2014 medicare partnership tour: partnering to reduce errors · 2014-07-17 · lcds organizational...
TRANSCRIPT
DISCLAIMER The information provided in this presentation
was current as of June 18, 2014. Any changes or new information superseding
the information in this presentation are provided in articles with publication dates after
June 18, 2014, posted on our website at: www.PalmettoGBA.com/J11A
CPT only copyright 2012 American Medical Association.
All rights reserved. The Code on Dental Procedures and Nomenclature is published in Current Dental
Terminology (CDT), Copyright © 2012 American Dental Association (ADA). All rights reserved.
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PALMETTO GBA – INNOVATION Use your smart phones and tablets to complete
workshop evaluations and to take a pre-test and post-test to measure education
effectiveness.
You will need a Quick Response (QR) Code
Reader application on your smartphone or
tablet, simply open the app and click on the QR
code on the screen. 3
Please take a moment to complete your Pre-Test.
4
Pre-Test
AGENDA Health Information Supply Chain (HISC) DMAIC Process Medical Review Strategy – Service-Specific Errors Medical Review Strategy
Going Forward 2 Midnight Education (2MN)
2MN Examples Preparing Audit Ready Documentation Audit Entities Comprehensive Error Rate Testing (CERT)
CERT Analysis CERT Tech Stop Process & TIP Letters
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AGENDA
Physician Queries Diagnosis Related Groups (DRGs)
Cardiac DRGs Heart Failure & Shock Pacemakers Septicemia/Sepsis Spinal Fusion
Partners in Compliance Comparative Billing Reports (CBRs) Rescue Your Resources A Call To Action! Educational Resources
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WHY ARE WE MEETING TODAY?
Collaborate to accomplish shared goals: Have your claims be processed (and approved!) the
first time (as long as the service meets medical necessity)
Eliminate documentation deficiencies Decrease errors, denials, and appeals
Why should we collaborate? It’s cheaper to get it right the first time Decrease costs of appeals Avoid delays in payment
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WORKING TOGETHER TO REDUCE ERRORS
o Requires: • Understanding of organizational cultures • Understanding of the process flows of physicians,
hospitals, and Palmetto GBA • Knowledge of the root cause of errors
o Sustainably reducing errors requires the 3
C’s: • Communication • Coordination • Collaboration
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COMMUNICATION
“The single biggest problem in communication is the illusion that it has taken place”
George Bernard Shaw
---------------------------------------- Despite the huge volume of records generated by our health care system, denials for poor or insufficient documentation persist.
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FOCUS ON QUALITY TO DECREASE DENIAL RATES
Traditional Quality Domains Clinical
Palmetto GBA’s Definition of Quality* Clinical Operational Financial Cultural * Dr. Joseph Fortuna, Chair of the American Society for Quality Healthcare Division
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PALMETTO GBA’S APPROACH TO DECREASING DENIAL RATES
Root Cause Analysis Health Information Supply Chain (HISC) Communication of Granular Errors DMAIC Procedure
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ROOT CAUSE ANALYSIS
Root cause analysis (RCA) is a method of problem solving that tries to identify the root causes of faults or problems
http://en.wikipedia.org/wiki/Root_cause_analysis 12
RCA: TRACING A PROBLEM TO ITS ORIGINS
In medicine, it's easy to understand the difference between treating symptoms and curing a medical condition When you're in pain because you've broken your
wrist, you WANT to have your symptoms treated – now!
Taking painkillers won't heal your wrist, you have to find the root cause of the pain and treat it before the symptoms can disappear for good
http://www.mindtools.com/pages/article/newTMC_80.htm
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But when you have a problem at work, how do you approach it? Do you jump in and start treating the symptoms? Or, do you stop to consider whether there's actually a
deeper problem that needs your attention? If you only fix the symptoms – what you see on the
surface – the problem will almost certainly happen again... which will lead you to fix it, again, and again, and again
If, instead, you look deeper to figure out why the problem is occurring, you can fix the underlying systems and processes that cause the problem
http://www.mindtools.com/pages/article/newTMC_80.htm
RCA: TRACING A PROBLEM TO ITS ORIGINS
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RCA: THREE BASIC TYPES OF CAUSES Problem: Company car fails to stop and has a wreck
Physical causes – Tangible, material items failed in some way (for e.g., the car's brakes stopped working)
Human causes – People did something wrong, or did not do something that was needed (no one filled the break fluid, which led to the breaks failing. Human causes typically lead to physical causes
Organizational causes – A system, process, or policy that people use to make decisions or do their work is faulty (for e.g., no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid)
http://www.mindtools.com/pages/article/newTMC_80.htm 15
THE HEALTH INFORMATION SUPPLY CHAIN
The unit of analysis for healthcare process improvement and quality management
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HEALTH INFORMATION SUPPLY CHAIN The HISC begins with a healthcare
encounter between a Medicare beneficiary and a provider
This encounter generates a record that is then used by a coder to translate the encounter into a form that a biller can use to communicate the reason for the encounter to Medicare
The biller does so through the submission of a Medicare claim that is then processed by Palmetto GBA
Feliciano, Harry. The Importance of a Strong Health Information Supply Chain (HISC). May 29, 2012
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HEALTH INFORMATION SUPPLY CHAIN CMS then uses the information to
enforce policy aimed at continuously improving the beneficiary-provider encounter
Having complete and accurate information in healthcare records is therefore the first step in the development of a HISC that will help Medicare providers continuously improve their services while supporting the Medicare Program
Feliciano, Harry. The Importance of a Strong Health Information Supply Chain (HISC). May 29, 2012
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COMMUNICATION OF GRANULAR ERRORS
Sustainable improvements require actionable information that is easy to share
Palmetto now communicates granular errors when denying claims
Benefits of this approach: Informs providers of areas to target in their
process improvement strategy Permits determination of % first pass yield Promotes the prevention of errors
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PUTTING IT ALL TOGETHER
Some of your claims have been denied. So what do you do now? You have to: Determine what happened Determine why it happened Figure out what to do to reduce the likelihood
that it will happen again
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THE DMAIC PROCEDURE
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DECREASING DENIALS BY IMPROVING EFFECTIVENESS OF HEALTHCARE RECORDS
efine
easure
nalyze
mprove
ontrol
D
M
A
I
C
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DEFINE
Palmetto GBA Research CMS
design requirements for addressing the potential or observed vulnerability
Communicate them to providers
Medicare Providers Define business
requirements Define business
processes
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MEASURE
Palmetto GBA Determine metrics
to track improvement
Construct impact severity risk maps for error classes undergoing record audits
Medicare Providers Measure business
process performance by implementing a data collection plan that determines the types of errors and relevant metrics
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ANALYZE
Palmetto GBA Conduct medical
review to validate the problem(s), prioritize errors, and target interventions
Medicare Providers Analyze the data
and process map to identify root causes of errors and opportunities for improvement
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IMPROVE
Palmetto GBA One-on-one education Educational articles LCDs Organizational Process
Improvement Coaching Project (OPICP)
Medicare Providers
Improve the relevant process by designing sustainable solutions to reduce the error
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CONTROL
Palmetto GBA Perform analysis of
claims to identify recurrent problems
Medicare Providers
Control the improvements to make them sustainable by developing and implementing an on-going monitoring plan
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GBD BLOG AND TWITTER Palmetto GBA is using the Going
Beyond Diagnosis (GBD) blog and Twitter account to help facilitate communication on error rate reduction http://palmgba.com/gbd @BeyondDx #MedicareHISC
Share this information with your colleagues
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MEDICAL REVIEW STRATEGY
SERVICE SPECIFIC ERRORS
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MEDICAL REVIEW STRATEGY Palmetto GBA Medical Review Strategy
is consistent with the goal to reduce provider claim denials in order to affect the claims payment error rate
Identifies issues, activities, projected goals, and the evaluation of activities and goals
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MEDICAL REVIEW STRATEGY Utilize data analysis from variety of sources to
identify program vulnerabilities to: Take action to prevent and address identified
error; Publish LCDs to provide guidance about
when items and services are medically reasonable and necessary
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MEDICAL REVIEW STRATEGY
Medical Review accuracy of problem identification has: Improved data analysis Created a strong collaboration
between statisticians and clinicians Increased identification of problem
areas
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MEDICAL REVIEW STRATEGY Efficiency of Edit Effectiveness Period of time from when we start
requesting records until the results are sent to the provider
Period of time from the date the last claim in the probe is reviewed until the results are sent to the provider
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ADDITIONAL DOCUMENTATION REQUEST (ADR)
Include barcoded ADR letter as first page for each separate claim
Respond within 30 days or claim automatically denies for no response on day 45
Do not use staples If sending a password protected CD; send
tracking number & password to: [email protected] and [email protected]
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TWO TYPES OF REVIEW
Provider-Specific Widespread Service- Specific
Examines 20-40 claims per provider when a problem is identified
Involves 100 claims from multiple providers
Results are sent directly to provider in a letter
Conducted when a larger problem is identified Results are published at www.palmettogba.com/j11a
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REVIEWS Palmetto GBA’s Medical Review focus
concentrates on two-day inpatient stays for surgical DRGs
Claims will be selected for service specific reviews
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ERROR IDENTIFIED If an error is identified, the severity of the
problem is classified Minor, moderate, or major
All levels of error will require that providers receive education on proper billing procedures and recoupment
A letter will be sent to the provider outlining the errors identified and will have granular detailed information This helps to ensure provider receives detailed
information (hopefully to prevent future errors)
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MR CLAIM REVIEW DECISION AND EDUCATION LETTER
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MR CLAIM REVIEW DECISION AND EDUCATION LETTER
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REDETERMINATION – 1ST LEVEL OF APPEAL
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MEDICAL REVIEW DENIALS
Palmetto GBA Denial Resolution tool includes resources for resolving the top claim medical review denial reasons
Save time and resources by looking here before you pick up the phone
Access denial reasons in plain language
Part A Denial Reason Codes
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MEDICAL REVIEW DENIALS
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MEDICAL REVIEW STRATEGY GOING FORWARD
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MEDICAL REVIEW STRATEGY
Going Beyond “The List” • Our goal is to assist providers in
lowering their denial rate in order to ultimately reduce the paid claims error rate!
