Knowledge Base Category -

The Office of Inspector General (OIG) recently released the report Medicare Incorrectly Paid Hospitals for Beneficiaries Who Had Not Received 96 or More Hours of Mechanical Ventilation. In fact, the report indicates that in the calendar years 2009 – 2011, Medicare overpaid hospitals $7.7 million.

Background

The OIG has done prior hospital compliance reviews of claims with MS-DRGs requiring 96 or more hours of mechanical ventilation. In past reviews the OIG found erroneous claims and as such this review was performed to determine whether payments made to hospitals for MS-DRGs requiring 96 or more hours of mechanical ventilation were correct. Hospitals use procedure code 96.72 (Continuous invasive mechanical ventilation for 96 consecutive hours or more) to identify these patients. This review focused specifically on two MS-DRGs:

• MS-DRG 207: Respiratory System Diagnosis with Ventilator Support 96+ Hours and
• MS-DRG 870: Septicemia or Severe Sepsis with Mechanical Ventilation 96+ Hours.

Audit by the Numbers

• $12,764,239: The amount of Medicare Part A payments covered in this audit.
• 290: The number of hospitals included in this audit.
• 377: The number of inpatient claims that were selected as at risk for billing errors.
• 4 days or less: This audit reviewed claims where the length of stay was 4 days or less.
• 14: The number of records where the Medicare payment was correct.
• 363: The number of records where the Medicare payment was incorrect due to the beneficiary not receiving 96 or more hours of mechanical ventilation.
• $7,714,825: The overpayments made by Medicare to the hospitals

As part of the audit process the OIG had the hospitals conduct an internal review of the claims to determine if the services had been billed correctly. The OIG also requested that the hospital provide them with the “itemized bills and medical record documentation, including timelog for the mechanical ventilation and summary of the inpatient stay to determine whether the beneficiaries had received 96 or more hours of mechanical ventilation.”

The report indicates that “the hospitals confirmed that these claims were incorrectly billed and generally attributed the errors to incorrectly counting the number of hours that beneficiaries had received mechanical ventilation or to clerical errors in selecting the appropriate procedure code.”

Centers for Medicare and Medicaid Services (CMS) Response and Action Plan

The OIG found that CMS did not have controls in place to identify the incorrectly paid claims. Since this review, CMS “implemented a new length-of-stay edit for continuous invasive mechanical ventilation for 96 consecutive hours or more. With this edit, effective October 1, 2012, claims found to have procedure code 96.72 and a length of stay fewer than 4 days are returned to the provider for validation and resubmission.”

Is Correct Coding of Ventilator Hours still on the Radar?

Since this review focused on 2009 through 2011 calendar year claims and an edit was put in place as a control to identify incorrectly paid claims, you may be thinking that this should no longer be an issue. However, other Contractors continue to review and or monitor correct coding of ventilator hours. Before we walk through a timeline of who is reviewing this issue it is important to note that most reviewers have expanded their efforts beyond MS-DRGs 207 and 870 to also include the following MS-DRGs:

• MS-DRG 003: Ecmo or Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck with Major O.R.
• MS-DRG 004: Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck without Major O.R.
• MS-DRG 927:Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours with Skin Graft
• MS-DRG 933: Extensive Burns or Full Thickness Burns with Mechanical Ventilation 96+ Hours without Skin Graft

Timeline of Review Efforts around Correct Coding of Ventilator Hours:

• Medicare Quarterly Compliance Newsletter October 2011: In the Volume 2, Issue 1 - October 2011 newsletter the CMS reported that Recovery Auditors reviewed MS-DRGs 003, 004, 207, 870, 927 and 933 due to Providers not adding the correct number of Ventilator hours during an inpatient admission. This Newsletter provides examples of their findings and education resources for hospitals.

• Cahaba GBA, the Medicare Administrative Contractor (MAC) for Alabama, Georgia and Tennessee completed a widespread probe review of MS-DRG 270 and posted the findings to their website on November 14, 2011. Their focus was on coding accuracy and medical necessity for acute inpatient hospitalization. One issue identified was that “documentation did not confirm 96 consecutive hours on ventilator support.” They took no further action as a result of this review but continue to monitor utilization through data analysis to see if further reviews are needed.

