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“The secret of getting ahead is getting started. The secret of getting started is breaking your complex overwhelming tasks into small manageable tasks, and then starting on the first one.”- Mark Twain

On January 26th, 2015 Health and Human Services Secretary Sylvia M. Burwell “announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.” This was the first time that CMS had set the following explicit goals for Alternative Payment Models (APMs) and Value Based Payment goals.

Alternative Payment Models Goal

By the end of 2016 have 30 percent of Medicare payments in alternative payment models.

By the end of 2018 have 50 percent of Medicare payments in alternative payment models.

Value Based Payments Goal

By 2016 have 85 percent of Medicare fee-for-service payments tied to quality of value.

By 2018 have 90 percent of Medicare fee-for-service payments tied to quality of value.

On March 3, 2016 CMS announced in a Fact Sheet that it estimates that the first target of 30 percent of Medicare payments being tied to APMs has been met 11 months ahead of schedule. CMS indicates that “when it comes to improving the way providers are paid, we aim to reward value and care coordination – rather than volume and care duplication.”

Alternative Payment Models by the Numbers

• $411 million is the amount that Medicare Accountable Care Organizations (ACOs) saved the program in 2014 alone through markedly improved quality and patient experience over previous years.
• $3,000 saved per Medicare beneficiary on average is what was saved in just one year through the Independence at Home Demonstration.
• 17% is the reduction from 2010 to 2014 in the number of hospital acquired conditions (HACs). This represents over 87,000 lives saved and $20 billion in cost savings.
• 565,000 is the estimated number of readmissions prevented across all conditions between April 2010 and May 2015.
• Medicare spent $315.9 billion less on personal healthcare expenses between 2009 and 2013 than what would have been spent if the 2000-2008 average growth rate had continued through 2013.

Health Care Payment Learning and Action Network

CMS created the Health Care Payment Learning and Action Network (LAN) March of 2015 “to help align the important work being done across the private, public, and non-profit sectors.”

CMS notes that this network has accelerated the transition to APMs by “fostering collaboration between Department of Health and Human Services (HHS), private payers, large employers, providers, consumers, and state and federal partners.”

Ready or not, the shift in payment is happening. To learn more about LAN you can visit the LAN web page at the CMS Innovation Center as well as the LAN website where you can join the network, view their Work Products, participate in webinars and sign up for the LAN e-newsletter.

The Comprehensive Care for Joint Replacement Model (CJR) is set to begin in just thirty days on April 1, 2016. For the first time, hospitals paid under the Inpatient Prospective Payment System (IPPS) in select Metropolitan Statistical Areas (MSAs) are required to participate in this model, with limited exceptions. Medicare beneficiaries electing to undergo any lower extremity joint procedure that is assigned to MS-DRG 469 or 470 will be included in this model.

CMS released Change Request (CR) 9533 on February 19th and related MLN Matters® article MM9533. Both are aimed at Provider Education with emphasis on the need for Providers to make sure that billing staff is aware of the changes.  

Demonstration Code 75

CMS will automatically apply the CJR Demonstration Code 75 to claims that meet criteria for inclusion in this project. Medicare beneficiaries to be included in this model must meet the following criteria:

• Enrollment in Medicare Part A and Part B;
• Medicare eligibility is not based on the End-Stage Renal Disease benefit;
• Not being enrolled in any managed care plan;
• Not being covered under a United Mine Workers of America health plan; and
• Medicare is the primary payer.

CMS notes that, if at any time during the episode the beneficiary no longer meets all of these criteria, the episode is cancelled.

CMS instructs that they will automatically apply Demonstration Code 75 when the inclusion criteria are met and that “participant hospitals need not include demonstration code 75 on their claims.” They go on to note that instructions for submission of claims for Skilled Nursing Facility (SNF) services will be communicated when the waiver of the three-day stay requirement is operationalized.

Billing and Paying for Post-Discharge Home Visits

In the CJR Final Rule, CMS finalized their proposal “to waive the “incident to” direct physician supervision requirement set forth at §410.26(b) (5), to allow a CJR beneficiary who does not qualify for home health services to receive up to 9 post-discharge visits in his or her home or place of residence any time during the episode following discharge from an anchor hospitalization.”

This service will be billed under the Medicare Physician Fee Schedule (MPFS) with a HCPCS G-Code (G9490). This G-Code will be payable for CJR model beneficiaries beginning April 1, 2016. “Claims submitted for post-discharge home visits for the CJR model will be accepted only when the claim contains the CJR specific HCPCS G-Code. Although CMS is associating the Demonstration Code 75 with the CJR initiative, no demonstration code is needed or required on Part B claims submitted with the post-discharge home visit HCPCS G-Code.

Additional information on billing and payment for the post-discharge home visit HCPCS G-Code will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the relative value units (RVUs) and payment for this HCPCS code will be included in the MPFS final rules and recurring updates each year.”

Billing and Payment for Telehealth Services

CMS also finalized to waive the geographic site requirement and the originating site requirement to permit telehealth visits to originate in the beneficiary’s home or place of residence. Waiver of the telehealth requirements will be subject to certain conditions that have been detailed in CR 9533 and MLN MM9533.

As with the Post-Discharge Home Visits, Telehealth Services will also be billed under the MPFS using one of nine HCPCS G-codes (G9481, G9482, G9483, G9484, G9485, G9486, G9487, G9488, and G9499). Attachment A of CR 9533 provides the long descriptors of these codes. These codes will also be payable beginning April 1, 2016.

“Claims submitted for telehealth home visits for the CJR model will be accepted only when the claim contains one of nine of the CJR specific HCPCS G-Code.” Similar to guidance for post-discharge home visits, no demonstration code is needed or required on Part B claims submitted with a post discharge telehealth visit HCPCS G-code. “Additional information on billing and payment for the telehealth home visit HCPCS G-Codes will be available in the April 2016 release of the MPFS Recurring Update. Future updates to the RVUs and payment for these HCPCS codes will be included in the MPFS final rules and recurring updates each year.”

This model is set to run for five years, ending December 31, 2020. Hospitals, providers and suppliers will continue to be paid as usual. At the end of each Performance Year, Medicare will reconcile claims paid and hospitals will receive a reconciliation payment or be responsible for repayment to Medicare depending on how actual spending compared to an established target price. Additional information about the CJR model can be found in a related article, Comprehensive Care for Joint Replacement Model Finalized or by visiting the CMS CJR Model web page.

