 29 separate projects that deal directly with the Affordable Care Act. In addition, the Work Plan will include an expansion of the review of Recovery Auditors from only working with Medicare providers to state Medicaid programs;

Impact on CAHs

When it comes to critical access hospitals, however, the scope of the entire Work Plan is not directly applicable to them. While some of the aforementioned items are of interest to CAHs, only two items in the Work Plan are directed specifically at CAHs. By focusing in on these projects, CAHs can put themselves in a better position—whether they have a compliance officer or not—when it comes to compliance audits and efforts in general, because though it may appear that these are fairly benign issues for CAHs, there are still risks associated with the regulations that pertain to these two topics, according to Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc. in Danvers, Mass.

Payment for swing-bed services. The Balanced Budget Act of 1997 created the CAH program to ensure access to healthcare in rural area, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 allows CAHs to receive Medicare reimbursement equal to 101% of reasonable cost and have up to 25 inpatient beds that could be used for acute care or swing-bed services, with CMS approval. Neither of these has established any length-of-stay limits for swing bed utilization. The OIG will compare reimbursement for swing-bed services at CAHS to the same level of care obtained at the traditional skilled nursing facility to determine whether Medicare could achieve cost savings through a most cost effective payment methodology.

Swing beds do not have an imposed length of stay restriction, but Medicare provides a 100-day benefit period of those patients. So while CAHs are paid cost for their swing bed services, a traditional SNF bed is paid under PPS, thereby creating a cost savings, according to Mackaman.

“Swing beds in CAHs have been the ‘bread and butter’ for many facilities and they should be aware of their overall length of stay as well as where the patient was discharged to (e.g. a PPS SNF bed),” she says. “One can assume that if the OIG is looking at a cost savings through the most effective payment methodology, there may be changes in the wind regarding a LOS restriction and facilities may want to consider the impact that may have on their bottom line in the future.”

Variations in size, services, and distance from other hospitals for critical access hospitals. CAH criteria states that a hospital must be located in a rural area, furnishing 24-hour emergency care, providing no more than 25 inpatient beds, and having an average annual length of stay of 96 hours or less. There are approximately 1,350 CAHs, but information about their structure and services is limited. The OIG will review the number and types of patients that CAHs treat in addition to reviewing them to profile variations in size, services, and distance from other hospitals.

Prior to January 1, 2006, states had the authority to waive the 35-mile relative location requirement by designating a facility as a necessary provider CAH. Since then, CMS has been very strict in making sure that CAHs are 35 miles from the nearest hospitals or 15 miles where there are only secondary roads or in mountainous areas. State surveyors have also been instructed by CMS to monitor the acute care LOS as well as the census for patient who are kept as an outpatient receiving observation services, as this is in an effort to root out hospitals that use outpatient observation as a way to circumvent the 96 annual average LOS and the 25 acute care bed limitation, explains Mackaman.

“Keep in mind that the the services that are provided by a CAH are based on the needs of the community and are not limited by the licensure as a CAH; however, the LOS and bed restrictions may help determine the types of services that are offered to its patients,” she says. “CAHs have been able to fly under the radar for several years; however, this may be coming to an end with more Recovery Auditor activity and now OIG scrutiny. “

View the 2013 OIG Work Plan:

https://oig.hhs.gov/reports-and-publications/workplan/index.asp

View a HealthLeaders Media summary of the Work Plan:

http://www.healthleadersmedia.com/content/FIN-285161/OIG-to-Investigate-Hospital-Payments-in-2013

Recovery Auditors on the hot seat: Scrutiny pouring in from numerous angles

Thu, 15 Nov 2012 04:00:00 GMT

On October 16, it was reported that legislation was introduced by Representative Sam Graves (R-MO) that essentially aimed to reform Recovery Auditors (RA) through various financial penalties and program limitations. On November 1, news broke that the American Hospital Association (AHA) and four health system filed suit in the U.S. District Court in Washington, DC, against the U.S. Department of Health and Human Services (HHS) for unfair Medicare practices pertaining to the Recovery Auditor program.