• The Program for Evaluating Payment Patterns Electronic Report (PEPPER) is now into their 12th Edition of the Short-Term Acute Care Hospitalizations Users Guide. Ventilator Support has been an at risk target since their 6th Edition Users Guide. Internally, providers can view their report to see if they are an outlier and follow the audit recommendations in the report.

• In the 2013 OIG Work Plan, the OIG indicated that “We will review Medicare payments for mechanical ventilation to determine whether the DRG assignments and resultant payments were appropriate. We will review selected Medicare payments to determine whether patients received fewer than 96 hours of mechanical ventilation. Mechanical ventilation is the use of a ventilator or respirator to take over active breathing for a patient. CMS requires that claims be completed accurately to be processed correctly and promptly. For certain DRG payments to qualify for Medicare coverage, a patient must receive 96 or more hours of mechanical ventilation.”

As you can see this is certainly not a new issue and hospitals need to remain vigilant in their efforts to correctly code ventilator hours.

We are now into the second day of the Centers for Medicare and Medicaid Services (CMS) 2014 Fiscal Year. For those that were unable to listen to the CMS Special Open Door Forum (ODF) this past Thursday September 26th, CMS appeared to have heard and has responded to the medical community’s concerns around the education and implementation of the new 2-Midnight Benchmark for inpatient admissions and the Physician Certification of all inpatient admissions.

Clarification of CMS Inpatient Hospital Policy, Why Now?

On the same day as the ODF, CMS also released a letter to the American Hospital Association (AHA). In both this letter and during the ODF, CMS indicated that they have been facing “pressures” that include:

• “An increase in the average length of observation stays;
• An increase in the Comprehensive Error Rate Testing (CERT) error rate for short inpatient stays;
• An increase in the number of inpatient appeals; and
• Requests from the hospital industry requesting clarification on inpatient review policy.”

The two year conversation around these “pressures” between CMS and the hospital industry are what prompted the implementation of the 2-Midnight Benchmark and Physician Certification process. CMS announced that the next three months (October 1, 2013 – December 13, 2013) will be a transition period where they will monitor the impact of the changes to ensure that they result in the best interest for Medicare beneficiaries. Further, they announced a New Probe and Education Program.

New Probe and Education Program

This new program will begin with dates of admission on or after October 1, 2013 through December 31, 2013. Specific instructions for Contractors include the following:

• Medicare Administrative Contractors (MACs)
• MACs will shift their pre-payment focus to admissions on or after October 1st through December 31st with “0” or “1” midnight lengths of stay.
• The focus of these reviews will be to “determine the medical necessity of the patient status in accordance with the two midnight benchmark.”
• The Pre-payment Probe limit has been set at 10-25 claims per hospital.
• If a MAC completes a probe and finds no issues they will “cease further such reviews for that hospital from October – December 2013, unless there are significant changes in billing patterns for admissions.”
• If a MAC does identify issues, education will be provided to the hospital and then the MAC will conduct further follow-up as necessary.
• Since these will be pre-payment reviews, a hospital could re-bill any denied claims in accordance with the Part A to Part B rebilling Final Rule.
• MACs will use their review findings to determine a hospital’s compliance with the new inpatient rules and provide feedback to CMS for development of joint education and guidance.

• Recovery Auditors (RAs)
• During this same 90 days, “CMS will not permit Recovery Auditors to review inpatient admissions of one midnight or less that begin on or after October 1, 2013.”
• The RA Pre-payment Demonstration will be suspended during the 90 day period for the 11 states that are participating in this demonstration (FL, CA, MI, TX, NY, LA, IL, PA, OH, NC, and MO).
• RAs will continue pre-payment reviews for Therapy Caps.

• Caution:
• CMS reminds providers that “physicians should make inpatient admission decisions in accordance with the 2 midnight provisions in the final rule. If at any time there is evidence of systematic gaming, abuse or delays in the provision of care in an attempt to surpass the 2-midnight presumption could warrant medical review.”
• During this transition period MACs can continue to perform coding validation reviews.
• The CERT contractor, Zone Program Integrity Contractors (ZPICs), Office of Inspector General (OIG), etc. are not limited by this 90 day time period and can continue to pick any claims for review.
• Contractor reviews specifically supporting the medical necessity of a surgery (i.e. total knee replacement) and correct coding reviews can continue during this time.