With the New Year looming, it is hard to believe that is has almost been a year since the U.S. Department of Health and Human Services (HHS) announced for the first time in the history of the Medicare program explicit goals for alternative payment models and value-based payments.

Alternative Payment Model Goals

By the end of 2016 have 30% of Medicare payments in alternative payment models.

By the end of 2018 have 50% of Medicare payments in alternative payment models.

Value Based Payment Goals

By 2016 have 85% of Medicare fee-for-service payments tied to quality of value.

By 2018 have 90% of Medicare fee-for-service payments tied to quality of value.

On November 25th, Patrick Conway, M.D., MSc, Acting Deputy Administrator and Chief Medical Officer, CMS announced in The CMS Blog an updated 2016 HHS National Quality Strategy (NQS) indicating that “the main purposes of the 2016 CMS Quality Strategy update are to achieve the broad aims of the NQS and to apply the Administration’s strategy for shifting Medicare payments from volume to value.”

National Quality Strategy: By the Numbers

Three Aims

1. Better Care
2. Healthier People, Healthier Communities
3. Smarter Spending

Six Priorities

1. Make Care Safer by Reducing Harm Caused in the Delivery System
2. Strengthen Person and Family Engagement as Partners in their Care
3. Promote Effective Communication and Coordination of Care
4. Promote Effective Prevention and Treatment of Chronic Disease
5. Work with Communities to Promote Best Practices of Health Living
6. Make Care Affordable

Four Foundational Principles

1. Eliminating racial and ethnic disparities,
2. Strengthening infrastructure and data systems across all settings of care,
3. Enabling local innovations, and
4. Fostering learning organizations.

The Centers for Medicare and Medicaid Services (CMS) has made the six priorities goals in the CMS Quality Strategy. They identified the Four Foundational Principles to help guide their action towards meeting these goals and believe that incorporating these “will drive change to improve quality and cost of care for all. “

CMS Quality Strategy Goals: A Call to Action

To advance the three aims, the CMS Quality Strategy Goals reflect the six priorities for the NQS. There are innumerable activities being implemented to achieve this vision. The remainder of this article will provide you a glimpse of what is being done to achieve each of these Goals.

Goal 1: Making Care Safer by Reducing Harm Caused in the Delivery System

Hospital-Acquired Conditions (HACs)

On December 3rd the Agency for Healthcare Research and Quality (AHRQ) announced that data from the recent report Saving Lives and Saving Money: Hospital-Acquired Conditions Update Interim Data from National Efforts to Make Care Safer, 2010-2014 shows between 2010 and 2014:

• An estimated 87,000 fewer patients died from a HAC,
• The overall incidence of HACs has been reduced by 2.1 million for an estimated savings of $19.8 billion; and
• In 2014 alone, 37,000 fewer patients died than would have died if the rate of adverse events had remained at the 2010 level. Most of the deaths averted resulted from a reduction in rates of pressure ulcers and adverse drug events (ADEs).

HAC Reduction Program

The Affordable Care Act (ACA) established the HAC Reduction Program as an incentive for hospitals to reduce HACs. CMS released the FY 2016 results for the Program on December 10th and they estimate that the total savings in FY 2016 will be $364 million.

Nationwide 758 out of 3,308 eligible hospitals are in the worst performing quartile and will have a one percent payment reduction applied to all Medicare discharges occurring between October 1, 2015 and September 30, 2016. The number of hospitals being penalized is up from the 724 hospitals subject to a payment reduction in FY 2015.

In the FY 2016 HAC Reduction Program, hospitals with a Total HAC Score greater than 6.7500 are subject to a payment reduction. You can find your hospital Total HAC Score at https://www.medicare.gov/hospitalcompare/HAC-reduction-program.html.

Goal 2: Strengthen Person and Family Engagement as Partners in their Care

Everyone with Diabetes Counts (EDC) Program

The Quality Innovation Network Quality Improvement Organizations (QIN-QIOs) are administering the EDC Program. This program offers evidence-based diabetes self-management training and is designed to improve health outcomes and quality of life among disparate and underserved Medicare populations.

Goal 3: Promote Effective Communication and Coordination of Care

CMS cites strengthening the hospital Conditions of Participation (CoP) for Discharge Planning and Bundled Payment Initiatives as two examples to further this goal.

Discharge Planning CoP

On October 29, 2015 CMS announced proposed revisions to the discharge planning requirements that hospitals, including long-term care hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Critical Access Hospitals (CAHs), and Home Health (HH) agencies must meet in order to participate in the Medicare and Medicaid program. They are currently soliciting comments from the healthcare community. You can read more about this in a related article at http://www.mmplusinc.com/news-articles/item/october-29-2015-cms-releases-a-discharge-planning-proposed-rule.

Bundled Payment Initiatives

CMS recently finalized the Comprehensive Care for Joint Replacement (CJR) Model which is set to begin on April 1, 2016 and run through December 31, 2020. CMS expects this model to result in $343 million in savings to Medicare over the 5 performance years. Notable about this model is that for the first time, selected hospitals are required to participate. You can read more about this in a related article at http://www.mmplusinc.com/news-articles/item/comprehensive-care-for-joint-replacement-model-finalized.

Goal 4: Promote Effective Prevention and Treatment of Chronic Disease

CMS indicates that more than 133 million Americans report at least one chronic condition, while many have multiple chronic conditions (MCC) affecting them at the same time. For example a person with diabetes and heart disease has multiple chronic conditions.

Million Hearts® Initiative

CMS cites being a lead partner in the Million Hearts® Initiative as one way they are promoting effective prevention and treatment of chronic disease. This initiative seeks to reduce the incidence of heart attacks and strokes by 1 million by 2017. The Million Hearts® website provides educational material for you and your patients, access to data and research, proven techniques to prevent and treat heart attack and stroke and education regarding risks, costs and consequences and ways to prevent heart disease and strokes.

