Knowledge Base Category -

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

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Hospitals are facing significant changes with the implementation of the 2014 IPPS Final Rule. Beyond medical necessity guidance, physician certification and recertification for a Part A inpatient admission and the Part A to Part B rebilling, the National Uniform Billing Committee (NUBC) developed and approved new discharge status codes that were finalized for use in the Final Rule.

An interesting twist is that these codes are to be used specifically for DRG 280 (Acute Myocardial Infarction, Discharged Alive with MCC), DRG 281 (Acute Myocardial Infarction, Discharged Alive with CC), DRG 282 (Acute Myocardial Infarction, Discharged Alive without CC/MCC) and DRG 789 (Neonates, Died or Transferred to Another Acute Care Facility).

DRGs 280, 281 and 282:

The finalized rule added one new code for this DRG group.

• New Code: 69 - Discharged/transferred to a designated disaster alternative care site
• Purpose: “Is to identify those patients diagnosed with an acute myocardial infarction (AMI) who were discharged/transferred to a designated disaster alternative care site alive.”
• Final Rule Comments: Most people that commented on this proposal were supportive of adding this new code and anticipate that it will be used infrequently.

The 15 remaining discharge status codes were proposed and finalized to identify planned readmissions after an AMI index admission. The new codes will replace codes already in place. In response to a comment CMS clarified that “at this time, these new discharge status codes are not related in any way to the Hospital Readmission Reduction Program and will not be taken into account in the readmission measures for that program.” The following table is a crosswalk from the current code to the new code. (This table can be found in the Final Rule on pages 50533 – 50534).

‍DRG 789:

Three new discharge status codes have been added to this DRG “to identify neonates that are transferred to a designated facility with a planned acute care hospital inpatient readmission.” The new codes can be found on page 50538 of the final rule and include:

Suggestions to prepare for the new discharge status codes:

• Work with your IT Department to ensure that your systems have been updated to reflect these changes,
• Provide physician education to help ensure that there is clear documentation in the Index admission that he/she is planning on readmitting the patient; and
• Educate HIM and Case Management staff.

The Medicare Hospital Conditions of Participation (CoPs) allow stamped signatures but Medicare conditions of payment do not allow stamped signatures and now there is an exception to the conditions of payment that does allow stamped signatures. Are you confused yet? Let’s see if we can sort this out.

Section 3.3.2.4 of the Medicare Program Integrity Manual addresses signature requirements for Medicare medical review purposes. This section states:

“For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable.” (emphasis added)

This means that for services to be approved for payment by Medicare, they must contain a legible handwritten or electronic signature. Stamped signatures are generally not acceptable for Medicare payment purposes. However, under the Rehabilitation Act of 1973 a stamped signature will be accepted in the case of an author with a physical disability.

Change Request 8219 (MLN Matters Article MM8219) clarifies that CMS will permit the use of a rubber stamp for signature when the author has a disability that prevents him/her from physically signing documentation. These providers must be able to provide proof to the Medicare contractor of their inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document. So if your hospital has a provider that uses a rubber stamp due to a physical disability remember to include the required proof of their inability to sign when you submit medical records containing their stamped signature to a Medicare review contractor.

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

Please share this article with the therapists at your facility.

In last week’s Wednesday@One, we discussed therapy documentation in the evaluation, re-evaluation, plan of care, and certification. This week we will note some potential areas of improvement for therapy documentation in the daily treatment notes, progress notes, and the discharge summary. Like last week, we encourage providers to review the