Dress Rehearsal

Moving forward, CMS has set up an Inpatient Hospital Reviews webpage on their website under Medical Review and Education and encourages hospitals to check this site frequently for updates.

Hospitals should take this time to use the next three months as a dress rehearsal to continue with staff education, proceed with your plans to be compliant with the 2-Midnight Benchmark and develop processes to ensure completion of the Physician Certifications prior to beneficiaries being discharged.

2014 IPPS Final Rule Resources:

Link to the Final Rule:  http://www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf

Link to September 5, 2013 Guidance - Hospital Inpatient Admission Order and Certification:  http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-09-05-13.pdf

Link to MLN Matters: SE1333 – Temporary Instructions for Implementation of Final Rule 1599-F for Part A to Part B Billing of Denied Hospital Inpatient Claims

 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1333.pdf

Link to CMS Open Door Forums webpage:  http://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/ODFSpecialODF.html

One thing that we all continue to hear about the transition to ICD-10-CM is the increased specificity of the codes. Asthma is one example of the increased specificity with ICD-10-CM. ICD-9-CM used an older classification for Asthma that is no longer relevant for treatment. Over the years the guidelines and classifications of Asthma have been revised. The latest update was released in 2007 by the National Asthma Education and Prevention Program which is coordinated by the National Heart, Lung and Blood Institute (NHLBI). ICD-10-CM has incorporated the classifications listed below into the new code set.

• Mild Intermittent Asthma (J45.2_)
• Symptoms occur less than two days per week and no interference with regular activities.
• Fewer than 2 days a month of night time symptoms
• Lung Function Tests (LFTs) are normal when they are not having an asthma attack
•  Mild Persistent Asthma(J45.3_)
• Symptoms occur more than 2 days per week, but not every day and there is interference of daily activities.
• Three to four times a month of night time symptom occurrences
• LFTs are normal when not having an asthma attack
•  Moderate Persistent Asthma (J45.4_)
• Symptoms occur daily requiring inhaled asthma medication and may restrict physical activity
• Night time symptoms occur more than once a week, but not every day
• Abnormal LFTs
• Severe Persistent Asthma (J45. 5_)
• Symptoms occur throughout the day with frequent severe attacks limiting the ability to breathe and perform physical activities
• Night time symptoms sometimes occur every night
• Abnormal LFTs

It is interesting to note that in ICD-9-CM Extrinsic Asthma codes to 493.0x and Intrinsic Asthma codes to 493.1x. However, in ICD-10-CM both Extrinsic/Intrinsic (allergic and nonallergic) are assigned to J45.909, Unspecified Asthma.

A discussion needs to take place with your physicians who treat Asthma patients to make them aware of the updated classifications so their documentation will reflect the medical complexity of their patients. Talking to your physicians now will hopefully reduce the amount of queries in the future.

Below are the links that contain the clinical information and updated guidelines for Asthma.

 http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf

 http://www.webmd.com/asthma/tc/classification-of-asthma-topic-overview

Over the years the American Health Information Management Association (AHIMA) has provided guidance on when and how to query for additional health record documentation in a compliant manner. They have recently published a new practice brief on “Guidelines for Achieving a Compliant Query Process” that augments and where applicable, supersedes prior AHIMA guidance on queries. MMP, Inc. encourages coders and clinical documentation specialists to read the AHIMA article for complete guidance and some excellent examples of compliant and non-compliant queries.

Key Points about Queries

The AHIMA article defines the purpose of a query as follows: “The desired outcome from a query is an update of a health record to better reflect a practitioner’s intent and clinical thought processes, documented in a manner that supports accurate code assignment.”

• Queries should be used to clarify documentation in the medical record for accurate code assignment, such as when
• Information is ambiguous, incomplete, or conflicting,
• Clinical indicators are not related to a specific condition,
• Clinical indicators to support a documented diagnosis are missing, or
• Greater specificity is needed.
• All queries must be accompanied by the relevant clinical indicator(s) that justify the need for the query. These indicators should be derived from the specific patient’s current episode of care and may contain elements from any part of the current medical record.
• Verbal queries should contain the same information and be in the same format as written queries.
• Queries should not indicate the impact on reimbursement or provider profiles.
• Queries should not be leading. A leading query is one that is
• Not supported by clinical indicators in the medical record and/or
• Directs or “leads” a provider to a specific diagnosis or procedure.