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MEDICAL REVIEW ACTIVITIES - CURRENT
Medical Review Activity Notifications
Probe of Inpatient Medicare Severity Diagnostic Related Groups (MS-DRG)
Probe Reviews for Progressive CAP for New 2-Midnight Guidance for IPPS Claims
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DRG MR Focus for Inpatient Hospital Services (Year 4) Any DRG
One-Day Stays for IPPS Providers Excluding IRF and CAH Facilities
291 Heart Failure and Shock w/ MCC – One-Day Stays 292 Heart Failure and Shock w/ CC – One-Day Stays 293 Heart Failure and Shock w/o MCC or CC – One-Day Stays 308 Cardiac Arrhythmia and Conduction w/ MCC – One-Day
Stays 309 Cardiac Arrhythmia and Conduction Disorders w/ CC – One-
Day Stays 391 Esophagitis, Gastroenteritis w/ MCC – One-Day Stays 392 Esophagitis, Gastroenteritis w/o MCC – One-Day Stays 640 - 641
Misc. Disorders of Nutrition, Metabolism, Fluid/Electrolytes w/ MCC & w/o MCC – One-Day Stays
470 Major Joint Replacement or Reattachment of Lower Extremity w/o MCC
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DRG MR Focus for Inpatient Hospital Services (Year 4) 689 Kidney and Urinary Tract Infections w MCC – One-Day
Stays 690 Kidney and Urinary Tract Infections w/o MCC – One-Day
Stays 302 Atherosclerosis w MCC – One-Day Stays
303 Atherosclerosis w/o MCC – One-Day Stays
313 Chest Pain – One-Day Stays
219–220
Cardiac Valve and Other Major Cardiothoracic Procedures
459 Spinal Fusion Except Cervical w/ MCC
460 Spinal Fusion Except Cervical w/o MCC
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2 MIDNIGHT (2MN) EDUCATION EFFORTS
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2MN EDIT BACKGROUND Inpatient hospital short stays have been
identified as prone to improper payments Most common finding: Inappropriate patient status The services furnished were reasonable and necessary, but should have been furnished on a hospital outpatient, rather than inpatient, basis Frequently related to hospital stays following minor surgical procedures and diagnostic tests
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PRIMARY REVIEW FOCUS
Principals of Documentation
Who Performing, supervising, & referring practitioners
What Services and quantities of services performed
Where Place of service (POS)
When Date of service (DOS)
Why Medical necessity and diagnosis
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DETAIL DISCOVERY
Common insufficient documentation findings: Date of service not documented Missing names, signatures, credentials Documentation not supporting services
billed Chief complaint was not determined Primary diagnosis was not documented
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DETAIL DISCOVERY Documentation Signatures: Treating physician’s signature must be present
in documentation associated with all services submitted to Medicare
Signature must be a legible identifier for the ordered rendered service
Handwritten or electronic signature required Stamped signatures are not acceptable signatures
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DETAIL DISCOVERY
Medically unnecessary services include situations where enough documentation in medical record is identified to make an informed decision that services billed were not medically necessary
If MAC determines admission is unnecessary due to not meeting an acute level of care, entire payment for admission is denied
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2MN PROBE STATUS UPDATE
State Claims Reviewed
Claims Denied
Charges Reviewed
Charges Denied
SC 120 85 $711,295.27 $521,544.28
NC 440 320 $3,551,962.39 $2,502,527.24
VA 300 186 $1,630,661.51 $1,007,754.40
WV 120 68 $586,546.52 $312,787.75
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2MN GRANULAR ERROR BREAKDOWN Denial Code Granular Description
5D908/5H908 THE PHYSICIAN CERTIFICATION SUBMITTED WAS NOT VALID AS SPECIFIED BY 42CFR 412.3(c) AND 42CFR 424.13(a).
5D910/5H910
BASED ON THE CLINICAL FACTORS DOCUMENTED IN THE MEDICAL RECORD THE MEDICAL NECESSITY OF THE INPATIENT SERVICE WAS NOT SUPPORTED AS REQUIRED BY 1862(A)(1) OF THE SOCIAL SECURITY ACT
5D909/5H909 THERE WAS NO DOCUMENTATION OF CURRENT MEDICAL NEEDS IN THE MEDICAL RECORD SUBMITTED AS REQUIRED BY 42CFR 412.3(e).
5D908/5H908 THE CERTIFICATION DOES NOT INCLUDE ORDER FOR INPATIENT ADMISSION AS REQUIRED BY 42CFR 412.3(c) AND 42CFR 424.13(a).
5D909/5H909
THERE WAS NO DOCUMENTATION OF PATIENT'S HISTORY AND COMORBIDITIES IN THE MEDICAL RECORD SUBMITTED AS REQUIRED BY 42CFR 412.3(e).
5D909/5H909 THERE WAS NO DOCUMENTATION OF SEVERITY OF SIGNS AND SYMPTOMS AS REQUIRED BY 42CFR 412.3(e).
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2MN FOUR COMPLEX MEDICAL FACTORS
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Patient’s history and co-morbidities
Severity of signs and symptoms
Current medical needs
Risk of an adverse event if the patient is not admitted
2MN RESOURCE For more information refer to: http://cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/ReviewingHospitalClaimsforAdmissionforPosting03122014.pdf
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EXAMPLES OF THE MOST COMMON 2MN DOCUMENTATION
ERRORS
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MISSING/FLAWED INPATIENT ADMISSION ORDER Mr. Jones arrived at the Emergency Department (ED) with chest pain Physician’s notes state that Mr. Jones is to be
worked-up, but it’s unlikely pain is cardiac-related Physician’s order states “admit to
observation” Mr. Jones is kept overnight and discharged
the next day Hospital submits a claim to Medicare for a 1-
day inpatient stay
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Upon review, the MAC denies Medicare Part A payment because the medical record:
1. Failed to support expectation of a 2-midnight stay and
2. Lacked an order to admit as an inpatient
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MISSING/FLAWED INPATIENT ADMISSION ORDER
It is in the interest of a hospital for the admitting practitioner to use language that clearly expresses intent to admit a patient as inpatient
Examples of such language include physician documentation to “admit to inpatient” or “admit to inpatient care”
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MISSING/FLAWED INPATIENT ADMISSION ORDER
CMS will continue to treat orders that specify a typically outpatient or other limited service as defining a non‐inpatient service ER, Observation, Recovery, Outpatient Surgery, Day
Surgery, or Short-Stay Surgery Such orders will not be treated as meeting the
inpatient admission requirements
Reference: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-
Certification-and-Order-01-30-14.pdf
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MISSING/FLAWED INPATIENT ADMISSION ORDER
SHORT STAY PROCEDURES Mrs. Smith presents for a procedure in which treatment and discharge typically occur in less than 2 midnights Physician wrote an order to admit to inpatient upon arrival at hospital for pre-operative care Procedure is not on inpatient-only list Medical record did not support the
expectation of a 2-midnight stay for hospital care
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SHORT STAY PROCEDURES Mrs. Smith underwent the procedure without
any complications either during or after and was discharged within 10 hours after arrival Hospital submits claim for a 0-day inpatient
stay Upon review, MAC denies Medicare Part A
payment because the medical record failed to support an expectation of a 2-midnight stay
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SHORT STAY PROCEDURES Instances in which the typical expected
length of stay for a procedure is less than 2 midnights should be initiated as outpatient
If it later becomes clear that 2 or more midnights of hospital care is required due to a complication or other factor; Physician can order an inpatient admission at
that time
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SHORT STAYS - MEDICAL CONDITIONS Mr. Ho presents to ED with recent onset of dizziness, denies any additional complaints, but blood pressure medication was recently adjusted Physician’s notes state Mr. Ho is stable, his
blood pressure medication is to be held and dosage adjusted
Physician intends to observe Mr. Ho overnight
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SHORT STAYS - MEDICAL CONDITIONS
Mr. Ho is discharged the next day and hospital submits a claim for a 1-day inpatient stay
Upon review, the MAC denied Medicare Part A payment because the medical record failed to support an expectation of a 2-midnight stay
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SHORT STAYS - MEDICAL CONDITIONS
Observation care is a well-defined set of specific, clinically appropriate services that include ongoing short term treatment, assessment and reassessment before a decision can be made whether further treatment as an inpatient is required or if able to discharge
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SHORT STAYS - MEDICAL CONDITIONS
If patient requires additional monitoring, diagnostics, or treatment to determine the expected length of stay;
Physician may keep the patient as an outpatient until it’s clear that the patient will require 2 or more midnights of hospital care
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PHYSICIAN ATTESTATION STATEMENTS
Without Supporting Documentation: Physician’s order contains a checkbox with
pre-printed text stating “Patient is expected to require 2 or more midnights of hospital care.”
Plan of care however states that the patient is to have diagnostics performed post-operatively, with a plan to discharge in the morning, if stable
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PHYSICIAN ATTESTATION STATEMENTS Without Supporting Documentation: Patient is discharged the following day as
planned after a 1-midnight stay and hospital submits a claim
Upon review, MAC denied Medicare Part A payment because the medical record failed to support an expectation of a 2-midnight stay when the order was written
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PHYSICIAN ATTESTATION STATEMENTS
Without Supporting Documentation Attestation statements indicating a hospital
stay is “expected to span 2 or more midnights” are not required under inpatient admissions policy Nor are they adequate by themselves to support the expectation of a 2-midnight stay
Expectation must be supported by the entirety of the medical record
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CERTIFICATION The physician order must be furnished
at or before the time of the inpatient admission
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CERTIFICATION Certification begins with the order for
inpatient admission Medicare Part A pays for inpatient
hospital services (other than inpatient psychiatric facility services) only if a physician certifies and recertifies the following:
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CERTIFICATION Hospitalization of the patient for inpatient
medical treatment or medically required inpatient diagnostic study; or, special or unusual services for cost outlier cases
The estimated time the patient will need to remain in the hospital
The plans for post hospital care, if appropriate
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CERTIFICATION Certifications must be signed by the
physician responsible for the case, or by another physician who has knowledge of the case and who is authorized to do so by the responsible physician or by the hospital's medical staff
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PREPARING AUDIT READY
DOCUMENTATION
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PREPARING AUDIT READY DOCUMENTATION
Design an internal quality control record review
Establish protocols and procedures Identify key personnel Implement the process
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PREPARING AUDIT READY DOCUMENTATION Develop a checklist for documentation based
on the information in this session Design an Internal Quality Control Record
Review Fix bad habits Keep records of the results of the audits Educate staff on what to look for when
submitting medical records Educate professional medical staff on proper
elements of documentation, especially signatures
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EXPANDED RESOURCES Our provider outreach and education
activities will target specific documentation errors
We will create more web activities to inform you about documentation requirements
Our goal is your compliance
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REMINDER
If you can’t read it, we can’t read it!