Daily Treatment Notes

• Daily notes should list each specific intervention/modality provided to the patient for both timed and untimed codes.
• Medicare requires that the treatment notes include the total treatment time in minutes (includes both timed and non-timed codes) and the total minutes of the timed codes. Therapists need to know which treatments are timed codes and which are non-timed codes.   Non-timed codes are reported as one unit per day while the total number of units allowed for timed codes is restricted by the total timed code treatment minutes. For example if a patient receives 10 minutes of therapeutic exercise, 10 minutes of neuromuscular re-education and 10 minutes of manual therapy, the total timed code minutes equals 30 minutes which is 2 units. This patient may have also received 20 minutes of unattended electrical stimulation; this is included in the total treatment time for a total of 50 minutes, but does not affect the calculation of timed code units since it is an untimed code.
• Units of timed codes are based on the following time scale:
• 8-22 minutes = 1 unit
• 23-37 minutes = 2 units
• 38-52 minutes = 3 units
• 53-67 minutes = 4 units, etc.
• The therapy professional(s) providing the treatment must sign the treatment note and include their credentials.
• Extra documentation in the daily notes, though not required, often helps to support medical necessity in case of a Medicare audit. This may include noting the patient’s response or any assistance / instruction the patient required. If pain is part of the patient’s functional deficit, a numeric evaluation or discussion of the patient’s pain is recommended.
• Some LCDs list specific requirements for certain therapy services. For example, Cahaba’s Physical Therapy LCD notes that the medication and dosage information is required for iontophoresis and, for manual therapy, the area(s) being treated and the soft tissue/mobilization technique used should be documented. Be sure to review your Medicare contractor’s coverage policies for any additional documentation requirements.

Interval Progress Notes

• After the evaluation, this is the most important documentation in supporting the medical necessity of the therapy services provided. Based on our reviews of therapy records, most progress reports consistently contain all of the required elements.
• These notes must include objective measurements that describe the patient’s current function. Note that under the new functional limitation reporting requirements, the patient’s function will be reported as a percentage of impairment which must be documented in the patient’s record.
• Progress notes that allow easy comparison of the patient’s initial status and the status at last progress interval to the current status make auditing the record easier. The original and any revised goals need to be listed or referenced by a numbering system and the patient’s progress toward each goal noted.
• The clinician must document an assessment of the patient’s progress or lack of progress. Clearly explain if the patient is on target, ahead of schedule or not progressing as expected including reasons, adjustments to treatments / goals and recommendation for continuation of treatment. Remember this is where the therapist makes his/her case for the medical necessity of continuing treatment.

Discharge Summary

• A discharge note or summary is required for each episode of outpatient treatment.
• It covers the period from the last progress note to the date of discharge.
• In the case of an unanticipated discharge, the therapist uses the daily treatment notes and verbal reports from the treating assistants to make judgments for the summary.
• The discharge note requires the same elements as an interval progress note and is the last opportunity to justify the medical necessity of the entire treatment episode in case the record is reviewed.

When documenting therapy services, remember that you are presenting a “story” to justify that

1. the patient has a condition for which therapy should be beneficial,
2. the services require the skills of a therapist, and
3. the services are appropriate for the individual needs of this particular patient.

Please share this article with the therapists at your facility.

With all of the new Medicare requirements for rehabilitative therapy, such as functional limitation reporting, cap amounts applied to hospital outpatient services, and manual medical review of therapy services exceeding the threshold, we thought now would be a good time to address therapy documentation. These Medicare requirements can be found in the Medicare Benefits Policy Manual, chapter 15, section 220.3. Also most Medicare Administrative Contractor shave local coverage determinations for therapy services that include additionald ocumentation requirements.

The Medicare Benefits Policy manual details the minimum documentation requirements for therapy services. They also list documentation elements that are “encouraged” though technically not “required.” But this is a catch 22 –therapy documentation must be sufficient to support the medical necessity of the services provided. The manual states, “It is encouraged but not required that narratives that specifically justify the medical necessity of services beincluded in order to support approval when those services are reviewed.” So, like Medicare, we encourage providers to cover their bases with the amount and type of therapy documentation.

We are not going to re-list all of the documentation elements that Medicare recommends to support therapy services. Most therapists are well aware of the documentation requirements but we recommend providers carefully review the Medicare Benefits Policy Manual and any therapy LCDs for their jurisdiction for complete documentation information. We are going to discuss a few elements we have identified during therapy audits that we believe have potential for improvement. This week we will address documentation in the therapy evaluation, re-evaluation, plan of care and certification.