Goal 5: Work with Communities to Promote Best Practices of Health Living

CMS is committed to partnering with key stakeholders to link Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) beneficiaries, and the providers that serve them, with communities and resources that support good health. One specific federal effort cited by CMS is the WIC Farmers’ Market Nutrition Program (FMNP)

The FMNP is associated with the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and was established by Congress in 1992 “to provide fresh, unprepared, locally grown fruits and vegetables to WIC participants, and to expand the awareness, use of, and sales at farmers’ markets.”

Goal 6: Make Care Affordable

Hospital Value Based Purchasing Program

This program adjusts hospital payments for inpatient services based on hospitals’ performance on measures that fall into a number of domains. For FY 2016 this program is funded by a 1.75% reduction from participating hospitals’ base operating diagnosis-related group (DRG) payments. The resulting funds are redistributed to hospitals based on their Total Performance Score (TPS).

CMS added the following measures for Fiscal Year (FY) 2016:

• IMM-2, Influenza Immunization (Clinical Process of Care domain)
• CAUTI, Catheter-Associated Urinary Tract Infection (Outcome domain)
• SSI, Surgical Site Infection Colon Surgery & Abdominal Hysterectomy (Outcome domain)

For those interested in learning more, CMS held a National Provider call on May 12, 2015 to provide an overview of all Hospital Inpatient Quality Reporting and Value-Based Purchasing Programs. Slides, an audio recording and written transcript are available on the CMS website.

One last valuable resource to find out “where we are now” is the CMS Innovation Center. The Innovation Center has a growing portfolio testing various payment and service delivery models that aim to achieve better care for patients, better health for our communities, and lower costs through improvement for our health care system. I encourage you to visit their website to find out where and what Innovation is happening in your state.

When you hear the word compliance, what comes to mind? The word compliance can and does actually bring to mind a varying degree of answers depending on who you were to ask in the hospital. For Example:

• A Hospital Compliance Officer among other things thinks about the fall release of the Office of Inspector General’s (OIG) annual Work Plan to guide compliance efforts for the coming year. .
• A Case Manager thinks about what is a compliant inpatient status order, does the Physician documentation support a 2-Midnight expectation, is my patient going to be compliant with his/her discharge plan instructions with a goal of preventing a 30-Day Readmission?
• For the Coder, with I-10 finally being implemented, he or she is dealing with compliance with the new coding system and I-10 Coding Clinics.
• A Clinical Documentation Specialist most likely thinks about a compliant query process.
• Infection control promotes compliance with best practices to prevent adverse outcomes for the patient.
• The billing department wants to be compliant while getting a “clean bill” out the door for payment for services rendered by the hospital.

While this is not an exhaustive list of healthcare providers who strive for compliance, it is clear that compliance is a very real concern and desired outcome and at the end of the day, each caregiver wants to “get it right” while providing the best care possible to the patient.

The Health Care Compliance Association (HCCA) defines compliance as being “the process of meeting the expectations of others. More specifically, it is the process of helping our health care professionals understand and meet the expectations of those who grant us money, pay for our services, regulate our industry, etc.” This is where MMP shines by living our mission of “Making HealthCare Make Sense.” This is what we enjoy. This is why when asked I tell people that my hobbies are my husband, my cats and reading the Federal Register.

Our Wednesday@One Newsletter already includes in our production schedule a coverage update the second week of the month and a Medical Review update the third week of each month. This week we are excited to debut a new monthly article the fourth week of each month to be known as The Making HealthCare Make Sense Spotlight. This month we begin by spotlighting free resources available to you on your compliance journey. The use of the term journey is very deliberate as the one thing that you can count on in healthcare is change and that is what makes your career a constant journey.

OIG Compliance Education Materials: Compliance 101:

The OIG developed the resources found on this web page to “help health care providers, practitioners, and suppliers understand the health care fraud and abuse laws and the consequences of violating them. These compliance education materials can also provide ideas for ways to cultivate a culture of compliance within your own health care organization” (http://oig.hhs.gov/compliance/101/).

Medicare Learning Network® (MLN) Provider Compliance page

The MLN Provider Compliance Page “contains educational products that inform health care professionals on how to avoid common billing errors and other improper activities when dealing with various CMS Programs. CMS’ claim review program’s overall goal is to reduce improper payment error by identifying and addressing coverage and coding billing errors. Since 1996, CMS has implemented several initiatives: to prevent improper payments before a claim is processed; and to identify, and recoup improper payments after the claim is processed” (https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html).

Examples of useful resources on this web page include:

• Provider Compliance Educational Products pdf,
• Fraud and Abuse Educational Products pdf,
• Provider Compliance MLN Matters® Articles pdf; and
• Archive of Medicare Quarterly Provider Compliance Newsletters.

Office of Civil Rights

As a Business Associate we take our HIPAA responsibilities very seriously. The Office of Civil Rights (OCR) has an entire Web page devoted to Health Information Privacy. This web page provides you with information to understand HIPAA Privacy, current enforcement activities and much more. (http://www.hhs.gov/ocr/privacy/index.html).

As we begin this series of articles, we welcome feedback and recommendations for future articles by you our reader. I also encourage you to read the related article in this week’s newsletter, Resources for your Hospital Compliance Plan.

The Fiscal Year (FY) 2016 Inpatient Prospective Payment System (IPPS) Final Rule builds on the CMS’s recurring theme of moving the health care system toward paying for quality rather than quantity as CMS indicates in a related Fact Sheet “the Administration has set measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on quality, rather than the quantity of care they give patients. The final rule includes policies that advance that vision and of several final rules that reflect a broader Administration-wide strategy to create a health care system that results in better care, smarter spending, and healthier people.”

This article highlights Fiscal Year 2016 IPPS Final Rule (CMS-1632-F) Payment Rate changes and changes to the Quality Programs.

Finalized Changes to Payment Rates for IPPS Participating Acute Care Hospitals

• Hospitals that successfully participate in the Hospital Inpatient Quality Reporting (IQR) Program and are meaningful electronic health record (EHR) users will see a 0.9% increase in operating payments.
• Hospitals that do not successfully participate in the Hospital IQR Program and submit the required quality data will see a one-fourth reduction in their Market Basket update.
• Hospitals that are not meaningful EHR users will see a one-half reduction in their Market Basket update.
• Additional Potential Penalties
• Hospital Value Based Purchasing (VBP) Program: Hospitals will either receive an incentive bonus or a penalty potentially as high as 3%.
• Hospital Readmission Reduction Program (HRRP): Hospitals will be penalized up to 3% for excessive readmission rates.
• Hospital Acquired Condition (HAC) Reduction Program: 1% penalty for hospitals in the lowest performing quartile.