Carefully pull and timely submit all the necessary documentation to support all
services!
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Audit Entities
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OTHER WATCHFUL EYES
• Palmetto GBA Medical Review Program • External Reviewers
– Recovery Auditors – Comprehensive Error Rate Testing (CERT)
Contractor – Zone Program Integrity Contractor (ZPIC)
Contractor – Strategic Health Solutions (SHS) – Office of Inspector General (OIG)
• Triggered by an accusation, utilization reports, legislation
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PARTNERING FOR SYSTEMIC, SUSTAINABLE FIXES
• Use the HISC and DMAIC processes • Use the Provider Outreach and Education (POE)
team to educate! • Use permanent, sustainable fixes • Keep Our Eyes Open • Avoid Regulatory Pitfalls • Manage Medicare Compliance • Develop a Strong Effective Framework • Maintain the Integrity and Credibility of the
Medicare Trust Fund
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COMPREHENSIVE ERROR RATE TESTING (CERT). .
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CERT
• Federally mandated program created by CMS • Measures paid claims error rate for Medicare
claims submitted to Medicare Administrative Contractors (MACs) • Ensures the Medicare program is paying claims correctly • Measures and compares national, contractor-specific, and
service-specific paid claim error rates
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CERT
• CERT program uses a random and service-specific sampling of claims
• Two contractors responsible for administering CERT program
• CERT Review Contractor (CRC)- selects samples of claims from Palmetto GBA
• CERT Documentation Contractor (CDC) - requests medical records, from the billing providers, physicians or suppliers and prepares the documentation for review
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CERT MEDICAL RECORDS REQUEST
• CERT requests medical records and other pertinent documentation from the billing provider • Initial request - via fax or e-mail • Failure to respond to the initial request within 30 days,
results in a second contact via fax or mail (reminder letter). Provider has 15 days to respond.
• If no response is received by day 45, the provider receives a contact via fax or mail
• A fourth contact is made via mail on day 60. Phone calls may be placed to the providers to collect the documentation
– Providers have 75 days to return the requested information
– On Day 76, CERT denies claims without documentation
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SAMPLE CERT RECORD REQUESTS
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Request for Additional Documentation (RAD)
Initial CERT Record Request
CERT RECORD REQUEST ENVELOPE
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RECORD REQUEST DETAILS
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BARCODED COVERSHEET
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CERT CHECKLIST
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REVIEW WHAT IS NEEDED • Know what services are being reviewed • Pull or obtain all records to support all services • Send ‘final’ authenticated records • Check for signatures • Verify records and signatures are legible • Double check request and assure all the records are
being sent • Include necessary orders, requisitions, or signed notes
documenting the intent to order for diagnostic test even if you must obtain from the ordering provider
• Include a signature attestation statement or signature log if necessary
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CERT DOCUMENTATION SUBMISSION
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Fax Submission
CD Submission Mail Submission
(240) 568-6222
CERT Documentation Office Attn: CID #: (Insert CID #) 9090 Junction Dr., Suite 9 Annapolis Junction, MD 20701
CERT Documentation Office Attn: CID #: (Insert CID #) 9090 Junction Dr., Suite 9 Annapolis Junction, MD 20701
CERT DOCUMENTATION BY ESMD
• Electronic Submission of Medical Documentation (esMD)
• Contact one or more of the Health Information Handlers (HIHs) to determine if esMD services are available to meet your needs • www.cms.gov/ESMD
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ESTABLISH A CERT CONTACT
• Designate and keep updated a specific point of contact to receive CERT information in your billing or medical records office • www.CERTprovider.org
• Palmetto GBA also has dedicated resources in-house to assist with CERT
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CERT REVIEW RESULTS
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No Overpayment
Found
You will NOT hear anything else about the claim from CERT
Palmetto GBA will: • Send a Teaching and Instruction (TIP) letter • Overpayment Demand Letter • Remittance Advice showing the adjusted claim
Overpayment Found
CERT TECH STOP CALL AND CERT TIP LETTER PROCESSES
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Courtesy call made to any provider that has failed to submit any documentation or incomplete documentation to support payment of service(s)
Details regarding required information are provided Providers encouraged to respond to the Tech Stop call
by obtaining and submitting all necessary documentation identified during the call
Failure to respond will result in a CERT error being called Results in the request for a refund of paid
dollars Multiple CERT errors by the same provider may
result in further audits
CERT TECH STOP CALLS
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CERT TIP LETTER
“This letter is being sent to
you for educational purposes….”
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CERT TIP LETTER
“Claim payments that are recouped as a result of
a CERT review may be appealed….”
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PALMETTO GBA’S GOAL
• Partner to decrease CERT error rate • Improve success rate of first time claim submission • Reduce appeals • Reduce potential for future audits
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CERT Analysis
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CERT - PAYMENTS
Palmetto GBA is notified of detected overpayments and underpayments for payment adjustments Overpayments identified in sample: CERT identified $5,057,759 in actual overpayments and as of report date, CMS collected $3,814,177 of those overpayments
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CERT Error Description No Documentation
Provider or supplier fails to respond to repeated requests for the medical records or they do not have the requested documentation.
Insufficient Documentation
Submitted medical documentation is inadequate to support payment for the services billed, or a specific documentation element that is required as a condition of payment is missing (for example, physician signature on an order).
Medical Necessity
There is adequate documentation in the medical records to make the informed decision that the services billed were not medically necessary based upon Medicare coverage policies.
Incorrect Coding
Provider submits medical documentation supporting: 1. A different code than was billed; 2. That the service was performed by someone other than the billing provider; 3. That the billed service was unbundled; or 4. That beneficiary was discharged to a site other than the one coded on claim
Other When a claim error does not fit in any other category (for example, duplicate payment error, non-covered or unallowable service).
CERT - FINDINGS
Error codes with strongest impact on overall error rate are: Medically unnecessary service or treatment –
(Error Code 21) - 49.3% Insufficient documentation (Error Code 21) –
12.8% Invasive Procedure Not Medically Necessary
(Inpatient PPS Only; Error Code 26) – 19.4%
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CERT - FINDINGS
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EXAMPLE: SUMMARY -BILL TYPE AND ERROR CODE Rank Bill
Type Bill Type
Description Error Code
Error code Description
No. of claims
Medicare Final Allowed Amount
Paid Incorrect
Amount
1 11x Hospital Inpatient (Part A)
25 Medically Unnecessary service
or treatment
36 $599,554.97 $599,554.97
2 11x Hospital Inpatient (Part A)
21 Insufficient documentation
5 $105,441.83 $105,441.83
3 11x Hospital Inpatient (Part A)
26 Invasive Procedure Not Medically
Necessary
9 $145,445.08 $97,111.21
4 11x Hospital Inpatient (Part A)
33 DRG change due to wrong procedure
code
4 $47,912.92 $31,718.11
5 11x Hospital Inpatient (Part A)
32 DRG change due to wrong diagnosis code
or wrong principal diagnosis
4 $85,736.64 $20,204.19
6 11x Hospital Inpatient (Part A)
90 Other errors 2 $36,875.79 $13.44
7 13x Hospital Outpatient
21 Insufficient Documentation
6 $3,278.19 $3,278.19
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CERT - FINDINGS Errors due to services provided in an
inappropriate setting: Patient has signs and/or symptoms severe
enough and of such an intensity they can only be furnished safely and effectively on an inpatient basis
Physician responsible for care also responsible for decision to admit as an inpatient
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CERT - FINDINGS There are situations where patient was
admitted as inpatient but clinical care and procedures should have been in outpatient or other non-hospital based setting Under Medicare statute these claims must
be denied in full, even if claim would be potentially payable in another setting
By law CMS cannot partially deny claim or allow provider to re-bill using a different setting
111
CERT - FINDINGS Services Incorrectly Coded Documentation submitted does not
match service/modifier/diagnosis submitted
Providers use standard coding systems Documentation submitted supported a
lower or a higher code than code submitted
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CERT – HISC Process of coding is as follows: Patient Encounter Review of Medical Records Selection of Diagnoses and Procedure
Codes Assignment of Code Number Sequencing of Codes
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CERT - FINDINGS Issues that lead to incorrect coding are: Incomplete notes Undocumented care Missing test results Post-op complications not listed Documentation not completed timely Illegibility Inconsistent documentation
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POE AND MR COLLABORATIVE EFFORTS POE and MR have collaborated and implemented a
new process to follow-up on CERT TIP letters that are sent to the providers by MR
POE calls the provider and discusses the TIP letter to see if there are any questions: Such as how to avoid denials for a particular
reason code How to appeal Ask if additional education is needed
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POE AND MR COLLABORATIVE EFFORTS
Medical review is sending referrals to POE on providers who have received a tech stop contact by the CERT
These contacts are made due to missing documentation in the record that may result in a denial of the claim
Palmetto GBA is working diligently to reduce the CERT error rate Please join us in this effort. Together, we
can do it!
116
CERT RESOURCES CERT resources on J11 Part A website: • www.PalmettoGBA.com/j11a
CMS CERT website: •www.cms.gov/CERT
CERT Provider website: • https://www.certprovider.com/Ho
me.aspx
CMS Program Integrity Manual •www.cms.gov/manuals/downloads/pim8
3c12.pdf • Publication 100-08
117
INTRODUCTION TO CERT WEBCAST
118
Physician Queries
119
WHAT IS A QUERY?