Plaintiffs the AHA, Missouri Baptist Sullivan Hospital (Sullivan MO), Munson Medical Center (Traverse City, Mich.), Lancaster General Hospital (Lancaster, Pa.), and Trinity Health Corporation (Livonia, Mich.) claim that the Medicare program has been “refusing to pay hospitals for hundreds of millions of dollars’ worth of care provided to patients, even though all agree that the care provided was reasonable and medically necessary as the Medicare Act requires.” The plaintiffs allege that the government’s refusal to pay is harming hospitals and patients, violates the Medicare Act and is unlawful. They want the court to overrule HHS’ policy and order the department to reimburse hospitals that have been denied payment.

Facilities need to constantly balance quality of care and financial concerns when dealing with Recovery Auditors, suggests Jonathan G. Wiik, MSHA, MBA, director of admissions and case management at Boulder Community Hospital in Boulder, Colo..

A clarification on billing for CAH swing bed services

Wed, 14 Nov 2012 04:00:00 GMT

In our last edition, we discussed a scenario about billing for CAH swing bed services that has confused some of our readers. In fact, this same issue has come up a number of times in recent articles we have done, so we thought that it would be helpful to take a look at exactly what is causing this confusion.

Here is the scenario that we presented:

Scenario: George, a Medicare patient, was in a covered swing bed stay receiving skilled nursing for complications related to a heart attack. During the stay, George began to complain of severe headaches, so the physician ordered a CT of the brain with and without contrast. After reviewing the exam, the physician determined the findings were normal and no additional treatment or skilled services were required, so the physician discharged George and he was free to go home. The CAH will bill the charges for the CT scan on an outpatient claim because the procedure is listed as one of the major categories for skilled nursing facility (SNF) consolidating billing.

True or false?

False. Although the CT scan is considered a major category and is an “excluded” service under the SNF PPS consolidated billing requirements, CAHs are exempt from using the list and services provided while the patient is in a CAH’s swing bed should be included on the swing bed claim, regardless of the reason for the service, the findings, or whether additional services were required. <Social Security Act §§ 1888(e)(7), 1883(b)(3), 42 CFR 413.114, MLN Matters SE0606>

In the past, we’ve covered similar scenarios as well, and most people say that the guidance we presented conflicts with guidance they have received from their Medicare administrative contractor (MAC). The MAC may have told them that services listed as excluded under the SNF consolidated billing rules should be billed on a separate outpatient claim, type of bill (TOB) 85X. However, a CAH bills all swing bed services on the swing bed claim, TOB 18X, because the CAH is paid cost for its swing bed services. There is some confusion here because there are two types of swing beds – those paid under the skilled nursing facility prospective payment system, (SNF PPS) and for those paid cost as a CAH swing bed – and some Medicare contractors and consultants do not completely understand the difference.

Let’s take a look at the history of this confusion and some citations you can reference if your MAC is giving you conflicting guidance. The Balanced Budget Act of 1997 required swing beds to be incorporated into the SNF PPS beginning July 1, 2002.

Swing beds paid under the PPS use the minimum data set (MDS) form for data collection and facilities bill their services using a resource utilization group (RUG) and assessment indicator (AI) to identify the resource utilization and intensity of services.

The Benefits Improvement and Protection Act of 2000 made CAHs exempt from the SNF PPS beginning with cost reporting periods December 21, 2000. CAHs began to be paid at 101% of reasonable costs with reporting January 1, 2004. MLN Matters article SE0606 mentions this change but CMS was not really clear and many CAH continued to bill swing beds as outpatient “excluded services” separately from the swing bed stay even though the CAH swing bed is not paid under SNF PPS, and is therefore exempt from the SNF consolidated billing rules.

CAHs are exempt from using the list of Major Categories for SNF Consolidated Billing and therefore, should not separately bill the patient for outpatient services when they are provided while the patient is in a swing bed. Services provided to the patient during a covered Part A swing bed stay must be billed on the swing bed claim using TOB 18X and the patient is not responsible for any Part B coinsurance and deductible. You can research these citations in their entirety for more information.