Hospital Inpatient Quality Reporting (IQR) Program

Pneumonia Cohort Expanded

CMS finalized proposed cohort refinements to the following two previously adopted Pneumonia measures:

• The Hospital 30-Day All-Cause, Risk-Standardized Mortality Rate (RSMR) following Pneumonia Hospitalization measure
• The Hospital 30-Day All-Cause, Risk-Standardized Readmission Rate (RSRR) following Pneumonia Hospitalization measure

CMS defines “cohort” as the hospitalization, or “index admission,” that is included in each measure to determine if a patient died within 30 days of the index admission in the case of the Mortality Measure or if the patient was readmitted within 30 days in the case of the Readmission Measure.

For the FY 2017 payment determination and subsequent years the cohort for both measures has been expanded to include:

• Patients with a principal discharge diagnosis of pneumonia (the current reported cohort),
• Patients with a principal discharge diagnosis of aspiration pneumonia (new); and
• Patients with a principal discharge diagnosis of sepsis (excluding severe sepsis) with a secondary diagnosis of pneumonia coded as present on admission (POA).

More interesting than the actual cohort changes are the reasons cited by CMS for making the change.

• “Recent evidence has shown an increase in the use of sepsis and respiratory failure as principal diagnosis codes among patients hospitalized with pneumonia. Pneumonia patients with these principal diagnosis codes are not currently included in the measure cohort, and including them would better capture the complete patient population of a hospital with patients receiving clinical management and treatment for pneumonia.
• Second, “efforts to evaluate changes over time in pneumonia outcomes could be biased as coding practices change.”

CMS Adds Seven New Measures to the Hospital IQR Program

CMS finalized seven new measures for the FY 2018 and 2019 payment determinations and subsequent years. The following table highlights the new measures and the year the measure will be included in a hospital’s payment determination.

CMS Removes Nine Measures from the Hospital IQR Program

For the FY 2018 payment determination and subsequent years, CMS finalized the removal of the following nine chart-abstracted measures:

1. STK-01 Venous Thromboembolism Prophylaxis
2. STK-06 Discharged on Statin Medication*
3. STK-08 Stroke Education*
4. VTE-1 Venous Thromboembolism Prophylaxis*
5. VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis*
6. VTE-3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy*
7. IMM-1 Pneumococcal Immunization
8. SCIP-Inf-4 Cardiac Surgery Patients with Controlled Postoperative Blood Glucose
9. AMI-7a Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival*

Note: Measures with an asterisk (*) were finalized to be removed from chart abstraction but are being retained as Electronic Clinical Quality Measures (eCQM) for the FY 2018 payment determination and subsequent years as proposed.

Hospital Value Based Purchasing (VBP) Program

In the Final Rule CMS estimates that the total amount available for value-based incentive payments for FY 2016 is $1,499,107,502, based on the December 2014 update of the FY 2014 MedPAR file. This estimate will be updated for the FY 2016 IPPS/LTCH PPS final rule, using the March 2015 update of the FY 2014 MedPAR file.

As required by section 1886(o)(7)(B) of the Act, incentive payments will be funded for FY 2016 through a reduction to the FY 2016 base operating DRG payment for each discharge of 1.75 percent.

CMS finalized the removal of two current measures effective with the FY 2018 program year.

• IMM-2 Influenza Immunization
  Note: CMS does believe that “this measure should continue to be part of the Hospital IQR Program measure set because it is the only measure that addresses the Best Practices to Enable Healthy Living goal in the CMS Quality Strategy and priority of the same name in the National Quality Strategy.”

• AMI-7a Fibrinolytic Therapy Received within 30 Minutes of Hospital Arrival

CMS finalized a New Care Coordination Measure for the FY 2018 Program Year.

• 3-Item Care Transition Measure (CTM-3) that will add the following three questions to the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems )Survey:

1. During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.
2. Strongly disagree
3. Disagree
4. Agree
5. Strongly Agree
   
   
6. When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
7. Strongly disagree
8. Disagree
9. Agree
10. Strongly Agree
11. When I left the hospital, I clearly understood the purpose for taking each of my medications.
12. Strongly disagree
13. Disagree
14. Agree
15. Strongly Agree
16. I was not given any medication when I left the hospital

Note: The CTM-3 measure was developed by Eric Coleman, MD, MPH, Professor of Medicine & Health at the Division of Health & Policy Research at the University of Colorado Anschutz Medical Campus. Dr. Coleman is the founder and director of The Care Transitions Program (www.caretransitions.org).

CMS indicated that they intend to propose in future rulemaking the inclusion of non-ICU locations in the Catheter Association Urinary Tract Infection (CAUTI) and Central Line-Associated Blood Stream Infection (CLABSI) measures beginning with the FY 2019 program year. “Selected ward (non-ICU) locations are defined as adult or pediatric medical, surgical, and medical/surgical wards [79 FY 50061; 78 FR 50787].”

CMS finalized a Hospital 30-day All-Cause, Risk-Standardized Mortality rate Following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization Measure for the FY 2021 Program Year.

CMS indicates that this measure “is appropriate for the Hospital VBP Program because it addresses a high volume, high cost condition, and chronic lower respiratory disease (including COPD) is the third leading cause of mortality in the United States. The measure aligns with the CMS Quality Strategy Goal of Effective Prevention and Treatment.”

Hospital Acquired Conditions (HAC) Reduction Program

Even though there were no proposals to add or remove measures for FY 2016, the CMS reminds readers that in the FY 2015 IPPS Final Rule they finalized the following measures for the FY 2016 Program:

• AHRQ PSI – 90 Composite

This measure currently consists of the following eight component indicators:             

• PSI-3 Pressure ulcer rate,
• PSI-6 Iatrogenic pneumothorax rate,
• PSI-7 Central venous catheter-related blood stream infections rate,
• PSI-8 Postoperative hip fracture rate,
• PSI-12 Perioperative pulmonary embolism or Deep vein thrombosis rate,
• PSI-13 Postoperative sepsis rate,
• PSI-14 Postoperative Wound dehiscence rate; and
• PSI-15 Accidental puncture and laceration rate.
• CDC Central Line-Associated Bloodstream infection (CLABSI),
• Catheter-Associated Urinary Tract Infection (CAUTI); and
• Colon and Abdominal Hysterectomy Surgical Site Infection (SSI).