Query Formats

Although open-ended queries are preferred, “yes/no” queries and multiple choice queries are acceptable under certain circumstances.

Yes/no queries:

• Are appropriate for example in
• determining if a documented condition was present on admission (POA),
• substantiating a diagnosis that is already present in the medical record,
• establishing a cause and effect relationship, or
• resolving conflicting documentation.
• Should include additional options besides “yes” and “no” such as “clinically undetermined”, “other”, and “not clinically significant”.
• Should not be used to document a condition/diagnosis that is not already documented in the medical record, i.e. a new diagnosis based on clinical indicators.

Multiple choice queries:

• Are appropriate for example to document greater specificity.
• Should include clinically significant and reasonable options as supported by the clinical indicators.
• Should include additional options such as such as “clinically undetermined”, “other”, and “not clinically significant”.
• Should allow the addition of free text by the provider.

Note: It is acceptable to include a new diagnosis as an option in a multiple choice list if supported by the clinical indicators, since other options including “other” and free text are also available.

Handling Missing Clinical Indicators

Is a query appropriate when a diagnosis is documented that does not appear to be supported by clinical indicators or should this type of conflict be addressed through the facility’s escalation policy? This is something your hospital will have to decide how to handle. CMS recommends that all facilities have an escalation policy that may include referral to a physician advisor, chief medical officer, or other administrative personnel. Even if you use queries in some of these situations, escalation will be needed for more complex situations, for unanswered queries and to address any concerns regarding queries. An example of a query from the brief that addresses documented conditions without clinical indicators is:

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.”

Should the Query Be Part of Your Medical Record?

Your facility should have internal policies that address query retention and whether the query is to be a part of the patient’s permanent medical record or stored as a separate business document. Either way, remember that the medical record should include the clinical rationale for all diagnoses. Also, capturing the content of the query and the provider’s response supports the sequence of events so that documentation does not appear out of context.

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Background

As part of the Deficit Reduction Act of 2005 (DRA), hospitals were required to begin reporting whether or not diagnoses were Present on Admission (POA) on or after October 1, 2007.

General POA Requirements:

• POA indicator is required for all claims involving Medicare inpatients admitted to general IPPS acute care hospitals.
• POA is defined as present at the time the order for inpatient admission occurs – conditions that develop during an outpatient encounter, including emergency department, observation, or outpatient surgery, are considered POA.
• The POA indicator is assigned to the principal diagnosis and secondary diagnoses.
• Inconsistent, missing, conflicting or unclear documentation must be resolved by the provider.
• POA indicator is not reported if a condition would not be coded and reported based on Uniform Hospital Discharge Data Set definitions and current Official Guidelines.
• CMS does not require a POA indicator for the external cause of injury code unless it is being reported as an “other diagnosis.”

(Source: CMS POA Fact Sheet)

Office of Inspector General (OIG) November 23, 2012 Report: Assessment of Hospital Reporting of Present on Admission Indicators on Medicare Claims.OEI-06-09-00310

The OIG recently released a report that assessed POA indicator accuracy and the nature of any miscoding. As background to this review the OIG indicated that Section 5001 (c) of the Deficit Reduction Act of 2006 mandated that hospitals would not receive increased Medicare reimbursement for certain conditions that develop during a hospitals stay that were not present on admission. These conditions are referred to as “hospital-acquired conditions” and the list of conditions is updated annually. Assigning POA indicators “provides a necessary framework” for making the determination of whether or not a diagnosis is a “hospital-acquired condition.”

For the report, the OIG utilized contracted certified coders that reviewed medical records and “documented all misreported POA indicators and described circumstances that may have contributed to the errors.”

The OIG found that “hospital coders incorrectly reported 3 percent of the 5,491 POA indicators reviewed, resulting in the presence of at least one incorrect indicator on 129 claims (18 percent).” There were three main groups of errors identified and include:

• Twenty-One Percent were related to the assessment of developing or chronic conditions
• Conditions that were developing at the time of admission with misreported POA indicators included systemic inflammatory response syndrome (SIRS), septic shock, blood infections, urinary tract infections, pneumonia, pressure ulcers, constipation, and malnutrition.
• Chronic conditions with misreported POA indicators included diabetes and patient’s experiencing an exacerbation of a chronic condition such as congestive heart failure.