Social Security Act §1888(e)(7)
Social Security Act §1883(b)(3)
42 CFR § 413.114
42 CFR § 483.20
MLN Matters SE0606
CMS Swing Bed Fact Sheet published in November 2011 – refer to the 2nd page under the section “Swing Bed Services Payments” for verification of this; however, this is not stated clearly. .

Recovery Auditors on the hot seat: Scrutiny pouring in from numerous angles

Tue, 13 Nov 2012 16:56:00 GMT

Recovery Auditor improvements, transparency highlight house legislation bill

Thu, 01 Nov 2012 04:00:00 GMT

Representative Sam Graves (R-MO) introduced legislation October 16 that aims to improve the performance of Medicare audit programs by implementing financial penalties for certain compliance failures. In addition, the legislation contains a number of significant potential reforms, highlighted below.

Documentation request limits

The Medicare Audit Improvement Act of 2012 (H.R. 6575) includes a combined additional documentation request limit. This legislation would establish annual limits that may not exceed 2% of all prepayment audit requests or complex postpayment audit requests in a year and 500 additional documentation requests during any 45-day period at a given facility. This section would take effect on the date the act passes and would apply to claims submitted for payment under title XVIII of the Social Security Act for items or services furnished by providers of services or suppliers on or after January 1, 2013.

Financial penalties for Recovery Auditors

One section of the bill focuses in on the improvement of Recovery Auditor operations. Specifically, the legislation would impose financial penalties—which would go to the Medicare trust funds— on the contractors that fail to meet the requirements for the following:

Audit deadlines. Completing a determination of each audit of a hospital the Recovery Auditor conducts within the applicable timeframe.
Timely communication. If a claim is denied, the Recovery Auditor must sent a demand letter to the hospital in a timely fashion.
Overturned appeals. Recovery Auditors must pay a fee to the prevailing party in the case of an overturned appeal. The HHS Secretary will establish a fee schedule to determine the amount of the fee.

New! Revenue Cycle Institute releases 2012 Principal Diagnosis White Paper

Tue, 23 Oct 2012 04:00:00 GMT

The Revenue Cycle Institute has released a new white paper, “2012 Principal Diagnosis Selection Update: Understanding factors and new guidance to determine appropriate codes, “by Jennifer Avery, CCS, CPC-H, CPC, CPC-I , regulatory specialist for HCPro, Inc.

To download the white paper, click here. Additional white papers can be accessed by clicking here.

CMS issues next wave of supervision decisions on Hospital Outpatient Payment Panel

Wed, 17 Oct 2012 04:00:00 GMT

Earlier this year, CMS held its first Hospital Outpatient Payment Panel meeting, which managed to slip under the radar for some. The panel—which meets to recommend the appropriate levels of supervision for individual hospital outpatient therapeutic services—met again recently, and on September 24, details of the meeting were released.

Following the first meeting of the year, which was held in March, CMS approved recommendations that became effective on July 1, 2012. This time, the panel met in August and CMS has issued proposals on the following changes to the current supervision levels for the following categories:

Influenza, pneumococcal and hepatitis B vaccine administration;
Trimming of nails;
Venipuncture via vein, VAD or central catheter;
Foley catheter insertion;
Changing of cystostomy tube;
Bladder scan for residual urine measurement;
Refilling portable pump;
Irrigation of implanted VAD; and,
V hydration, initial hour and each additional hour.

The last item, IV hydration, had been previously identified by CMS as a “non-surgical extended duration service,” in the CY 2011 OPPS final rule. These types of services must be provided under direct supervision during the initiation of the service, followed by general supervision for the remainder of the service, says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.; who also explains that initiation of this service is defined as the beginning portion of the service until the supervising physician or non-physician practitioner determines the patient is stable and the remainder of the service can be delivered safely under general supervision. The supervising physician must document the transition from direct to general supervision in the patient’s medical record.

News: OIG Work Plan targets review of MS-DRG system, contractor efforts

Thu, 11 Oct 2012 10:30:00 GMT

Every October, the Office of Inspector General (OIG) releases its Work Plan for the upcoming fiscal year (FY). The Work Plan provides brief descriptions of investigations the agency plans to initiate of programs within the Department of Health and Human Services (HHS).