A physician query is a method of communication used by coders to request clarification of patient diagnoses or procedures from the physician.
A physician query is the process recommended by the American Hospital Association (AHA) Coding Clinic guidelines when specificity or clarification regarding a specific diagnosis being treated is not clearly stated in the medical record
Coding Clinic 1Q 1993
120
DEFINITION OF PHYSICIAN QUERIES AHIMA’s definition is: Questions asked to physicians to obtain
additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes
OIG. Compliance Program Guidance for Hospitals. Federal Register Notices, Feb 23 1998, 63(35), p. 8991 AHIMA. Managing an Effective Query Process. Journal of AHIMA79, no.10 (October 2008): 83-88
121
AHIMA STANDARDS OF ETHICAL CODING
Coders “should consult physicians for clarification and additional documentation prior to code assignment when there is conflicting or ambiguous data in the health record.”
American Health Information Management Association. Standards of Ethical Coding. 2008
122
WHEN AND HOW TO QUERY
The generation of a query should be considered when the health record documentation: • Is conflicting, imprecise, incomplete, illegible, ambiguous, or
inconsistent • Describes or is associated with clinical indicators without a
definitive relationship to an underlying diagnosis • Includes clinical indicators, diagnostic evaluation, and/or
treatment not related to a specific condition or procedure • Provides a diagnosis without underlying clinical validation • Is unclear for present on admission indicator assignment
AHIMA. "Guidelines for Achieving a Compliant Query Practice." Journal of AHIMA 84, no.2 (February 2013): 50-53.
123
APPROPRIATE QUERY FORMAT Queries should:
• Use precise language • Identify documented clinical findings, indicators,
observations • Ask the provider to make a clinical interpretation of these
facts • Always include basic query components: – Identifiers (name, record number, account number) – Admission and query dates – Clinical indicators – Question addressing the documentation concern – Name and contact information of the coder
AHIMA. "Managing an Effective Query Process“ Journal of AHIMA79, no.10 (October 2008): 83-88.
124
INAPPROPRIATE QUERY FORMAT
AHIMA states that queries should not: • Target a diagnosis that would not be
supported by the chart • Sound presumptive, directive, prodding, or
as if leading to an assumption • Indicate financial impact or quality
reporting • Require only a physician signature
AHIMA. "Managing an Effective Query Process“ Journal of AHIMA79, no.10 (October 2008): 83-88
125
INAPPROPRIATE QUERY FORMAT
• Be leading • Be poorly constructed • Question a provider‘s clinical judgment • Utilize blanket querying • Routinely target insignificant or irrelevant
findings • Introduce new information
126
CLARIFICATION FOR SPECIFICITY OF A DIAGNOSIS EXAMPLE
Documentation: Obtunded patient admitted with three-day history of nausea and vomiting. CXR revealed right lower lobe (RLL) pneumonia. Clindamycin ordered. • Leading query:
– Is the patient’s pneumonia due to aspiration? • Nonleading query:
– Can the etiology of the patient’s pneumonia be further specified? It is noted in the admitting history and physical examination (H&P) this obtunded patient had a history of nausea and vomiting prior to admission to the hospital and is treated with clindamycin for RLL pneumonia. Based on the above, can the etiology of the pneumonia be further specified? If so, please document the type/etiology of the pneumonia in the progress notes.
127
Source: AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010): expanded web version.
QUERY EXAMPLE
Clinical Scenario 1 • Documentation: Laboratory finding of serum sodium of
120 mmol/L and the attending physician documents hypernatremia in the final diagnostic statement.
• Query: Please review the laboratory section of the present record to confirm your discharge diagnosis of hypernatremia. Laboratory findings indicate a serum sodium of 120 mmol/L.
AHIMA. "Guidelines for Achieving a Compliant Query Practice." Journal of AHIMA 84, no.2 (February 2013): 50-53.
128
QUERY EXAMPLE Clinical Scenario 2 • Documentation: Four-year old child sustains a
cautery injury to upper lip during maxillofacial surgery. Silvadene and dressing is applied to the affected area at the completion of the procedure and plastic surgery was consulted. The surgeon documented in the operative report that there were “no intraoperative complications.”
• Query: Please review the operative note notation of “a cautery lesion to the upper lip,” subsequent treatment with Silvadene and clarify your documentation of “no intraoperative complications.”
129
EXAMPLE MULTIPLE CHOICE QUERY A patient is admitted for a right hip fracture. The H&P notes that the patient has a history of chronic congestive heart failure. A recent echocardiogram showed left ventricular ejection fraction (EF) of 25 percent. The patient’s home medications include Metoprolol XL, Lisinopril, and Lasix. • Leading: Please document if you agree the patient
has chronic diastolic heart failure. • Non-leading: It is noted in the impression of the
H&P that the patient has chronic congestive heart failure and a recent echocardiogram noted under the cardiac review of systems reveals an EF of 25 percent.
Source: AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010): expanded web version
130
QUERY EXAMPLE - CONTINUED
• Can the chronic heart failure be further specified as:
• Chronic systolic heart failure ____________________
• Chronic diastolic heart failure ____________________
• Chronic systolic and diastolic heart failure ____________________
• Some other type of heart failure ____________________
• Undetermined ____________________
131
COMPLIANT OR NON-COMPLIANT? Clinical scenario: On admission bilateral lower extremity edema is noted, however, there are no other clinical indicators to support malnutrition. Query: Do you agree that the patient’s bilateral lower extremity edema is diagnostic of malnutrition? Please document your response in the health record or below. • Yes______________ • No ______________ • Other ___________ • Clinically Undetermined ______________ • Name: ___________________ Date:__________
Physician Query Examples Feb 01, 2013 Journal of AHIMA
132
COMPLIANT OR NON-COMPLIANT Clinical scenario: A patient is admitted with an acute gastrointestinal bleed, and the hemoglobin drops from 12 g/dL to 7.5 g/dL and two units of packed red blood cells are transfused. The physician documents anemia in the final discharge statement.
Physician Query Examples Feb 01, 2013 Journal of AHIMA
133
COMPLIANT OR NON-COMPLIANT
Query: In this document your response in the health record or below accompanied by clinic patient admitted with a gastrointestinal bleed and who underwent a blood transfusion after a drop in the hemoglobin from 12 g/DL on admission to 7.5 g /dL, can your documentation of anemia be further specified as an acute blood loss anemia? Please call substantiation. Yes ______________ No ______________ Other ____________ Clinically Undetermined ____________ Name: ___________________ Date:__________
134
COMPLIANT OR NON-COMPLIANT?
Clinical scenario: In the impression of the pathology report, ovarian cancer is documented; however, only ovarian mass is documented in the final discharge statement by the provider. Query: Do you agree with the pathology report specifying the “ovarian mass” as an “ovarian cancer”? Please document your response in the health record or below. Yes____________ No ____________ Other ___________ Clinically Undetermined __________ Name: ___________________ Date:__________
AHIMA. "Guidelines for Achieving a Compliant Query Practice." Journal of AHIMA 84, no.2 (February 2013): 50-53.
135
COMPLIANT OR NON COMPLIANT? Clinical scenario: Consulting pulmonologist documents pneumonia as an impression based on the chest X-ray. However, the attending physician documents bronchitis throughout the record, including in the discharge summary. Query: Do you agree with the pulmonologist’s impression that the patient has pneumonia? Please document your response in the health record or below. Yes ______________ No _______________ Other _____________ Clinically Undetermined____________ Name: ___________________ Date:__________
AHIMA. "Guidelines for Achieving a Compliant Query Practice." Journal of AHIMA 84, no.2 (February 2013): 50-53.
