documentation updates for physicians - sjhsyr.org · • cfr §424.13 14 . ... – as specified in...
TRANSCRIPT
* HFMA staff and volunteers determined
that this product has met specific criteria
developed under the HFMA Peer Review
Process. HFMA does not endorse or
guarantee the use of this product.
©2013 Executive Health Resources, Inc. All rights reserved.
AHA Solutions, Inc., a subsidiary of the American Hospital
Association, is compensated for the use of the AHA marks and for
its assistance in marketing endorsed products and services. By
agreement, pricing of endorsed products and services may not be
increased by the providers to reflect fees paid to the AHA.
Documentation Updates
for Physicians
CMS IPPS 2014 Final Rule
1
Agenda
• Background
• FY2014 IPPS Compliance Requirements
– Physician order
– “2-Midnight Rule”
– Medical Necessity Documentation and Physician
Certification
• Summary
2
IPPS Key
Requirements/Changes
• The Time the patient is expected to stay in
the hospital (2 midnights is guide)
• The Order to “admit to inpatient” or “refer
for observation/outpatient”
• The Documentation & Certification of
medical necessary to support the patient’s
inpatient admission.
3
* HFMA staff and volunteers determined
that this product has met specific criteria
developed under the HFMA Peer Review
Process. HFMA does not endorse or
guarantee the use of this product.
©2013 Executive Health Resources, Inc. All rights reserved.
AHA Solutions, Inc., a subsidiary of the American Hospital
Association, is compensated for the use of the AHA marks and for
its assistance in marketing endorsed products and services. By
agreement, pricing of endorsed products and services may not be
increased by the providers to reflect fees paid to the AHA.
Time: 2 Midnight
Expectation
4
• “Benchmark of 2 midnights”
– “the decision to admit the beneficiary should be based on the cumulative time
spent at the hospital beginning with the initial outpatient service. In other
words, if the physician makes the decision to admit after the beneficiary arrived
at the hospital and began receiving services, he or she should consider the
time already spent receiving those services in estimating the beneficiary’s
total expected length of stay.”
Page 50946, IPPS
• “Presumption of 2 midnights”
– “Under the 2-midnight presumption, inpatient hospital claims with lengths of
stay greater than 2 midnights after formal admission following the order
will be presumed generally appropriate for Part A payment and will not be
the focus of medical review efforts absent evidence of systematic gaming,
abuse or delays in the provision of care…”
Page 50949, IPPS
Benchmark vs. Presumption
5
Exceptions to the
2 Midnight Rule
• Medicare Inpatient only Surgical List
• AMA
• Transfers
• Death
• Other Rare exceptions
6
Expectation/Certification
• Physician must document if they expect the patient’s
hospital care to span more or less than 2 midnights
– Treatment time spent in the ED can be counted towards
2 midnights
• Guidelines:
– If you believe the patient will be discharged same day
or the day following hospitalization, consider
ordering Outpatient or Observation
– If you believe the patient will NOT be ready for
discharge the day after hospitalization, consider
ordering Inpatient
7
* HFMA staff and volunteers determined
that this product has met specific criteria
developed under the HFMA Peer Review
Process. HFMA does not endorse or
guarantee the use of this product.
©2013 Executive Health Resources, Inc. All rights reserved.
AHA Solutions, Inc., a subsidiary of the American Hospital
Association, is compensated for the use of the AHA marks and for
its assistance in marketing endorsed products and services. By
agreement, pricing of endorsed products and services may not be
increased by the providers to reflect fees paid to the AHA.
Physician Orders
8
• For payment of hospital inpatient services under
Medicare Part A, the order must specify the
admitting practitioner’s recommendation to admit
“to inpatient,” “as an inpatient,” “for inpatient
services,” or similar language specifying his or
her recommendation for inpatient care
Page 50942, IPPS
• “Admit to Tower 7” or “Admit to Dr. Smith” are
not recommended
Physician Order
9
Some commenters commented that their current processes provide for admission “to case management” or “to utilization
review” rather than specifying inpatient admission.
Response: “As we discussed above, many public comments from physicians indicated that they believed the physician should be involved in the determination of patient status, and we agree. To reinforce this policy and reduce confusion among hospitals, beneficiaries, and physicians on the differences between outpatient observation and inpatient services, we are providing in this final rule that the order for inpatient admission must specify admission “to or as an inpatient.”