New on its agenda is a review of the MS-DRG system. The OIG says it will review the billing of inpatient stays since MS-DRG implementation in FY 2008. According to the Work Plan, the OIG “will describe how billing for inpatient stays in FY 2012 varied among different types of hospitals and how hospitals ensure compliance with Medicare requirements for inpatient billing.”

Also new on the OIG’s list is a review of billing for mechanical ventilation to review whether patients received fewer than 96 hours of mechanical ventilation.

Several new items on the OIG’s Work Plan focus on review of CMS’ oversight of its contractors.

One topic “Overview of CMS’s Contracting Landscape,” states that CMS awarded $4 billion in contracts in FY 2009 and that the Government Accountability Office (GAO) found “pervasive deficiencies” in how CMS manages its control over contractors.

“Given the number of contracts and the obligated dollars for which CMS is responsible, oversight and monitoring are vital for ensuring effective programs,” the Work Plan states.

The OIG also plans to review CMS’ efforts to reduce errors and “assess CMS’ oversight of the process and determine the extent to which it affects overall contractor evaluation.” And it plans to examine CMS assessment and monitoring of its Medicare Administrative Contractors’ performance.

Hospital readmissions and inpatient versus outpatient and observation services billing are among a few items remaining under OIG scrutiny in FY 2013.

When reports are issued, they are posted to OIG's website. OIG's email list subscribers automatically receive notification when new reports are posted to the website.

CMS releases latest Recovery Auditor improper payment figures

Thu, 04 Oct 2012 04:00:00 GMT

Following the close of each fiscal year (FY) quarter, CMS releases statistics for the amount of overpayments and underpayments made each quarter. In the latest report, the fiscal year 2012 trend continues to point upward, as CMS has once again corrected more improper payments than the previous quarter, this time to the tune of $701.3 million.

The report shows that, in the latest quarter, CMS collected $657.2 million in overpayments and $44.1 million in underpayments to combine for the $701.3 million total. In the previous quarter, CMS identified $588.4 million in overpayments and $61.5 million in underpayments for a total of $649.9 million in corrections. Since October 2009, CMS has corrected a grand total of $2.8 billion in improperly billed Medicare claims.

The upward trend continues to show that providers must get their billing and documentation shored up on the front end, says Elizabeth Lamkin, MHA, CEO, Pace Healthcare Consulting, LLC, in Hilton Head, S.C.

“Put the bulk of your care management staff and resources on the front end with bed status determination [inpatient or observation], use second-level physician advisor reviews, and have a clinical documentation improvement specialist reviewing concurrently,” she says.

CMS policies and conversion from ICD-9 to ICD-10

Wed, 03 Oct 2012 04:00:00 GMT

It was a rather quiet week last week as CMS and the Medicare contractors, including providers, get ready to implement the IPPS final rule on October 1, 2012. A transmittal was published last week that may be worthy of a little more discussion.

CAH interpretation

In particular, this transmittal serves as a reminder that critical access hospitals (CAH) continue to face a particular dilemma of trying to identify which CMS notifications, transmittals, and other guidance have a direct impact on their operations, according to Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc. While oftentimes the CMS guidance will include CAHs in the actual language, it is often left up to the individual CAH to do the translating, says Mackaman, who also states that in the case of most national and local coverage determinations, these will be applicable to CAHs.

“If CAHs use a medical necessity screening tool or module – either manual or computer-assisted – they must be aware of any changes that will occur to their procedures on October 1, 2014,” she says. “In addition, if CAHs have created their own internal edits, they must be updated and the appropriate version used based on the date of service.”

She continues, “CAHs have limited staffing based on their hospital bed size and census limitations so doing a little extra work now in preparation for the conversion will save a lot of time on the back end.”

Official guidance and items of note

As we all know, the implementation deadline for ICD-10 was officially changed from October 1, 2013 to October 1, 2014 for all providers and suppliers. Although this may seem like a long way off with all of the other items that need more immediate attention, keep in mind that it takes a lot of work behind the scenes to convert ICD-9 data to ICD-10 data – especially when there is not a one-to-one match for many of the code conversions.