As part of the National Quality Foundation maintenance review process, the Agency for Healthcare Research and Quality (AHRQ) is considering adding the following to the PSI Composite measure:

• PSI-9 Perioperative hemorrhage rate,
• PSI-10 Perioperative physiologic metabolic derangement rate; and
• PSI-11 Post-operative respiratory failure rate.

CMS indicates that the potential inclusion of these measures would be a significant change and that they would engage in notice-and-comment rulemaking prior to requiring the reporting of a revised composite for the HAC Reduction Program.

Hospital Readmissions Reduction Program (HRRP)

CMS Expands the Pneumonia Readmission Measure Cohort

CMS finalized a refinement to the pneumonia readmissions measure which would expand the cohort for the FY 2017 payment determination and subsequent years. As discussed earlier in this article, CMS defines “cohort” as the hospitalizations or “index admissions,” that are included in the measure.

Currently, this measure includes hospitalizations for patients with a principal discharge diagnosis of pneumonia indicating viral or bacterial pneumonia. CMS finalized a modified version of their proposal to include patients with a principal discharge diagnosis of pneumonia or aspiration pneumonia, and patients with a principal discharge diagnosis of sepsis (excluding severe sepsis) with a secondary diagnosis of pneumonia coded as POA.

CMS indicates that “the purpose of expanding the cohort of the current pneumonia readmission measure is to include a broader spectrum of pneumonia patients and respond to changes in coding practices that were potentially biasing estimates of the performance of hospitals.”

A related Fact Sheet indicates that the “CMS is also continuing to monitor the impact of socioeconmomic status on provider results in our quality programs, and is working with the National Quality Forum as they undertake a two-year trial to test sociodemographic factor risk adjustment. The Office of the Assistant Secretary for Planning and Evaluation is currently researching the impact of sociodemographic status as directed by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), and CMS will closely examine the findings presented in their reports to Congress and related Secretarial recommendations at such time as they are available.”

Do You Know Your Hospital’s Readmission Penalty?

With hospitals facing financial challenges, do you know your Hospital’s Readmission Penalty for the coming Fiscal Year? Kaiser Health News (KHN) is a nonprofit national health policy news service and on August 3rd, Jordan Rau of KHN released the article Half of Nation’s Hospitals Fail Again To Escape Medicare’s Readmission Penalties. This article provides the reader a link to a PDF file of Medicare Readmission Penalties by Hospital for all four years of the program (FY 2013 through FY 2016).

The entire article can be accessed at: http://khn.org/news/half-of-nations-hospitals-fail-again-to-escape-medicares-readmission-penalties/?utm_campaign=KHN%3A+Afternoon+Edition&utm_source=hs_email&utm_medium=email&utm_content=21032373&_hsenc=p2ANqtz--tfj9Nw4n9neCfizWv04BocrIp3tC95xA5l23W02GylGLyB4LwwY-TqyPtYDzFc3SMx6mV8RP_X1MzflMnd3EhbTYe4g&_hsmi=21032373

The entire Final Rule can be accessed at http://www.gpo.gov/fdsys/pkg/FR-2015-08-17/pdf/2015-19049.pdf.

For those closely involved with Quality Initiatives in your facility here is list of where you can find the specific Quality Program Updates in the Final Rule pdf.

• Hospital Readmission Reduction Program is on pages 206-219,
• Hospital Value-Based Purchasing (VBP) Program is on pages 220-246,
• Hospital-Acquired Condition (HAC) Reduction Program is on pages 246 – 257; and
• Hospital Inpatient Quality Reporting (IQR) Program is on pages 316-380.

Merriam-Webster defines confusion as “a situation in which people are uncertain about what to do or are unable to understand something clearly,” or “the feeling that you have when you do not understand what is happening, what is expected, etc.” and finally as “a state or situation in which many things are happening in a way that is not controlled or orderly.”

All three definitions are apt depictions of how the healthcare industry felt in response to the 2014 Inpatient Prospective Payment System (IPPS) Final Rule and more specifically how to implement the then new 2-Midnight Rule and Physician Certification Requirements. Adding to the confusion, the Physician Certification Requirements changed again on January 1, 2015 with the implementation of the 2015 Outpatient Prospective Payment System (OPPS) Final Rule and more recently, the Centers for Medicare and Medicaid Services (CMS) have extended the Inpatient Probe and Educate process through April 30, 2015. We have recently come across certain Myths about the regulations and wanted to equip our readers with the Facts.

Myth: As of April 1st, 2015, the Centers for Medicare and Medicaid Services (CMS) have once again delayed implementation of the 2-Midnight Rule.

Fact: On April 1st the CMS indicated that “given potential Congressional action on H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015, CMS will continue the Inpatient Probe and Educate process until April 30, 2015 and will continue to prohibit Recovery Auditor inpatient hospital patient status reviews for dates of admission occurring between October 1, 2013 and April 30, 2015.”

However, hospitals should have implemented the 2-Midnight Rule at the start of the CMS 2014 Fiscal Year on October 1, 2013. This rule was intended as guidance for Physicians in identifying patients appropriate for inpatient admission. CMS has NEVER delayed the implementation date for hospital compliance with the 2-Midnight Rule. The Inpatient Probe and Educate Process was put in place to delay Contractor inpatient hospital status reviews thereby allowing hospitals time to further understand and implement this policy.

Note: Congress has passed legislation and, at the time of this posting, President Obama has indicated that he will sign it into law. This means that the Probe and Educate process will be extended to the end of the fiscal year on September 30, 2015.

Myth: As a result of the 2-Midnight Rule, CMS will not reimburse hospitals for inpatient hospitalizations that do not span 2 Midnights.

Fact: In Sub-regulatory guidance following implementation of the 2014 IPPS Final Rule, the CMS indicated that there may be “unforeseen circumstances” or possible “exceptions” to when a beneficiary is appropriately placed in an inpatient status but does not remain in the hospital 2 Midnights. To date the CMS has identified four Unforeseen Circumstances and one possible Exception.