136
Diagnosis Related Groups (DRGs)
Top 25 By Disbursement
137
TOP 25 DRG BY DISBURSEMENT
Rank DRG Code
DRG Description
No. of Claims Total Disbursed
1 470 Major Joint Replacement Or Reattachment Of Lower
Extremity W/O MCC 48,727 447,905,058 2 871 Septicemia Or Severe Sepsis W/O Mv 96+ Hours W MCC 45,456 428,588,249
3 003
ECMO (extracorporeal membrane oxygenation) or Tracheostomy with Mechanical Ventilation 96+ Hours
Principal Diagnosis Except Face, Mouth and Neck with Major O.R. 1,731 177,269,980
4 885 Psychoses 26,147 171,392,683
5 460 Spinal Fusion Except Cervical W/O MCC 8,460 166,358,801
6 291 Heart Failure & Shock W MCC 22,630 162,203,879 7 853 Infectious & Parasitic Diseases W O.R. Procedure W MCC 5,497 157,837,978 8 193 Simple Pneumonia & Pleurisy W MCC 17,117 117,516,864
9 207 Respiratory System Diagnosis W Ventilator Support 96+
Hours 3,687 113,133,911
10 329 Major Small & Large Bowel Procedures W MCC 3,967 110,099,290
11 682 Renal Failure W MCC 13,643 105,422,565
12 004
Tracheostomy with Mechanical Ventilation 96+ Hours or Principal
Diagnosis Except Face, Mouth and Neck without Major O.R. 1,764 101,958,665
138
TOP 25 DRG BY DISBURSEMENT
139
Rank DRG Code
DRG Description No. of Claims Total Disbursed
13 189 Pulmonary Edema & Respiratory Failure 16,619 100,711,080
14 247 Percutaneous cardiovascular procedure with drug-eluting
stent without MCC 10,574 98,006,945 15 292 Heart Failure & Shock W CC 22,032 97,964,884 16 870 Septicemia Or Severe Sepsis W MV 96+ Hours 3,013 94,893,556
17 208 Respiratory System Diagnosis W Ventilator Support <96 Hours 7,833 92,406,427 18 177 Respiratory Infections & Inflammations W MCC 8,776 89,751,834 19 190 Chronic Obstructive Pulmonary Disease W MCC 16,584 85,476,947 20 194 Simple Pneumonia & Pleurisy W CC 18,649 83,773,324 21 683 Renal Failure W CC 19,057 82,270,241
22 219 Cardiac Valve & Oth Maj Cardiothoracic Procedure W/O Card
Cath W MCC 1,683 80,707,887 23 064 Intracranial Hemorrhage Or Cerebral Infarction W MCCc 8,653 79,356,359 24 481 Hip & Femur Procedures Except Major Joint W CC 8,349 76,310,934 25 378 G.I. Hemorrhage W CC 16,718 73,425,313
DOLLARS MR DENIED BY DRG DRG Region(s) Claims
Reviewed Claims Denied Dollars Denied CDR%
DRG 074 NC 29 3 $12,896.00 11.42%
DRG 192 NC, SC,VA, WV 49 5 $47,631.08 8.93%
DRG 195 NC, SC,VA, WV 43 4 $21,357.03 10.06%
DRG 227 NC, SC,VA, WV 44 6 $38,427.85 12.50%
DRG 244 NC, SC,VA, WV 38 10 $131,626.00 36.48%
DRG 245 SC 3 1 $30,350.00 34.00%
DRG 247 NC, SC 29 6 $118,615.22 38.00%
DRG 251 NC, SC, VA 39 11 $121,054.25 28.91%
DRG 253 NC, VA 31 0 $0.00 0.00%
DRG 264 NC, SC,VA, WV 43 5 $62,589.89 7.85%
DRG 287 NC, SC,VA, WV 38 6 $40,782.53 12.65%
140
DOLLARS DENIED BY DRG
DRG Region(s) No. Claims Reviewed
Claims Denied Dollars Denied CDR%
DRG 291 NC, SC, VA/WV 328 281 $2,321,607.86 77.6%
DRG 292 NC, SC, VA/WV 348 314 1636818.06 91.5%
DRG 293 NC, SC,VA, WV 29 6 $16,165.47 8.75%
DRG 392 NC, SC,VA, WV 433 386 $1,414,781.60 89.1%
DRG 392 NC, SC,VA, WV 43 9 $45,840.04 12.97%
DRG 460 NC, SC, VA 65 14 $232,949.33 17.05%
DRG 470 NC, SC,VA, WV 83 17 $241,564.45 21.09%
DRG 490 NC, SC,VA, WV 22 2 $20,760.00 11.40%
DRG 491 NC, VA, WV 8 2 $13,162.00 21.00%
DRG 493 NC, SC,VA, WV 22 5 $87,263.20 35.00%
DRG 494 NC 8 1 $10,141.93 32.00% DRG 517 VA 3 0 $0.00 0.00% DRG 641 NC, SC,VA, WV 41 12 $83,604.69 27.00%
DRG 689 NC, SC, VA/WV 278 260 $1,534,494.50 93.6%
Total 2,097 1,366 $8,284,482.98
141
ALL DRGS
Claims Reviewed 1,837
Claims Denied 1,248
Dollars Denied $6,796,098.65 CDR 67.7%
142
Cardiac DRGs
143
TOP CARDIAC DRG CERT DATA
Nat
iona
l Im
prop
er
Pay
men
t R
ate
J11
Pro
ject
ed
Err
or R
ate
J11
Pro
ject
ed
Impr
oper
P
aym
ent
Overall Part A(Inpatient Hospital PPS) 9.9% 7.7% $661,574,767
Permanent Cardiac Pacemaker Implant (242, 243, 244)
35.2% 53.2% $74,063,332
Circulatory Disorders Except AMI, W Cardiac Catheterization (286, 287)
17.1% 18.6% $24,784,696
Cardiac Defibrillator Implant W/O Cardiac Catheterization (226, 227)
40% 35.5% $17,880,435
Heart Failure & Shock (291, 292, 293) 8.3% 3.2% $8,978,901
144
WHICH DRG SHOULD I USE?
DRG 311: Angina Pectoris DRG 313: Chest Pain DRG 303: Atherosclerosis without MCC DRG 302: Atherosclerosis with MCC
145
DOLLARS AT RISK
DRG 313 DRG 302 DRG 303 Total dollars at risk
$16,122,130 $1,924,624 $5,637,162
Dollars at risk per claim
$2,072
$4,979 $2,400
146
DRG 313 NC
DRG 313 Claims Reviewed 107 Claims Denied 103 Dollars Denied $275,396.46 CDR 96% Top Granular Error(s):
Need for service/item is not medically necessary – 100%
147
DRG 313 VA/WV
DRG 313
Claims Reviewed 95 Claims Denied 93 Dollars Denied $230,896.88 CDR 98% Top Granular Error(s):
Need for service/item is not medically necessary – 95% No orders for inpatient admission – 5%
148
CODING CORONARY ARTERY DISEASE VS. ANGINA
• When a patient presents with both unstable angina and CAD and some type of intervention is performed, such as a Percutaneous Transluminal Coronary Angioplasty, the CAD is sequenced as the principal diagnosis
• The rationale for this is that unstable angina pectoris requires immediate attention and the underlying cause is the CAD
• A diagnostic test does not need to be performed in order to list the atherosclerosis as the principal diagnosis
• The provider needs only to state that CAD is the cause of the angina pectoris
Coding Clinic, Second Quarter 2004, p. 3-4 149
MS DRG 313 CHEST PAIN • MS DRG 313 results when the principal diagnosis is
chest pain, precordial pain or observation for suspected cardiovascular disease
• Since chest pain is a symptom code, certain coding rules apply: – Code chest pain as principal diagnosis when it is
followed by contrasting/ comparative diagnoses – Do not code chest pain as principal diagnosis when
a related definitive diagnosis has been established
Coding Clinic 4th Q 2008 302-304
150
PRINCIPAL DIAGNOSIS
Myocardial Infarction (MI) Angina Coronary Artery Disease Costochondritis Gastroesophageal Reflux
Disease Cholecystitis Cholelithiasis Viral Syndrome Cocaine Poisoning
Pleurisy Pulmonary Hypertension Esophageal Spasm Gastritis Hiatal Hernia Constipation Anxiety Attack Bronchitis Cardiac Device, Implant or
Graft Complication
151
Change the principal diagnosis when the underlying etiology of the chest pain is determined. Look for these possibilities:
http://www.faircode.net/blog-ms-drg-of-the-month/ms-drg-of-the-week-ms-drg-313-chest-pain
DOCUMENTATION TO SUPPORT THE PRINCIPAL DIAGNOSIS
When reviewing these charts, determine whether or not a cause was established for the chest pain
If a cause was established, the principal diagnosis becomes the cause of the chest pain, since chest pain is a symptom
Chest Pain ICD-9-CM CODING GUIDELINES
152
CHEST PAIN GUIDELINES 2012 ACCF/AHA Focused Update of the
Guideline for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update)
Circulation August 14, 2012 vol. 126 no. 7 875-910
153
DRG EXAMPLE 66 year old patient presented with altered
mental status and chest ‘tightness’ Past Medical History Arthritis Diabetes HTN
154
COURSE OF TREATMENT Elevated Troponin 0.21 Ruled in for non-Q wave MI Transferred to admitting facility for
cardiac catheterization
155
HOSPITAL CODING ICD-9 code 786.59 Chest pain; other Procedure code 37.22 Left Heart Cardiac Catheterization
DRG code 287 Circulatory disorders except AMI, W
Cardiac Catheterization W/O MCC
156
WRONG DIAGNOSIS CODE Change ICD 9 code to 410.71 Subendocardial infarction, initial episode of
care Change DRG to 281 Acute myocardial infarction, discharged
alive W/CC
157
CHEST PAIN AFTER MYOCARDIAL INFARCTION
Chest Pain Less Than 8 Weeks After a Myocardial Infarction: DRG 280 - Acute Myocardial Infarction, Discharged
Alive W MCC DRG 281 - Acute Myocardial Infarction, Discharged
Alive W CC DRG 282 - Acute Myocardial Infarction, Discharged
Alive W/O CC/MCC DRG 283 - Acute Myocardial Infarction, Expired W
MCC DRG 284 - Acute Myocardial Infarction, Expired W CC DRG 285 - Acute Myocardial Infarction, Expired W/O
CC/MCC
158
CHEST PAIN AFTER MYOCARDIAL INFARCTION
DRG: Acute Myocardial infarction, subsequent episode: 341 – with MCC 315 – with CC 316 – without MCC/CC
159
Heart Failure and Shock
• 291 Heart failure & shock with MCC
• 292 Heart failure & shock with CC
• 293 Heart failure & shock without CC/MCC
160
DOLLARS AT RISK
291 292 293 Total
dollars at risk
$98,302,153 $78,721,246 $13,976,208
Dollars at risk per
claim
$7,299 $4,627
$4,627
161
DRG 291 NC
DRG 291 J11 – NC Claims Reviewed 118
Claims Denied 107 Dollars Denied $902,471.45
CDR 89% Top Granular
Error(s):
Need for service/item is not medically necessary – 99.0% Information submitted does not support dates of service
billed – 1.0%
162
DRG 291 SC
DRG 291 J11 – SC Claims Reviewed 95
Claims Denied 85 Dollars Denied $682,282.17
CDR 89% Top Granular
Error(s):
Need for service/item is not medically necessary – 97.7%
Records not submitted timely – 2.3%
163
DRG 291 VA/WV
DRG 291 J11 – VA/WV Claims Reviewed 95
Claims Denied 85
Dollars Denied $682,282.17 CDR 89%
Top Granular Error(s):
Need for service/item is not medically necessary – 91.8%
Information submitted does not support dates of service billed – 3.5% No orders for inpatient admission –
4.7%
164
DRG 292 SC
DRG 292 DRG 292 SC Claims Reviewed
96
Claims Denied 87 Dollars Denied $444,913.73
CDR 92% Top Granular
Error(s): Need for service/item is not medically necessary – 100%
165
DRG 292 NC
DRG 292 DRG 292 NC Claims Reviewed 127
Claims Denied 116 Dollars Denied $620,879.93
CDR 93% Top Granular
Error(s): Need for service/item is not medically necessary – 99.1%
No orders for inpatient admission – 0.9%
166
DRG 292 SC
DRG 292 DRG 292 SC Claims Reviewed 96
Claims Denied 87 Dollars Denied $444,913.73
CDR 92% Top Granular
Error(s): Need for service/item is not medically necessary – 100%
167
DRG 292 VA/WV
DRG 292 DRG 292 VA/WV Claims Reviewed 125
Claims Denied 111
Dollars Denied $571,024.40
CDR 89%
Top Granular Error(s):
Need for service/item is not medically necessary – 91.5%
No orders for inpatient admission – 4.7%
Information submitted does not support dates of service billed – 3.8%
168
DRG 293 NC
DRG 293 DRG 293 NC Claims Reviewed 114
Claims Denied 108 Dollars Denied $387,338.94
CDR 95% Top Granular
Error(s): Need for service/item is not medically necessary – 93.1%
Information submitted does not support dates of service billed –
1.0% No response to ADR within 30 days
– 5.9%
169
DRG 293 SC
DRG 293 DRG 293 SC Claims Reviewed 100
Claims Denied 99
Dollars Denied $334,439.11 CDR 99%
Top Granular Error(s):
Need for service/item is not medically necessary – 93.6%
No response to ADR within 30 days – 6.4%
170
DRG 293 VA
DRG 293 DRG 293 VA Claims Reviewed 67
Claims Denied 58 Dollars Denied $186,475.24
CDR 86% Top Granular
Error(s): Need for service/item is not medically necessary – 100%
171
DRG 293 WV DRG 293 DRG 293 WV
Claims Reviewed 39 Claims Denied 39 Dollars Denied $119,385.82
CDR 100% Top Granular
Error(s):
Need for service/item is not medically necessary – 81%
No orders for inpatient admission – 9.5%
Information submitted does not support dates of service
billed – 9.5%
172
HOW DOES THE BLOOD FLOW?