CMS is announcing in transmittal R1122OTN that it is beginning the process of converting the ICD-9 diagnosis and procedure codes over to “comparable” ICD-10 codes including any related denial messages, frequency edits, and other claims processing logic. We know what a huge operational task our own data conversion will be; however, CMS must also convert national coverage determinations as well as make other system changes well in advance to prevent unnecessary denials and delays in payment to its providers.

One item of interest in this transmittal is that CMS has stated that they will not only be updating but also creating national coverage determination (NCD) hard-coded shared system edits as they relate to the coding conversion. At first glance, the statement that they would be creating new NCD edits sounded a little opportunistic and outside of the current policy making procedures. However, CMS included the following “disclaimer” in the transmittal:

THIS EXERCISE IN NO WAY IS INTENDED TO EXPAND, RESTRICT, OR ALTER EXISTING MEDICARE NATIONAL COVERAGE. NOR IS IT INTENDED TO MINIMIZE THE AUTHORITY GRANTED TO MEDCARE ADMINISTRATIVE CONTRACTORS IN THEIR DISCRETIONARY IMPLEMENTATION OF NCDs OR LCDs. HOWEVER, WHERE HARD-CODED EDITS WERE NOT INITIALLY IMPLEMENTED DUE TO TIME AND/OR RESOURCE CONSTRAINTS, DOING SO AT THIS TIME WILL BETTER SERVE THE INTENT AND INTEGRITY OF NATIONAL COVERAGE AND THE MEDICARE PROGRAM OVERALL.

If the purpose is to create only edits to match the current policies and/or policies that are created between now and October 1, 2014, that makes sense in an effort to have efficient conversion processes and ultimately kill two birds with one stone. One new edit that will be created in the Common Working File (CWF) is for frequency restrictions when billing the HCPCS codes for bone density to be 1 X per 23 month period. This edit will not be a change in current coverage policy but rather will put into place front end processes to streamline claims payment systems.

Usually, providers will see in the transmittal an effective date that is on or before the implementation date that the Medicare contractors have to comply with. In this rare case, we see the reverse where their implementation date is January 7, 2013 and the providers’ effective date is October 1, 2014.

Going forward, providers, including CAHs should monitor these types of transmittals and share with their ICD-10 implementation committees. CAHs need to keep in mind that LCDs and NCDs as well as ICD-10 affect their facilities the same as prospective payment system hospitals. Both local and national coverage determinations will be converted and if facilities have created their own internal edits, these will also need to be updated to prevent delays inadvertently caused by the providers themselves.

CAH perspective: CMS' proposal to redefine inpatient

Wed, 19 Sep 2012 04:00:00 GMT

Editor’s note: On August 23, HCPro released an article that outlines a request that CMS made for comments in the 2013 proposed rule that would define inpatient at a specific period of time. This proposal would have an immediate and profound impact on providers, patients, and review contractors. The following is an adaptation of this article by Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc. specifically for critical access hospitals (CAH).

In the 2013 OPPS proposed rule, CMS states:

Some in the hospital community have indicated that it may be helpful for the agency to establish more specific criteria for patient status in terms of how many hours the beneficiary is in the hospital, or to provide a limit on how long a beneficiary receives observation services as an outpatient. We are inviting public comments regarding whether there would be more clarity regarding patient status under such alternative approaches to defining inpatient status.

This is a very interesting proposal that would have a positive effect when it comes to determining whether someone is an inpatient. It could benefit providers because denials surrounding medical necessity should decrease with a more bright line rule. In addition, it would reduce the need for utilization review after the first 24 hours, allowing staff resources to be focused on this critical time period.

Impact on medical necessity and auditors

Denials of inpatient cases are a major source of income and a highly targeted area for Recovery Auditors, for both PPS hospitals and CAHs.

Even though CAHs are limited to 48 hours of covered observation care, there continues to be an increase in observation services that extends beyond this time frame. While the hours beyond the 48 would not be reimbursed by the MAC/FI, CAHs may see this as an option to avoid an audit and denial of the inpatient short stay and their cost-based payment. CAHs have long been on the radar for their high utilization of one- and two-day inpatient stays in comparison to other providers so a more definitive designation of inpatient status may provide relief in this target area.