• Thirty-Two Percent involved errors in assigning POA indicators to exempted conditions.
• In these cases the hospital coder either assigned a POA indicator code when he/she should have identified the diagnosis as exempt or coded a diagnosis as exempt when it was not on the published list of exemptions and should have been assigned POA indicators.

• Forty-Seven Percent involved other reporting errors not associated with developing or chronic conditions or with exemptions. Specific examples in the report include:

• The OIG coders found documentation contradicting the POA designation.
• Medical record review clearly indicated the presence or absence of a diagnosis at the time of admission. “This suggests that hospital coders may have failed to notice or disregarded the information necessary to make an accurate POA assessment.”
• Physician’s documentation not clearly indicating when a condition developed.
• Other issues such as a diagnosis changing during the hospitalization.

The OIG concluded that the 3-percent error rate is relatively low and no recommendations were made. At MMP we believe that it is important to point out that in their conclusion, the OIG indicates that “POA indicators provide an opportunity for monitoring hospital quality of care and are critical to CMS’s efforts to link payment to quality, but they must be accurate to serve these purposes. Encouraging hospitals to assess POA reporting practices related to developing conditions and exemption codes, and to retrain staff as needed, could help to ensure accuracy.”

When talking to hospital staff and Physicians about high resource consumption, high readmission rates and high mortality rates, one explanation you almost always hear is “my patients are sicker.”

But how do you know if your patients are sicker? Understanding your facility’s Case Mix Index (CMI) is a good way to answer this question. However, to understand CMI you need to first understand the basic fundamentals of the Inpatient Prospective Payment System (IPPS) and how a Coder in a hospital determines the Diagnosis-Related Group (DRG) assignment for every hospital inpatient stay.

Background:

In 1983, Congress mandated the Inpatient Prospective Payment System (IPPS) for all Medicare inpatients. IPPS uses Diagnosis-Related Groups (DRGs) to determine reimbursement for hospitals.

Beginning October 1, 2007 the DRG system began transitioning to a new system called Medicare Severity MS-DRG. The transition to MS-DRGs allowed for an improved accounting of a hospital’s resource consumption for a patient and the patient’s severity of illness.

Assigning a DRG:

Principal Diagnosis:

The Uniform Hospital Discharge Data Set (UHDDS) defines the Principal Diagnosis as “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

Comorbidities and Complications (CCs and MCCs):

These are conditions that increase a patient’s resource consumption and may cause an increase in length of stay compared to a patient admitted for the same condition without a co-morbidity or complication. When the DRG system transitioned to MS-DRGs the comorbidites and complications were divided into three levels. The three levels are DRGs without a CC or MCC, DRGs with a CC and DRGs with a MCC.

• Comorbidities are the conditions that patients “bring with them” when they are admitted to a hospital and continue to require some type of treatment or monitoring while in the inpatient setting. For example:
• A patient with a history of atrial fibrillation is continued on his home medications and placed on telemetry monitoring.
• A patient with a history of Diabetes is placed on pattern blood sugars with sliding scale insulin
• A patient has a history of hypercholesterolemia and is continued on their home Statin therapy.
• Complications are those conditions that occur during the inpatient hospitalization. For example:
• A patient undergoes hip surgery and experiences acute post-op blood loss anemia in the peri-operative period requiring serial Hemoglobin and Hematocrit checks and possibly blood transfusions.
• A patient with a history of chronic obstructive pulmonary disease undergoes surgery and develops post-op respiratory failure.

• Major Comorbidities and complications (MCCs): DRGs with MCCs reflect the highest level of severity. For example:
• A patient with chronic systolic heart failure is admitted for a GI bleed, becomes volume overloaded and develops acute on chronic systolic heart failure during the admission.

As many times as we have heard it said it remains true, if you don’t document it then it wasn’t done or in the case of DRG assignment it wasn’t present and treated during the hospitalization. A Coder’s ability to code to the most appropriate DRG is dependent upon the Physician documentation in the medical record. Coding Guidelines do not allow coders to interpret lab findings, radiology findings, EKGs or pathology reports to assign diagnosis codes.

A successful DRG program in a hospital is dependent on the Physician providing a complete accounting of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status.