http://www.phschool.com/science/biology_place/biocoach/cardio1/intro.html
173
CHF DOCUMENTATION SUGGESTIONS
Describe clinical signs and symptoms (e.g., exertional dyspnea, orthopnea, peripheral edema, pulmonary rales or crackles, or jugular vein distention, etc.)
Document work-up (e.g., chest x-ray, EKG, Swan-Ganz, echocardiogram, etc.)
Document treatment (e.g., diuretics, ACE inhibitors, digitalis, beta-blockers, O2, morphine sulfate, monitoring input and output, daily weights, etc.)
“Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from website: http://www.hce.org/medicare/mcareHPMP.html
174
CHF DOCUMENTATION SUGGESTIONS
Etiology (e.g., valvular heart disease, renal failure with volume overload, congestive cardiomyopathy, myocardial ischemia, new onset atrial fibrillation, etc.)
Note LVEF (Left ventricular ejection fraction), assessment for ACE inhibitor (angiotensin-converting-enzyme inhibitor) use, and contraindications for non-use of ACE inhibitors
“Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from website: http://www.hce.org/medicare/mcareHPMP.html
175
SYMPTOMS AND SIGNS TYPICAL OF HEART FAILURE
Symptoms Signs Typical More specific
Breathlessness Elevated jugular venous pressure
Orthopnea Hepatojugular reflux Paroxysmal nocturnal
dyspnoea Third heart sound (gallop
rhythm) Reduced exercise tolerance Laterally displaced apical
impulse Fatigue, tiredness, increased
time to recover after exercise
Cardiac murmur
Ankle swelling
176
SYMPTOMS AND SIGNS TYPICAL OF HEART FAILURE
Symptoms Signs Less typical Less Specific
Nocturnal cough Peripheral edema (ankle, sacral, scrotal)
Wheezing Pulmonary crepitations
Weight gain (>2 kg/week) Reduced air entry and dullness to percussion at lung bases (pleural effusion)
Weight loss (in advanced heart failure) Tachycardia
Bloated feeling Irregular pulse
Loss of appetite Tachypnea (>16 breaths/min)
Confusion (especially in the elderly) Hepatomegaly
Depression Ascites
Palpitations Tissue wasting (cachexia)
Syncope
177
CONGESTIVE HEART FAILURE (CHF) Document the criteria that substantiate CHF:
Results Of The Chest X-ray Presence Of Dyspnea With Mild Exercise Presence Of Rales Paroxysmal Nocturnal Dyspnea Orthopnea Fatigue With Exertion Jugular Vein Distention Ankle Swelling Pitting Edema Of The Lower Extremities
TMF® Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
178
TYPE OF HEART FAILURE
Document if known: • Systolic • Diastolic • Congestive, unspecified
TMF® Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.
179
IS 291-293 THE CORRECT DRG?
If the patient….. Consider DRG…. Have acute MI?
DRG 280-282 if
discharged alive 283-284 if expired
Have a pulmonary embolism?
DRG 175-176
Did patient have major
cardiovascular procedure?
DRG 237-238
180
Pacemakers
181
USE THE CORRECT PACEMAKER DRG
182
Temporary pacemaker and permanent pacemakers are different DRGs
Replacing a pacemaker is not the same as inserting a new pacemaker
USE THE CORRECT PACEMAKER DRG
DRGs 242 -244 are for Permanent Cardiac Pacemaker Implant when a pacemaker was not in place already
183
USE THE CORRECT PACEMAKER DRG
DRGs 260-262 are for Cardiac pacemaker revision (not removed)
184
USE THE CORRECT PACEMAKER DRG
DRGs 258-259 Cardiac pacemaker device replacement of an existing pacemaker
185
USE THE CORRECT PACEMAKER DRG
Commonly Assigned DRGs for Temporary Pacemaker Procedures are DRGs 308-310
(Cardiac Arrhythmia and Conduction Disorders)
186
DOLLARS AT RISK
DRG 308 DRG 309
Total dollars at risk
$26,232,057 $25,219,505
Dollars at risk per claim
$6,026 $3,614
187
SINGLE CHAMBER AND DUAL CHAMBER PERMANENT CARDIAC PACEMAKERS
Single chamber pacemakers typically target either the right atrium or right ventricle
Dual chamber pacemakers stimulate both the right atrium and the right ventricle
188
https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R161NCD.pdf Change Request 8525 Transmittal 161
SINGLE CHAMBER PACEMAKER
http://www.ohsu.edu/xd/health/services/heart-vascular/getting-treatment/test-procedures/images/pacemaker-1.gif
189
DUAL CHAMBER PACEMAKER
http://stanfordhospital.org/images/greystone/heartCenter/images/ei_0344.gif
190
COVERAGE GUIDELINES
Nationally Covered Indications Nationally Non-Covered Indications Diagnoses for Pacemaker Placement https://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/Downloads/R161NCD.pdf
191
COMMON DUAL-CHAMBER PACEMAKER ERRORS
Common Dual-Chamber Pacemaker Errors Identified Through the CERT Review Process No documentation to support the choice of a
dual-chamber rather than a single-chamber pacemaker
Dual-chamber pacemaker implantation in patients with a clear contraindication, such as chronic atrial fibrillation
Hospitalization for Elective Cardiac Electrophysiology Procedures August 13, 2013 Heart rhythm Society
192
CONDITIONS THAT MAY WARRANT INPATIENT ADMISSION STATUS
Urgent implantation of any device • Hospitalization is triggered by onset of
symptoms or detection of a potentially serious condition, i.e. syncope, heart block, ventricular tachycardia
• Any resynchronization therapy device implant
• Device implantation during hospitalization for another problem
PHYSICIAN GUIDELINES Inpatient Admission Criteria for Implantable Cardioverter-Defibrillator and Pacemaker Placement Effective 07-01-2013
193
CONDITIONS THAT MAY WARRANT INPATIENT ADMISSION STATUS
Required lead extraction as part of the implantation or re-implant procedure
Complex anticoagulation needs that require admission for the peri-surgical management of these anticoagulation issues
194
CONDITIONS THAT MAY WARRANT INPATIENT ADMISSION STATUS
Pacemaker/implantable cardiac defibrillator (ICD) implants or electrophysiologic(EP)/ ablation in patients with uncontrolled co-morbidities including, but not limited to, renal insufficiency, angina, congestive heart failure, severe chronic obstructive pulmonary disease (COPD), and electrolyte disturbances in whom in the attending physician’s best judgment requires inpatient admission for optimal medical management
The physician must clearly document in the medical record the comorbidities, whether they are uncontrolled or of recent onset, and the treatment plan to address these issues
PHYSICIAN GUIDELINES Inpatient Admission Criteria for Implantable Cardioverter-Defibrillator and Pacemaker Placement Effective 07-01-2013
195
CONDITIONS THAT MAY WARRANT INPATIENT ADMISSION STATUS
New ICD implants or patients undergoing ICD generator replacement with concomitant lead replacement who are New York Heart Association (NYHA) class II, III or IV
Patients undergoing an atrio-ventricular junction (AVJ) ablation and acute device implant due to the need for extended monitoring for potentially life-threatening arrhythmias
Hospitalization for Elective Cardiac Electrophysiology Procedures August 13, 2013 Heart rhythm Society
196
CONDITIONS THAT MAY WARRANT INPATIENT ADMISSION STATUS
Determination of hospital status should be a clinical decision made by the patient’s attending physician after a careful consideration of multiple clinical factors including, but not limited to: Specific procedure planned Urgency of the procedure
Hospitalization for Elective Cardiac Electrophysiology Procedures August 13, 2013 Heart rhythm Society
197
CONDITIONS THAT MAY WARRANT INPATIENT ADMISSION STATUS
Hemodynamic stability of the patient Patient co-morbidities and the likelihood
and consequences of complications arising from the procedure
The rationale for the decision should be documented in the medical record
198
Hospitalization for Elective Cardiac Electrophysiology Procedures August 13, 2013 Heart rhythm Society
Septicemia/Sepsis
• 870 Septicemia w/ MV 96+ hours • 871 Septicemia w/o MV 96+ hours w/
MCC • 872 Septicemia w/o MV 96+ hours
w/o MCC
199
DEFINITIONS
Systemic Inflammatory Response Syndrome Sepsis Severe Sepsis Septic Shock Septicemia Bacterima
200
SIRS Systemic inflammatory response
syndrome (SIRS) is an inflammatory state affecting the whole body
May be due to: Infection Burn Trauma
201
SEPSIS Sepsis can have many causes but is often due
to an infection when an unusually large number of microorganisms are present in a body cavity or in a patient’s bloodstream for which there is no pathological response
In many cases, the microorganisms are found in a body cavity that is normally sterile
Sepsis and Septicemia: Clear Up Coding and Documentation Confusion http://www.hcpro.com/content/241083.pdf
202
SEVERE SEPSIS
Severe sepsis refers to sepsis associated with organ dysfunction or failure, hypoperfusion (i.e., decreased blood flow through an organ), or hypotension (i.e., abnormally low blood pressure)
Sepsis and Septicemia: Clear Up Coding and Documentation Confusion http://www.hcpro.com/content/241083.pdf
203
SEPTIC SHOCK Sepsis can lead to septic shock or organ dysfunction or
failure without treatment Is a sudden disturbance of mental or physical
equilibrium and is a condition of hemodynamic and metabolic disturbance marked by the circulatory system’s failure to maintain adequate blood flow to vital organs
Inadequate blood volume (i.e., hypovolemic shock) may cause septic shock, as can inadequate cardiac function (i.e., cardiogenic shock) or inadequate vasomotor function (i.e., neurogenic shock)
Sepsis and Septicemia: Clear Up Coding and Documentation Confusion http://www.hcpro.com/content/241083.pdf
204
BACTEREMIA VS. SEPTICEMIA
Bacteremia is the presence of bacteria in the blood and denotes only an abnormal laboratory finding
Septicemia is the presence of microorganisms or their toxins in the blood
Bacteremia and Septicemia are not necessarily the same
205
A QUICK REFERENCE A quick reference guide is available at: http://www.acsteam.net/sites/acs/uplo
ads/documents/newsletters/sepsis_newsletter_FY13.pdf
206
DOCUMENTATION TIPS
According to the American College of Chest Physicians and the Society of Critical Care Medicine, the clinical manifestations include: • Fever of greater than 100.4 or hypothermia
with a temperature of less than 98.6 • Leukocytosis, white blood cell count of
greater than 12,000 cells per cubic millimeter
Wiedemann, Lou Ann. "Coding Sepsis and SIRS." Journal of AHIMA 78, no.4 (April 2007): 76-78.