Evaluation

• Onset date – this is usually documented on the evaluation/certification form though the exact onset date is often hard to pin down. Our recommendation involves chronic conditionsa nd those conditions with an insidious onset. To support medical necessity, we recommend the evaluation answer these questions - If this condition has been going on for a while, why is therapy needed now? Has there been a recent decline in function, increase in pain or stiffness, increase in number of falls, or an exacerbation of the condition,etc.? Is the therapy intended to improve function or prevent further decline? Documentation that clearly addresses these questions helps to support the medical necessity of the therapy services.
• ADLs, ADLs, ADLs – The evaluation will include the patient’s functional deficit with objective measurements, but discussing the patient’s prior function and current limitations in terms of activities of daily living helps to support the medical necessity of the planned therapy. It is great to know the patient has limited mobility or restricted range of motion, but understanding the patient is unable to go grocery shopping or dress themselves is more dramatic and convincing of the need for treatment.

Plan of Care

• ADLs Again – In addition to the objective measures in the goals, linking the goals to improvement in a particular activity of daily living makes the goal more meaningful to the patient and to an outside reviewer.
• The functional impairments identified and expressed in the long term treatment goals must be consistent with those used in the claims-based functional reporting, using non-payable G-codes and severity modifiers.

Re-evaluation

• Continuous assessment of the patient's progress is a component of ongoing therapy services and is not payable as a re-evaluation.
• Re-evaluations are indicated when there are new clinical findings, a significant change in thepatient's condition, or failure to respond to the therapeutic interventionsoutlined in the plan of care.

Certification

• Certification requires a dated signature on the plan of care or some other document that indicates approval of the plan of care. Make sure the signature of the certifying practitioner is dated and be sure to include a copy of the signed certification when submitting records for external review. Medicare may deny services if a signed certification if not available in the medical records submitted for review.
• Let’s discuss timing of the certification -Certifications should be obtained as soon as possible after the plan of care is established or at least within 30 days of the initial treatment. Certifications are acceptable without justification for 30 days after they are due but certifications delayed beyond this time frame should include evidence to justify the delay.Evidence that the provider made immediate and on-going attempts to obtain the certification signature should be included in the record. Note however that delayed certifications are accepted by Medicare unless the contractor has reason to believe that there was no physician involved in the patient’s care, or treatment did not meet the patient’s need (and therefore, the certification was signed inappropriately).

Next week, we will look at daily treatment notes, progress notes, and the discharge summary.

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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Last Friday, CMS issued Transmittal R442PI which clarifies the requirements necessary for amendments, corrections and late entries to the medical record to be considered by Medicare contractors during medical review. Medicare contractors that review records for payment determinations include the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT), Recovery Auditors (RAs or RACs) and Zone Program Integrity Contractors (ZPICs).

Providers are encouraged to enter all relevant documents and entries into the medical record at the time they are rendering the service. If actions that were actually performed were not properly documented at the time of the service, a correction, amendment or late entry is acceptable for Medicare review only if it adheres to the following standards:

• Any amendment, correction or late entry shall be clearly and permanently identified as such,
• The date and author must be clearly identified, and
• Original content must also be clearly identified and not deleted.

These requirements apply to both paper and electronic medical records.

Corrections to paper medical records require that:

• The original content is still readable which can be accomplished by using a single line strike through
• The author of the alteration sign and date the revision
• Amendments or late entries be clearly signed and dated upon entry into the medical record.

Acceptable revisions in an electronic record must:

• Distinctly identify any amendment, correction or delayed entry, and
• Provide a reliable means to clearly identify the original content, the modified content, and the date and authorship of each modification of the record.

The requirements note that Medicare reviewers shall exclude from consideration undated or unsigned entries handwritten in the margin of a document. The manual also warns against potentially fraudulent entries.

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.