Unforeseen Circumstances

• Beneficiary death or transfer,
• A beneficiary rapidly improving and the reasonable 2-Midnight expectation was clearly documented in the record,
• A beneficiary leaves Against Medical Advice (AMA), or
• In the event that a beneficiary declines further workup and/or treatment and elects Hospice Care.

Exception

• “CMS believes a physician will generally expect beneficiaries with newly initiated mechanical ventilation to require 2 or more midnights of hospital care, if the physician expects that the beneficiary will only require 1 midnight of hospital care, inpatient admission and Part A payment is nonetheless generally appropriate. NOTE: This exception is not intended to apply to anticipated intubations related to minor surgical procedures or other treatment.”

Myth: CMS has suspended review of all inpatient claims submitted by hospitals to the Medicare program between October 1, 2013 and April 30 of this year.

Fact: It is true that Recovery Auditors are prohibited from patient status reviews on inpatient claims with dates of service from October 1, 2013 now through April 30, 2015.

However, during this time, Medicare Administrative Contractors (MACs) are facilitating the Probe & Educate program in which they are performing a limited number of pre-payment probe reviews of 1 day or less inpatient hospitalizations with dates of services on or after October 1, 2013. MACs were instructed to assess for compliance with the admission order requirements, physician certification requirements and 2-Midnight Benchmark Guidance. While this is a Probe and Educate program, hospitals do not receive payment for denied claims.

CMS outlines reviews not impacted by the 2014 IPPS Final Rule on the Inpatient Hospital Reviews Webpage. Specifically, “MACs, Recovery Auditors and the Supplement Medical Review Contractor will continue other types of inpatient hospital reviews, including, but not limited to:

• Coding reviews,
• Reviews for the medical necessity of a surgical procedure provided to a hospitalized beneficiary, and
• Inpatient hospital patient status reviews for dates of admission prior to October 1, 2013 (based on the applicable policy at the time of admission).”

Myth: All Medicare inpatient admissions need an Initial Physician Certification completed prior to the patient being discharged

Fact: This was true for Medicare admissions with dates of service on or after October 1, 2013 through December 31, 2014. However, this changed with the 2015 OPPS Final Rule. As of January 1, 2015, CMS finalized their “policy as proposed in the CY 2015 OPPS/ASC proposed rule, which limits the requirement for physician certification to long-stay (20 days or longer) and outlier cases.” Furthermore, they finalized their “proposed revision of paragraph (b) of § 424.13, without modification, to specify that certifications for long-stay cases must be furnished no later than 20 days into the hospital stay.”

Myth: Any practitioner treating a Medicare Inpatient can write a valid Inpatient Status Order.

Fact: Per the January 30, 2014 CMS Sub-regulatory guidance Hospital Inpatient Admission Order and Certification, the order must be provided by a Physician or other practitioner that meets the following criteria

1. Is licensed by the state to admit inpatients to hospitals,
2. Has been granted privileges by the hospital to admit inpatients to that specific facility, and
3. Is knowledgeable about the patient’s hospital course, medical plan of care, and current condition at the time of the admission.

Resources:

CMS Inpatient Hospital Reviews Web page: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html

January 30, 2014 CMS Sub-regulatory Guidance: Hospital Inpatient Admission Order and Certification

http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf

On January 26th, Health and Human Services Secretary Sylvia M. Burwell “announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.” According to the CMS Press Release, “this is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments.”

This call to action by Secretary Burwell brings to mind the Institute for Health Improvement’s (IHI) Plan-Do-Study-Act (PDSA) cycle that involves planning a test or observation, trying out the test on a small scale, analyzing data and studying the results and finally, refining the change based on what was learned.

Plan-Do-Study

Long before the Affordable Care Act, it was obvious that the current state of healthcare in the United States was more reactive than proactive and that the current Prospective Payment System was not financially sustainable.

In a related Fact Sheet to the January 26th announcement, CMS indicated that “the Affordable Care Act offers many tools to improve the way providers are paid to reward for quality and value instead of quantity, to strengthen care delivery by better integrating and coordinating care for patients, and to make information more readily available to consumer and providers. Doing so will improve coordination and integration of health care, engage patients more deeply in decision-making and improve the health of patients – with a priority on prevention and wellness.”

While not an all-inclusive list, specific examples of progress attributed to the Affordable Care Act by CMS include:

• Years 2011, 2012 and 2013 saw the slowest growth in real per capita national healthcare expenditures on record in part due to slow growth in per-beneficiary spending across Medicare, Medicaid, and the private insurance beneficiary population.
• “Looking forward, due primarily to the persistent slowdown in health care costs, the Congressional Budget Office now estimated that Federal spending on Medicare and Medicaid in 2020 will be $188 billion below what it projected as recently as August 2010.”
• The Partnership for Patients has been instrumental in “patient harm falling by 17%, saving 50,000 lives and billions of dollars.”
• The Affordable Care Act tied Medicare payment for hospitals to readmission rates. Since 2012 the efforts made by hospitals “translates into an 8 percent reduction in the rate and an estimated 150,000 fewer hospital readmissions among Medicare beneficiaries between January 2012 and December 2013.”
• Providers are engaged as evidenced by the fact that currently “there are 424 organizations currently participating in Medicare ACOs, serving over 7.8 million Medicare beneficiaries” and the “ACOs participating in the Shared Savings Program and the Pioneer ACO Model combined generated over $417 million in savings for Medicare.”
• The three mandated quality programs for hospitals (Hospital Value-Based Purchasing Program, Hospital Readmissions Reduction Program and Hospital-Acquired Condition Reduction Program) reward hospitals for the quality of care they provide to patients.
• Improvement in the availability of information to guide the beneficiary in their decision-making has been made available through Physician Compare, updates to Hospital Compare, and the May 2013 release of Charge Data for Hospital and Physician Services by CMS.

Act

Again, Secretary Burwell made the HHS call to action by setting explicit alternative payment model goals and value based payment goals to “help drive the health care system towards greater value-based purchasing – rather than continuing to reward volume regardless of quality of care delivered.”

Alternative Payment Models Goal

By the end of 2016 have 30 percent of Medicare payments in alternative payment models.