207
DOCUMENTATION TIPS
Leukopenia, white blood cell count of less than 4,000 cells per cubic millimeter Tachycardia Hyperventilation
208
DOCUMENTING CONSEQUENCES OF SEPSIS Acute Kidney Failure - not insufficiency Acute Respiratory Failure – not hypoxia Critical Illness Myopathy – not weakness DIC (Disseminated intravascular coagulation) –
not coagulopathy Encephalopathy – not AMS (Achalasia
microcephaly) Acute Hepatic Failure – Not Elevated Liver
Enzymes Note: State ALL manifestations of Sepsis in the Discharge Diagnosis!
Sepsis – Impact of Coding upon Metrics Paul Evans, RHIA, CCS, CCS-P, CCDS Manager, CDI
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ORGAN SYSTEMS • Review carefully the documentation regarding the
following organ systems: – Lungs: early fall in arterial PO2 (Arterial Partial
Pressure of Oxygen) , ARDS (Acute Respiratory Distress Syndrome), capillary leakage into alveoli, tachypnea, hyperpnea, acute respiratory failure
– Kidneys: acute renal failure or acute kidney injury, olguria, anuria, azotemia, proteinuria
Note: Clinical information, queries help reduce confusion when coding sepsis
October 8, 2013 http://www.justcoding.com/297100/clinical-information-queries-help-reduce-confusion-when-coding-sepsis
210
ORGAN SYSTEMS Liver function: acute hepatic necrosis,
elevated levels of serum bilirubin, alkaline phosphatase, cholestatic jaundice
Clotting mechanism: disseminated intravascular coagulopathy often associated with thrombocytopenia
211
CODING TIPS Know how to apply sequencing guidelines Wait for the discharge summary If a physician documents a diagnosis as
probable, suspected, likely, questionable, possible, or still to be ruled out at the time of discharge, coders can report the condition as if it existed or was established
Seven savvy tips for coding sepsis and SIRS May 22, 2012
212
CODING CONCEPTS All coding is based on physician documentation Do not code on the basis of laboratory or radiological
findings alone ICD-9-CM code assignment issues related to
inconsistent, missing, conflicting or unclear documentation must be resolved by the provider
Whenever there are concerns about a diagnosis and/or treatment, query the physician
Coding Septicemia, SIRS, and Sepsis Copyright 2008 American Health Information Management Association. All rights reserved
213
SEPSIS W/ UNDERLYING INFECTION
Diagnosis DRG Sepsis due to Cellulitis 872
SIRS criteria met due to infectious process.
Clarify to determine whether sepsis actually POA (present
on admission), but not documented on admission. Were SIRS criteria present
on admission?
Cellulitis w/ Sepsis (sepsis not POA)
602
Sepsis due to Urinary Track Infection
872
UTI w/ Sepsis (sepsis not POA)
689
Sepsis due to Pneumonia (any type)
871
Complex Pneumonia w/ Sepsis (sepsis not POA)
177
Simple Pneumonia w/ Sepsis (sepsis not POA)
193
214
SEPSIS AS COMPLICATION Diagnosis DRG
Sepsis from Postoperative Infection 862
Physician documentation must
link infection and device or
identify postoperative infection
Postoperative Infection (not identified as sepsis) 863
Sepsis from Enterostomy / Colostomy Infection 393
Enterostomy / Colostomy infection (not identified as sepsis)
395
Sepsis due to UTI from Foley 698
UTI from Foley (not identified as sepsis) 700
UTI from Foley w/ Sepsis (sepsis not POA) 698
Sepsis due to Ventricular Assist Device or Central Venous Catheter
314
Ventricular Assist Device or Central Venous Catheter Infection (not identified as sepsis)
316
215
VENT PATIENTS
Diagnosis DRG
Respiratory Dx on Mechanical Vent 96+ hrs
207
Carefully count vent times —
includes weaning time
Respiratory Dx on Mechanical Vent <96 hrs
208
Sepsis on Mechanical Vent 96+ hrs
870
Sepsis due to Pneumonia (or other MCC) on Mechanical
Vent <96 hrs
871
Sepsis due to non-MCC condition on Mechanical
Vent <96 hrs
872
MS-DRG News. Administrative Consultant Services, LLC. Issue date January 2, 2013. http://www.acsteam.net/sites/acs/uploads/documents/newsletters/sepsis_newsletter_FY13.pdf
216
DRG 459-460
Spinal Fusion
217
DRG 459-460 CERT DATA
PART A (INPATIENT HOSPITAL PPS) Type of
Service
Nat
iona
l Im
prop
er
Pay
men
t R
ate
J11
Pro
ject
ed
Err
or R
ate
J11
Pro
ject
ed
Impr
oper
P
aym
ent
Spinal Fusion Except Cervical (459, 460)
7.8% 13.6% $20,420,264
218
DRG 460
$91,990,598 dollars at risk Dollars at risk per claim are $19,788
219
DRG 460 NC
DRG 293 DRG 460 NC Claims Reviewed 137
Claims Denied 90 Dollars Denied $2,246,323.73
CDR 65% Top Granular
Error(s):
Need for service/item is not medically necessary – 98.6% Information submitted does not support dates of service
billed – 1.4 %
220
DRG 460 VA/WV
DRG 293 DRG 460 VA/WV
Claims Reviewed 114
Claims Denied 78
Dollars Denied $1,895,448.24
CDR 65%
Top Granular Error(s):
Need for service/item is not medically necessary – 98.8%
No orders for inpatient admission – 0.6% Information submitted does not support
dates of service billed – 0.6 %
221
SPINAL FUSION Spinal fusion is a surgical procedure
used to correct problems with the small bones in the spine (vertebrae)
It is essentially a "welding" process The basic idea is to fuse together the
painful vertebrae so that they heal into a single, solid bone
222
STRATEGIES TO IMPROVE DOCUMENTATION The following strategies could reduce audit errors
caused solely by information missing from the hospital record: Hospitals may proactively obtain previous
diagnostic and therapeutic records from the surgeon and other practitioners
These records may include pertinent: Physical assessment of condition, including pain
level Physician history and physical
223
STRATEGIES TO IMPROVE DOCUMENTATION
– Progress notes – “Consultations” – Physical and occupational therapist evaluations
and therapy notes – Radiology reports – Therapeutic procedure notes, such as joint
injections • Practitioners should either create clinically
meaningful inpatient records or supply the hospital with relevant documents from their outpatient records
224
STRATEGIES TO IMPROVE DOCUMENTATION
This list contains examples of documentation that, if clearly documented, may help support payment for spinal fusion-related hospital care Previous non-surgical treatment, including, but not limited
to:
Physical therapy Occupational therapy Joint injections Analgesia Assistive devices
225
STRATEGIES TO IMPROVE DOCUMENTATION • Physical examination clearly documenting the
progression of any: – Neurological deficits – Upper or lower extremity strength – Activity modification – Pain levels
• Diagnostic test results and interpretations, such as Magnetic Resonance Imaging (MRI)
226
DOCUMENTATION EXAMPLE
Date: 12/15/20XX Chief complaint: Low back pain radiating
down legs History: Patient has spondylolisthesis,
gradually progressing with increased spinal stenosis over the past 5–7 years. Most recent MRI (11/2/11) shows spondylolisthesis at L3-L4 and L4-L5 with moderately severe stenosis at both levels
227
DOCUMENTATION EXAMPLE Patient has been treated as follows:
– Ibuprofen 400 mg QID since January (allergic to codeine); PT 3 x week from 6/15/11 to 9/30/11
– Epidural steroid injections in October and facet joint injections in November gave only minor temporary improvement
– Pain is now constant at level 5/10 when sitting, but 9/10 on rising or ambulation and radiates down both legs
– Is slightly better with water therapy – The pain keeps patient awake at night with severe
stabbing, throbbing and aching
228
DOCUMENTATION EXAMPLE (CON’T)
Physical exam: Patient has limited lumbar range of motion and
severe pain on palpation Knee and ankle reflexes are reduced to 1+ (they
were 2+ in October) Patient has diminished sensation in lower legs, but
strength and pulses are within normal limits The patient has positive sitting root and leg raises
bilaterally Faber Four is negative bilaterally
229
DOCUMENTATION EXAMPLE (CON’T) Impression: Worsening pain, deteriorating reflexes and
significant interference with function Current therapy ineffective Lumbar fusion is only option for pain
control Orders: Admit to inpatient care for L3-L4 and L4-
L5 lumbar fusion
230
TELL A GOOD STORY
Documentation should: Tell a good story that anyone can
understand substantiating the medical necessity of the procedure for that particular patient
Suppose the physician has treated the patient for two years for back pain and leg problems, but medication and injections aren’t working Spinal Fusion Is New PEPPER Target, With Focus on Medical Necessity of Procedures . Report on Medicare Compliance February 6, 2012. Copyright © 2012 by Atlantic Information Services, Inc.