While some medical necessity denial issues will still remain if, for example, a 24-hour bright-line rule for inpatient status is enacted; the overall impact of such a rule will be quite beneficial for most providers. First, the rule would give providers some degree of comfort with inpatient status determinations for cases that go beyond 24 hours. This would shift the focus to the medical necessity of the care rather than the setting it is being provided in (i.e., sorting out the patients that need continued inpatient care and those that are merely receiving custodial care at 24 hours).

And while a bright-line rule is very provider friendly, defining an inpatient after a set amount of time may also have a major impact on recovery audits. Recovery Auditors will have much less to audit when it comes to inpatient cases because only cases for patient stays less than the specified time frame (e.g., 24 hours) will be in question.

Effect on admission review procedures

This rule could potentially change the way admissions review staff operate with their focus on the first 24 hours. In that sense, the proposed rule could actually increase the need for seven-day-a-week staffing in order to adjust to making more immediate inpatient determinations.

This is a staffing area that has always been difficult for CAHs. It is not uncommon for case management or utilization review nursing staff to be limited “after hours” or on the weekends and holidays, leaving the regular nursing staff to step in and review admissions in addition to their patient care duties. Although a clear definition or bright-line rule would benefit CAHs in the long run, staffing and procedural adjustments would need to be made on the front end to ensure compliance in this area. This is an easier adjustment to make by larger hospitals and CAHs should be looking ahead to consider how this option may be implemented if CMS adopts a more clear definition.

Hospitals given an opportunity to comment

Upon first impression, the idea of defining inpatient by a specific time frame may sound great and may help to end the lengthy discussions and costly denials over inpatient status. However, there will still be issues that will require attention because determinations will still need to be made for some cases prior to the 24-hour mark.

Hospitals were encouraged to offer their comments to CMS by September 4 on the impact a specific timeframe would have on their operations and their patients, as well as a time frame that might be appropriate (e.g. 12 hours, 24 hours, etc.). Those comments and CMS’ responses will be published in the final rule and it will be interesting to see what the stakeholders had to say to CMS.

Often CAHs are left wondering if CMS guidance applies to their operations or not and many times it is not very clear. Since the current definitions of inpatient status and observation services apply equally across PPS and CAH providers, I would hope that CMS includes the CAH community in their discussion and final ruling so that we are all operating under the same guidance.

To listen to an audio spotlight of Ralph Wuebker, MD, MBA, vice president of audit, compliance, and education for Executive Health Resources, and Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro talking about this proposal, click here. Additionally, this topic and others, including observation services, inpatient-only procedures, out-patients in a bed, and condition code 44, will be covered in depth at HCPro’s annual Medicare Compliance Forum in Orlando October 18 and 19. For more information on this conference, please click here.

Medicare Compliance Forum 2012 spotlight: CMS' proposal to redefine inpatient

Thu, 06 Sep 2012 04:00:00 GMT

In the recently released 2013 OPPS proposed rule, CMS issued a request for comments that suggests that the agency is ready to hear new ideas when it comes to the guidance surrounding the definition of inpatient. Specifically, CMS is asking for comments on defining inpatient at a specific period of time. This proposal would have an immediate and profound impact on providers, patients, and review contractors.

Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.,provides insight to this proposal in a complimentary spotlight article, which can be downloaded here. Ralph Wuebker, MD MBA, Vice President of Audit, Compliance and Education for Executive Health Resources (EHR)—both of whom are speakers at HCPro’s 2012 Medicare Compliance Forum—discuss this proposal in an audio spotlight.

To listen to the audio spotlight, click here. This year’s Compliance Forum features new sessions such as Physician Documentation: Impact on ICD-9 and ICD-10 and Evaluating Compliance Management Issues: Case studies and discussion. In addition, it will feature popular returning sessions such as the Mock ALJ Hearing, Observation Services and Condition Code 44, and the Three-Day Payment Window. For more information on this conference, click here