Page 50942, IPPS
Physician must be involved in
Order Determination
10
Physician Order Clarification
• Qualifications of the ordering/admitting practitioner: – At some hospitals, practitioners who lack the authority to admit inpatients under either
State laws or hospital by‐laws may nonetheless frequently write the sets of admitting orders that define the initial inpatient care of the patient. In these cases, the ordering practitioner need not separately record the order to admit ….. the order must identify the qualified “ordering practitioner”, and must be authenticated by the ordering practitioner (or by another practitioner with the required admitting qualifications) prior to discharge.
• Verbal orders: – A verbal or telephone inpatient admission order must be authenticated (signed, dated
and timed) by the ordering practitioner (or by another practitioner with the required admitting qualifications in his or her own right) in the medical record prior to discharge, unless the hospital or the State requires an earlier timeframe
• Timing: – The order must be furnished at or before the time of the inpatient admission.
Sept 5 CMS Update Memo
11
• Inpatient Cases: must include the words “Admit” and
“Inpatient” to be a valid inpatient order
• Observation/Outpatient Cases: Should include the phrase
“refer for Observation Services” or “outpatient status”
– Avoid using “admit” and “Observation or Outpatient” in the same
order. CMS considers this to be contradictory
– “Admit to Tower 7” or “Admit to Dr. Smith” are not recommended
Physician Order Guidelines
12
* HFMA staff and volunteers determined
that this product has met specific criteria
developed under the HFMA Peer Review
Process. HFMA does not endorse or
guarantee the use of this product.
©2013 Executive Health Resources, Inc. All rights reserved.
AHA Solutions, Inc., a subsidiary of the American Hospital
Association, is compensated for the use of the AHA marks and for
its assistance in marketing endorsed products and services. By
agreement, pricing of endorsed products and services may not be
increased by the providers to reflect fees paid to the AHA.
Physician
Documentation and
Certification
Requirements
13
Certification Requirements
• CMS requires physician certification of the patient’s inpatient admission in
the medical record. The certification must include:
– Order for inpatient admission (as discussed)
– Diagnosis and rationale for hospitalization/ inpatient medical treatment
– Documentation of the estimated time the patient will need to remain in the hospital (as
discussed)
– Plans for post-hospital care, if appropriate
– May be entered on forms, notes, or records that the appropriate individual signs, or on a
special separate form.
– If information is in different places (i.e. progress notes, H+P) [certification] statement should
indicate where it may be found
– Certification must be signed and documented in the medical record prior to the hospital
discharge
• CFR §424.13
14
Sept 5 CMS Update:
Physician Certification
Timing: The certification must be completed, signed, dated and documented in the medical record
prior to discharge
Authorization to sign the certification: The certification or recertification may be signed only by one
of the following:
– (1) A physician who is a doctor of medicine or osteopathy.
– (2) A dentist in the circumstances specified in 42 CFR 424.13(d).
– (3) A doctor of podiatric medicine
Format:
– As specified in 42 CFR 424.11, no specific procedures or forms are required for certification
and recertification statements. The provider may adopt any method that permits verification.
The certification and recertification statements may be entered on forms, notes, or records
that the appropriate individual signs, or on a special separate form.
• Sept 5 CMS Update Memo
15
Guidelines for
Documentation/Certification
• Excellent patient care should continue to be the
top priority.
• Clearly document and sign the diagnosis,
medical rationale, plan of care and anticipated
discharge.
• Sign the admission order and certification (if
appropriate) prior to discharge.
16
Medical Documentation Takeaways
6 key pieces of documentation for medical necessity
• Past Medical History
Comorbidities
• Severity of signs and symptoms
Pertinent positives on physical exam
• Current Medical needs Plan of care and orders
• Facilities available for adequate care
• Predictability of an adverse outcome
Suspected diagnosis and rational
• Expectation Length of Stay
17
Surgical Takeaways
• Medicare's Inpatient Only List should be reviewed at the
time the procedure is scheduled
– For procedures that are on the Medicare IP only list,
• the order for Inpatient must be on the chart PRIOR
to the surgery
– If the procedure changes during surgery to an Inpatient
only case
• ensure the IP order is put on the chart ASAP after
the procedure
18