231
TELL A GOOD STORY The physician knows why the patient requires
surgery and the procedure is legitimate, but the physician may not incorporate the outpatient notes into the inpatient record
So the documentation is thin and the reviewer is left wondering why the patient needed surgery
232
DOCUMENTATION
By far the most common reason for denial has been a lack of specific information about conservative care before the surgical intervention
233
LACK OF DOCUMENTATION Statements such as:
“Failed outpatient therapy, admit for spinal fusion,” are simply not sufficient evidence of medical necessity for the admission or the surgery
234
LACK OF DOCUMENTATION History of illness from onset to decision
for surgery Prior courses of treatment and results Current symptoms and functional
limitations Physical exam detailing objective
findings supporting history of illness Results of special tests
Lumbar Fusion procedures and RAC Audits: What you need to Know Christopher P Kauffman Spine line March-April 2013
235
NEED FOR SERVICES NOT MEDICALLY AND REASONABLY NECESSARY
No documentation of pain impacting the functional ability of beneficiary
No documentation of conservative measures/treatments failed (without specific interventions given) or neurological impairment-spinal stenosis
No X-ray, CT or MRI results submitted detailing mechanical instability, deformity of the lumbar spine or neural compression
236
NEED FOR SERVICES NOT MEDICALLY AND REASONABLY NECESSARY
There were no biopsy or LP results submitted showing significant infection that would require this type of procedure
The operative procedure was not included in the documentation submitted (Thoracic, Lumbar, Sacral Fusion)
237
PARTNERS IN COMPLIANCE
238
COMPLIANCE COMMITMENT
Palmetto GBA is diligent to provide education on CMS program safeguards through: Publications Customer service Compliance initiatives Website
239
COMPLIANCE COMMITMENT Ensures an understanding of the importance
of being compliant with: Documenting their services correctly Filing claims properly with correct
information Adhere to program guidelines and coverage
policies
240
COMPLIANCE COMMITMENT All these efforts help ensure Medicare contractors
and providers uphold and continue to work toward Paying it right the first time, every time!
Eliminates the appeals process!
Increases staff productivity by working on billing new claims as opposed to completing redetermination request forms and pulling medical records
Increases provider cash flow by having claim paid right the first time it is submitted to Palmetto GBA
241
COMPLIANCE – ANALYSIS CMS Division of Data Analysis activities
include: Program for Evaluating Payment Patterns
Electronic Report (PEPPER) First-Look Analysis Tool for Hospital
Outlier Monitoring (FATHOM) Comparative Billing Report (CBR)
242
COMPLIANCE - PEPPER
Comparative data report provides hospital specific Medicare data statistics for discharges vulnerable to improper payments Support a hospital’s compliance efforts by
identifying where it’s an outlier for risk areas
Data helps identify potential overpayments and underpayments
243
COMPLIANCE - PEPPER
• Created by TMF Health Quality Institute to: – Prioritize hospital specific findings – Provide guidance on areas in which a hospital may
want to focus auditing/monitoring efforts – Identifies areas of potential over/under coding – Questionable medical necessity of admission
• Pepper Resources are available at:
http://www.pepperresources.org/
244
COMPLIANCE - FATHOM CMS provides each State with hospital-
specific Medicare claims data statistics Identify areas having high payment errors Statistics serve as relative indicators of payment
errors FATHOM reports include:
Short-Term acute care inpatient PPS hospitals Long-term acute care inpatient PPS hospitals CAHs, IRFs and IPF
FATHOM articles at: www.palmettogba.com
245
COMPLIANCE – AVOID ERRORS
Be proactive rather than reactive! By reviewing errors after claim submission
Staff struggles to deal with errors leading to bill holds, rebilling, coding problems, and denials
Shift responsibility from after submission to before - while patient is being treated Focus on preventing errors in first place through proper
and appropriate documentation
246
COMPLIANCE – AVOID ERRORS Core of billing compliance is that each and
every physician service performed : Meets criteria for being reasonable and medically
necessary Must be supported by appropriate documentation that
leads to proper coding
It is critical to have complete and accurate medical records!
247
WHAT ARE CBRS?
• CBR letters are intended to show providers how their billing patterns compare to their peers
• Not intended to be punitive or sent as an indication of fraud
• Intended to be a proactive statement that will help the provider identify potential errors in their billing practice
• The last CBR letters Provider Outreach & Education sent out were for Evaluation & Management services
248
TWO TYPES OF CBRS
• CMS contractor issued CBRs – developed and disseminated under contract by eGlobalTech, a Federal services firm based in Arlington, VA.
• Palmetto GBA issued CBRs – developed and disseminated by Palmetto GBA
249
IF YOU RECEIVE EITHER TYPE OF CBR
• Evaluate your agency’s billing patterns to ensure the claims are billed accurately
• Examine the issue identified in the report to see if there are reasons your agency is an outlier in the data
• Evaluate the CPT/HCPCS/ICD-CM codes used related to the issue in the report to verify the most appropriate code is used
250
HOW ARE CBRS USED?
• Contains peer comparisons which can be used to provide helpful insights into their coding and billing practices
251
HOW CAN CBRS HELP PROVIDERS?
• The information provided is designed to help the provider prevent improper billing and payment
252
CBR RESOURCES
http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf
253
CMS IOM Publication Program Integrity Manual,
Chapter 3, Section 3.7.2
RESCUE YOUR RESOURCES
254
OUR GOAL IS YOUR GOAL
• Reduce errors • Get claims processed and paid with the first
submittal • Reduce appeals • Reduce all errors including reducing the CERT error
rate • Save money!
255
TOTAL J11 PART A CLAIMS RECEIVED
Part A Claims Workload
(June, 2013 – May 2014)
TOTAL 13,577,460
256
How many claims did you submit last year?
NON CERT APPEALS
Part A Appeal
Requests Redetermination
Receipts Reopening Receipts Total
Total 88,748 858 89,606
257
How many appeals did you submit last year?
CERT APPEALS
J11 Part A CERT Appeals
Year State
Total CERT Appeals
Completed Total
Overturned Reversal % at 1st level of Appeal Overturned at higher level
2013 WV 26 7 26.92% 4
VA 46 15 32.61% 1
SC 243 83 34.16% 6
NC 73 31 42.47% 6
Total 388 136 35.05% 17
2014 WV 4 2 50.0% 0
VA 10 1 10.00% 0
SC 50 15 30.00% 0
NC 23 4 17.39% 0
Total 87 22 25.29% 0
258
A CALL TO ACTION!
259
A CALL TO ACTION! • Use the HISC and DMAIC processes • Develop and implement policies, procedures, and
practices designed to ensure compliance • Take advantage of educational opportunities • Utilize our website resources to enhance your
Medicare knowledge • Perform a complete and prompt review of medical
records requests • Deliver documentation within the time frame
requested • Be proactive and ensure the provider billing staff are
responsible for completing pre bill audits
260
EDUCATIONAL RESOURCES
261
E-MAIL UPDATES
Please be sure that you register for e-mail updates from Palmetto GBA
The ListServ messages are free The only requirement is that you register You may choose the type of updates you
receive Link to register is located on the
Palmetto GBA Part A website at the top of the page under “Email Updates”
262
EDUCATIONAL RESOURCES Gateway to customized learning!
Medicare Advisory and Articles Frequently Asked Questions (FAQs) Ask the Contractor Teleconference (ACT) Listserv E-Mail Updates Workshops and teleconferences Online courses via ON24 Web chat is available Monday – Wednesday
10:30 a.m. – 12:00 p.m. and 2:00 p.m. – 3:00 p.m.
263
EDUCATIONAL RESOURCES Provider Outreach & Education (POE)
Education Requests Requested educational sessions provide
education targeted to meet particular needs Complete the form found under Forms link
on J11 Part A website
264
ONLINE PROVIDER SERVICES (OPS) Online Provider Services (OPS) Free Internet-based, self-service portal
Real-time information Web access for: Eligibility Claim Status Remittance Advices (RAs) Financial Information (Showing the last 3 Checks on the Payment Floor)
265
OPS Eligible to participate in OPS if you have a
signed EDI Enrollment Agreement on file If you already submit claims electronically,
you do not need to submit new agreement OPS application is user-friendly and easy-to-
use Help buttons available on each page link to
Frequently Asked Questions (FAQs) and other helpful information
266
OPS
Enhanced benefits for providers: e-Check e-Offset Ability to file an appeal online
using OPS
267
GOING BEYOND DIAGNOSIS Palmetto GBA is addressing the need to
improve the quality of health care records by incorporating the concepts of the International Classification of Functioning, Disability and Health (ICF) into health care policy and education
Harry Feliciano, M.D. our Senior Part A Medical Director, is at the forefront of this process
268
GOING BEYOND DIAGNOSIS To learn more about Going Beyond
Diagnosis and how to communicate better with Palmetto GBA and other third-party payers more efficiently, visit the Going Beyond Diagnosis blog www.palmettogba.com/goingbeyonddi
agnosisblog
269
GOING BEYOND DIAGNOSIS BLOG
Palmetto GBA and Provider DMAIC activities are posted on GBD blog:
http://palmgba.com/gbd/category/dmaic/ Twitter@BeyondDx
270
SOCIAL NETWORKING
Ways to Stay Connected
271
TIME FOR QUESTIONS
272
Thank you for attending.
Please take a few moments to complete the post test and
evaluation.
Post Test Evaluation
273