We all know about the cloning of genetic material (remember Dolly the sheep), but are you aware of the risks associated with the cloning of medical record documentation? This type of “cloning” occurs when each entry in the medical record for a patient or patients is worded exactly alike or similar to previous entries. It is also known as “cut and paste” or “carrying forward” and generally occurs with using a preprinted template or an electronic health record (EHR).

Templates and electronic records offer many benefits, such as increased documentation speed and efficiency, but there are potential risks. The Office of Inspector General (OIG) and several Medicare Administrative Contractors (MACs) have published articles about the use of cloned documentation. Their concerns are that “cloned” documentation can lead to fabricated information, improper payments and corrupted patient records. Several MACs state that “this ‘cloned documentation’ does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter.” See the references at the end of this article for specific excerpts from government agencies and contractors.

So, as a hospital, how should you identify “cloned” documentation and what should you do about it?

• It is likely that your medical record coders, clinical documentation improvement staff, and/or case managers can tell you if there are instances of cloned documentation in your medical records.
• To identify problems with repetitive documentation look for contradictory information in the medical record associated with such entries, progress notes that do not change from day to day, and the repetition of typographical errors from note to note.
• Develop a policy addressing the use and controls for carry forward documentation and documentation templates
• Educate physicians and practitioners about the appropriate use of EHR tools and the importance of verifying accurate and complete documentation
• Audit medical records for inappropriate “cloning” and have processes in place to address abuses.

Two excellent articles that address this topic are a reprint of a Report on Medicare Compliance article by AISHealth and an AHIMA article on Documentation Bad Habits.

Medicare Resources

OIG Top Management and Performance Challenges: Integrity and Security of Health Information Systems and Data“Finally, EHRs should facilitate more accurate billing and support better quality of care but, when misused, may promote fraudulent billing or inappropriate care. For example, cut-and-paste features and auto-fill templates can reduce paperwork burdens, but can also be misused to fabricate information, generating improper payments and corrupting patients' records with inaccurate and potentially dangerous information. Similarly, well-designed decision support tools can help physicians select the best care for their patients, but inappropriately designed decision support tools can promote waste and inappropriate care."

Palmetto GBA: Medical Record Cloning“The word 'cloning' refers to documentation that is worded exactly like previous entries. This may also be referred to as 'cut and paste' or 'carried forward.' Cloned documentation may be handwritten, but generally occurs when using a preprinted template or an Electronic Health Record (EHR). While these methods of documenting are acceptable, it would not be expected the same patient had the same exact problem, symptoms, and required the exact same treatment or the same patient had the same problem/situation on every encounter. Cloned documentation does not meet medical necessity requirements for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”

Cahaba GBA: FAQ Medical Reviewregarding cloning“The medical necessity of services preformed must be documented in the medical record and Cahaba GBA would expect to see documentation that supports reasonable and medically necessary services and any changes and or differences in the documentation of the History of Present Illness, Review of System and Physical Examination. The medical record must be authenticated by the provider of services. CMS acceptable signature methods are hand written and electronic signatures. Stamp signatures are not acceptable.”

CGS: Electronic Medical Records Tips“Cloning occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. This "cloned documentation" does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”

First Coast: Cloning of Medical Notes“Cloning of Medical Notes: Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. Cloning of documentation is considered a misrepresentation of the medical necessity requirement for coverage of services. Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”

Noridian: Documentation Software Templates“NAS Part B MR has noted that some Electronic Medical Record (EMR) software programs auto-populate certain aspects of the medical record with information that is not patient specific. This issue is more profound in the HPI when discussing the context of a certain illness and/or co-morbidity. Documentation to support services rendered needs to be patient specific and date of service specific. These auto-populated paragraphs provide useful information such as the etiology, standards of practice, and general goals of a particular diagnosis. However, they are generalizations and do not support medically necessary information that correlates to the management of the particular patient. Part B MR is seeing the same auto-populated paragraphs in the HPI’s of different patients. Credit cannot be granted for information that is not patient specific and date of service specific."