Example:

A patient presents with chest pain and has a known history of GERD. A Myocardial Infarction (MI) was ruled out based on EKG and Cardiac Enzymes and the patient was discharged home with a new prescription for Prilosec. In this case chest pain is a symptom code and a more specific diagnosis would be chest pain related to GERD. However, if the only diagnosis written by the Physician in the record is chest pain then the coder can only assign the code for unspecified chest pain.

This is why Coders and in more recent years Clinical Documentation Specialist send queries to Physicians. As far back as 2007, CMS has indicated that “we do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record.” (Source: Federal Register / Vol. 72, No. 162 / Wednesday, August 22, 2007 / Rules and Regulations – page 47180)

Diagnosis-Related Group (DRG) is a diagnosis classification that groups patients that have a similar resource consumption and length-of-stay.

Relative Weight (RW) is a numeric weight assigned to each DRG that is indicative of the relative resource consumption associated with that DRG. For CMS fiscal year 2011 (October 1, 2010 through September 30, 2011) relative weights range from as high as DRG 001: Heart Transplant or Implant of Heart Assist System with MCC at 26.3441 to as low as DRG 795: Normal Newborn at 0.2284. Medical DRGs (e.g. chest pain, pneumonia, congestive heart failure) will have a lower relative weight than surgical DRGs.

Case Mix Index (CMI): The Ingenix 2011 DRG Expert defines CMI as “the sum of all DRG relative weights, divided by the number of Medicare cases. A low CMI may denote DRG assignments that do not adequately reflect the resources used to treat Medicare patients.”

An easier way to explain CMI is to compare it to a student’s Grade Point Average (GPA). A higher GPA is reflective of a student’s academic success. Likewise, a higher CMI for a hospital is reflective of a successful DRG program.

GPA Example:

(A=4 grade points / B=3 grade points / C=2 grade points / D = 1 grade point / F = 0 grade points)

Formula for GPA: Total Grade Points ÷ Sum of Credit Hours = GPA

21 ÷ 10 = 2.10 GPA

Case Mix Index Example A:

Formula for Case Mix Index:

Sum of Relative Weights ÷ Total Number of DRGs Coded = Case Mix Index

Example A Case Mix Index: 3.7543 ÷ 4 = 0.9386 Case Mix Index

Example B: The Potential Impact Physician Queries can have on DRG Assignment:

1. Example B Case Mix Index: 4.9944 ÷ 4 = 1.2036 Case Mix Index

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“The higher the case mix index, the more complex the patient population and the higher the required level of resources utilized. Since severity is such an essential component of MS-DRG assignment and case mix index calculation, documentation and code assignment to the highest degree of accuracy and specificity is of utmost importance.”

(Source: Ingenix 2011 DRG Expert)

Challenges for Hospitals:

Understanding what can make your hospitals CMI fluctuate?

• A decrease in CMI may be reflective of:
• Non-specific documentation by the Physician
• Increase in Medical Volume with a decrease in Surgical Volume as Surgical DRGs have a higher Relative Weight.
• Surgeons being on vacation
• Physicians being unresponsive to Coder and Clinical Documentation Specialist queries
• An increase in CMI may be reflective of:
• Tracheostomy procedures that have an extremely high Relative Weight
• Ventilator patients
• Open Heart Procedures
• Improved Physician Documentation
• Improved Physician response rate to queries resulting in an improved CC / MCC capture rate

Realizing the Importance of every Medical Professional’s role in the success of a hospital’s DRG program:

• The Physician’s Role: Is to provide complete and accurate documentation of a patient’s Principal Diagnosis, comorbidities and complications, any procedures performed, the plan of care and the patient’s discharge status in the medical record.

• The Clinical Documentation Specialist’s Role: Is to perform concurrent medical record reviews and ask queries whether verbal or written when indicated.

• The Coder’s Role: May be concurrent medical record review or a retrospective review after discharge; also ask queries when indicated.

The American Health Information Management Association (AHIMA) published a practice brief “Managing an Effective Query Process” in October 2008. The AHIMA brief states that “Providers should be queried whenever there is conflicting, ambiguous, or incomplete information in the health record regarding any significant reportable condition or procedure” or if “additional information is needed for correct assignment of the POA indicator.”