By the end of 2018 have 50 percent of Medicare payments in alternative payment models.

The Medicare Shared Savings Program (MSSP) and Pioneer Accountable Care Organizations (ACOs), the Bundled Payment for Care Initiative, and the Comprehensive Primary Care Initiative are examples of current Alternative Payment Models. “HHS is working with private payers, including health plans in the Health Insurance Marketplace and Medicare Advantage plans, as well as state Medicaid programs to move in the same direction toward alternative payment models and value-based payment to providers and to meet or exceed the goals outlined above wherever possible.”

Value Based Payments Goal

By 2016 have 85 percent of Medicare fee-for-service payments tied to quality of value.

By 2018 have 90 percent of Medicare fee-for-service payments tied to quality of value.

The Hospital Value Based Purchasing Program, Hospital Readmission Reduction Program and the Hospital-Acquired Condition Program are the three Affordable Care Act Mandated Quality Programs that have begun to tie a hospitals payment to quality of value.

How to Reach the Goals

Secretary Burwell also announced the creation of a Health Care Payment Learning and Action Network. This Network “will accelerate the transition to more advanced payment models by fostering collaboration between HHS, private payers, large employers, providers, consumers, and state and federal partners. Working together, Learning and Action Network partners will:

• Serve as a convening body to facilitate joint implementation and expansion of new models of payment and care delivery
• Identify areas of agreement around movement toward alternative payment models and define how best to report on these new payment models
• Collaborate to generate evidence, share approaches, and remove barriers
• Develop common approaches to core issues such as beneficiary attribution, financial models, benchmarking, and risk adjustment
• Create implementation guides for payers and purchasers

Alignment between HHS, private sector payers, employers, providers, and consumers will help health care payments transition more quickly from pure fee-for-service to alternative payment models – a critical step toward better care, smarter spending, and healthier people.” The first Network meeting is set for March 2015.

As health care in this country is propelled towards new payment models and payment for quality instead of quantity, there are a couple of valuable resources that hospitals should be familiar with.

First is the CMS Innovation Center. Per the Affordable Care Act, “the purpose of the [Center] is to test innovative payment and service delivery models to reduce program expenditures…while preserving or enhancing the quality of care furnished to individuals under such titles.” I encourage you to visit their website to find out where and what Innovation is Happening in your state and while there check out the November 10, 2014 CMS Innovation Center Update Webinar that featured Dr. Patrick Conway, CMS Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer.

A second resource is the Health Care Transformation Task Force. On January 28, 2015, just two days after the CMS announcement, this group “whose members include six of the nation’s top 15 health systems and four of the top 25 health insurers, challenged other providers and payers to join its commitment to put 75 percent of their business into value-based arrangements that focus on the Triple Aim of better health, better care and lower costs by 2020.”

Resources:

Fact Sheet: Better Care, Smarter Spending, Healthier People: Why It Matters: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-2.html

Fact Sheet: Better Care, Smarter Spending, Healthier People: Paying Providers for Value, Not Volume: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html

Fact Sheet: Better Care, Smarter Spending, Healthier People: Improving Out Health Care Delivery System: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26.html 

American Hospital Association Response to January 26th Announcement:

http://www.aha.org/presscenter/pressrel/2015/150126-pr-medicare.shtml

American Medical Association Response to January 26th Announcement: http://www.ama-assn.org/ama/pub/news/news/2015/2015-01-26-hhs-shifting-medicare-reimbursements-volume-value.page

Yes, it is true that in this age of electronic health records (EHRs) that most Physician notes are no longer written with a pen. However, in the January 2015 release of the Medicare Quarterly Compliance Newsletter, there are two Comprehensive Error Rate Testing (CERT) review findings that share the denial commonality of “the physician’s failure to document a reasonable expectation that the beneficiary would require a hospital stay that would cross 2 or more midnights.” So hand written or electronic, it is a fact that the denials were due to the Physician’s pen.

First, for those that may still be unfamiliar with this newsletter, it is a resource provided by the CMS to serve as an “educational product, to help providers understand the major findings identified by MACs, Recovery Auditors, Program Safety Contractors, Zone Program Integrity Contractors, the Comprehensive Error Rate Testing (CERT) review contractor and other governmental organizations, such as the Office of Inspector General.” If you are interested in viewing past issues, the CMS maintains a Newsletter Archive of all of the newsletters to date.

The January edition of the newsletter includes findings from the Office of Inspector General (OIG), Recovery Auditor and CERT. This article focuses on two of the CERT findings.

Surgical Procedures Related to Hemodialysis being billed as an Inpatient
Provider Types Affected: Physicians and Hospitals

Background

Placement of an arteriovenous fistula (AVF) is the best option for beneficiaries requiring hemodialysis for end-stage renal disease (ESRD). The procedure is typically an outpatient procedure. “Inpatient hospital admission is appropriate when the beneficiary has some other acute problem requiring inpatient care or when a serious post-operative complication arises.”

Medicare payment to a hospital for surgical procedures includes the procedure itself and all normal post-op recovery and monitoring even if the monitoring extends overnight. Also, hemodialysis and a beneficiary’s need for chronic hemodialysis “does not justify an inpatient hospital admission for a vascular access-related procedure.”

Review Finding

Most improper payments identified by the CERT were due to the hospital inappropriately billing Medicare for the surgery and post-op care as an inpatient hospital admission.

Denial due to the Physician’s Pen

The CERT asserted that the most common denial for an inpatient hospitalization spanning less than 2 midnights “is the physician’s failure to document a reasonable expectation that the beneficiary would require a hospital stay that would cross 2 or more midnights.”

What You Should Know

“Physicians do not need to include a separate attestation of the expected length of stay; rather, this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes. Expectation of time and the determination of the underlying need for medical care at the hospital are supported by complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event, which are expected to be documented in the physician’s assessment and plan of care.”

The 2 Midnight Rule and Elective Procedures
Provider Types Affected: Physicians Facilities and Hospitals

Background

The 2014 IPPS Final Rule (CMS-1599-F) 2-Midnight Rule provision maintains that an inpatient admission and payment under Medicare Part A is generally appropriate when the physician:

1. “Expects the beneficiary to require a stay that crossed at least two midnights; and
2. Admits the beneficiary to the hospital based upon that expectation.”