Further, AHIMA suggests querying when documentation in the patient’s record fails to meet one of the following five criteria:

• Legibility
• Completeness (e.g. abnormal test results without notation of clinical significance)
• Clarity (e.g. diagnosis without statement of cause or suspected cause)
• Consistency (e.g. conflicting documentation)
• Precision (e.g. greater specificity)

The entire brief can be found at AHIMA's Managing an Effective Query Process.

So, how do you know if your patients are sicker?

Internally, hospitals can:

• Work with their Decision Support staff to develop CMI reports by facility and by individual physicians.
• Perform root-cause-analysis when you see fluctuations in the CMI rate.
• Use CMI reports to compare Physicians in like specialties to each other.

External Resource for hospitals:

MMP, Inc’s sister company RealTime Medical Data (RTMD) affords hospitals the unique ability to finally compare their CMI rates to other hospitals within their defined market as well as statewide. RTMD uses real Medicare paid claims data and reports are based on the total market – all residents, all physicians, and all hospitals within Alabama, Mississippi, Tennessee, Georgia, Florida, Louisiana, Arkansas, Delaware, District of Columbia, Maryland, New Jersey, North Carolina, Oklahoma, Pennsylvania, South Carolina and Texas.

RTMD reports that can help a hospital and physician’s answer this question include:

• CMI Detail Reports
• Provider CMI Details by DRG with Statewide CMI: This report represents CMI for the Provider with DRG details and includes Statewide CMI for all providers.
• Provider CMI Details by Physician: This report represents CMI for the Provider with Physician Details.

A successful DRG program is dependent on accurate documentation. Addressing issues that can impact CMI will enable you to capture the most accurate severity of illness, have a positive impact on reimbursement and support the medical necessity of inpatient admissions.

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

Coding Issues

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

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

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

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

Billing Issues

Outpatient within Inpatient Stay

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

Inappropriate Hospital Admissions

Respiratory Conditions

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

DRG 581, Other Skin, Subcutaneous Tissue and Breast Procedures

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

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

Medicare Hospital Dialysis Services 

CMS Transmittal 2455 released April 26, 2012 informs hospitals about the correct billing of acute dialysis services for Medicare inpatients and outpatients.

HCPCS code G0257 is only to be billed for hospital outpatients with ESRD. G0257 is not to be reported for hospital inpatient services billed under Part B (12x type of bill) or for hospital outpatients who do not have ESRD. HCPCS code G0257 is used for hospital outpatients with ESRD when the criteria listed below from the Medicare Claims Processing Manual, chapter 4, section 200.2 is met.

“Payment for unscheduled dialysis furnished to ESRD outpatients and paid under the OPPS is limited to the following circumstances:

• Dialysis performed following or in connection with a dialysis-related procedure such as vascular access procedure or blood transfusions;
• Dialysis performed following treatment for an unrelated medical emergency; e.g., if a patient goes to the emergency room for chest pains and misses a regularly scheduled dialysis treatment that cannot be rescheduled, CMS allows the hospital to provide and bill Medicare for the dialysis treatment; or
• Emergency dialysis for ESRD patients who would otherwise have to be admitted as inpatients in order for the hospital to receive payment.”

HCPCS code G0257 may only be reported on Type of Bill (TOB) 13X (hospital outpatient service) or TOB 85X (Critical Access Hospital). Effective for services on and after October 1, 2012, claims containing HCPCS code G0257 will be returned to the provider for correction if G0257 is reported with a type of bill other than 13X or 85X (such as a 12x inpatient claim).

Hospitals should report HCPCS code 90935 (Hemodialysis procedure with single physician evaluation) for the following hospital dialysis services.

• Hospital inpatients with or without ESRD who have no coverage under Part A, but have Part B coverage. The service must be reported on a Type of Bill 12X or Type of Bill 85X.
• Hospital outpatients who do not have ESRD and are receiving hemodialysis in the hospital outpatient department. The service is reported on a TOB 13X or l 85X.

CPT code 90945 (Dialysis procedure other than hemodialysis (e.g. peritoneal dialysis, hemofiltration, or other continuous replacement therapies)), with single physician evaluation, may be reported by a hospital paid under the OPPS or CAH method I or method II on type of bill 12X, 13X or 85X.

For complete information see the transmittal at the link above or the MLN Matters Article MM7732.