Medicare Administrative Contractors (MACs) have been performing reviews under the Probe and Educate Program that began with admissions on or after October 1, 2013 and is currently set to end on March 31, 2015.

This review focuses on the review findings “as they pertain to admissions for elective procedures.”

Exception to the 2 Midnight Rule and Unforeseen Circumstances

When the Expected Length of Stay was Less Than 2 Midnights

It would not be appropriate to admit a beneficiary as an inpatient when they present for an elective surgical procedure that is not designated as Inpatient Only by Medicare and the physician does not expect to keep the patient in the hospital beyond 2 midnights.

Contractors will deny this type of claim unless there is documentation in the record of an approved exception. Currently the only approved exception is “newly initiated mechanical ventilation (excluding anticipated intubations related to minor surgical procedures or other treatment).”

When the Expected Length of Stay was 2 or More Midnights

There are times when a physician expects a beneficiary to require a 2 midnight or longer hospitalization but due to unforeseen circumstance the stay is less than 2 midnights. CMS approved examples of unforeseen circumstances includes “unexpected death, transfer to another hospital, departure against medical advice, clinical improvement, and election of hospice care in lieu of continued treatment in the hospital.”

Denial due to the Physician’s Pen

The CERT again asserted in this review that the most common denial for an inpatient hospitalization spanning less than 2 midnights “is the physician’s failure to document a reasonable expectation that the beneficiary would require a hospital stay that would cross 2 or more midnights.”

Two examples of Medicare Part A Inpatient Denied Claims provided in this review include a vascular procedure where the documentation did not support the inpatient admission and a urologic procedure where there was no inpatient order and the documentation did not support a 2 midnight expectation.

What You Should Know

Just as in the first CERT review findings, this article asserts that what you should know is that “Physicians do not need to include a separate attestation of the expected length of stay; rather, this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes. Expectation of time and the determination of the underlying need for medical care at the hospital are supported by complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event, which are expected to be documented in the physician’s assessment and plan of care.”

I encourage you to take the time to read this entire newsletter as it provides the issues, what you should know as well as valuable links to resources to find more information about each review type.

It pains me to admit that my nursing school days are now decades in the past. With that said, there are still key mnemonics that helped me survive the information overload. One particular example is the five stages of coping or D.A.B.D.A. (Denial, Anger, Bargaining, Depression and Acceptance). As I began writing this article it struck me that the stages of coping must be similar to the stages hospital Appeals Coordinators are dealing with in regards to Medicare’s five stages of appeals.

Level 1: Redetermination by a Medicare Administrative Contractor (MAC) a.k.a. Denial

Once a claim has been denied by your MAC, and on internal review you can’t believe that the hospitalization was denied you would request a Redetermination. It is at this level that the MAC will perform a document review of the initial claim determination.

Level 2: Reconsideration a.k.a. Anger

At this point you can become both frustrated and irritated that the same MAC has denied what you believe to be a medically necessary hospitalization twice so you press on to the Reconsideration level. At this level a Quality Independent Contractor (QIC) will perform a document review of the Redetermination and a hospital may still submit any evidence not previously present to support the medical necessity for the admission.  

Level 3: Administrative Law Judge (ALJ) Hearing a.k.a. Bargaining

It is at this level that we will spend the most time on today.

This past July, Nancy J. Griswold, the Chief Administrative Law Judge for the Office of Medicare Hearings and Appeals (OMHA) made a statement before the United States House Committee on Oversight & Government Reform. Ms. Griswold reported that the OMHA adjudication capacity is approximately 72,000 appeals a year. However, “weekly appeal levels have ranged between 10,000 and 16,000 throughout FY 2014. As a result, OMHA had over 800,000 appeals pending on July 1, 2014. At current receipt and adjudication capacity levels, OMHA’s Central Operations, which is the focal point for all incoming appeals, is receiving one year’s worth of appeals every four to six weeks.”

So, what exactly does this translate into at the individual hospital level? According to the OMHA web page, “the average processing time for appeals decided in fiscal year 2014 is 414.8 days.” However, as you continue to look through their web page, by September of this year the average appeals processing time was 514.5 days.

Added to this delay is the recent release of Transmittal 543 where CMS asserts that “significant time and effort is spent by CMS and its contractors to ensure that review staff are making quality decisions. It is important for contractors to support and defend their medical review decisions throughout the appeals process, including at Administrative Law Judge (ALJ) hearings.” In line with this assertion this Transmittal instructs Medicare Administrative Contractors (MACs) “to support their medical review decisions through the ALJ level of appeal.”

Key Guidance in Transmittal 543 Effective October 27, 2014:

• For claim determinations made by the MAC they “shall assign a physician to participate or take party status “ at ALJ hearings,
• The Physician “is generally the primary individual overseeing and/or taking party/participant status, a contractor may elect to have an attorney or clinician take party or participant status, or another qualified individual if approved by the COR.”
• MACs shall determine a process to identify cases that they will participate in at the ALJ level of appeal. “Factors to be examined should include, but not be limited to policy implications, dollars at issue, source of the denial, program integrity matters, and the extent to which a particular issue is, or has been, a recurring issue at the ALJ level of appeal.”
• “MACs shall coordinate with the QIC to ensure timely notification of all ALJ hearings.”
• “For extrapolation cases, the MAC shall be prepared to discuss the background on how the provider/supplier was selected for review, results of the sample case adjudications, as well as matters related to the extrapolation process.”

Why include the MACs now? In part, this could be in response to the 2012 OIG report where the OIG found that improvements are needed at the ALJ Medicare Appeals level, that in FY 2010 the ALJ reversed the decisions of the QICs in favor of the appellants 56 percent of the time, and one recommendation made in this report was to “continue to increase CMS participation in the ALJ appeals.”

This is where the bargaining comes into play. As a hospital, should we stay the course with the appeal even though it may be more than a year before it goes before the ALJ, or should we consider one of the options currently being offered by CMS (Statistical Sampling Initiative, Settlement Conference Facilitation Pilot, or the Medicare Appeals Settlement Offer)?

Level 4: Medicare Appeals Council Review a.k.a. Depression

CMS instructs that “if you disagree with the ALJ decision, or you wish to escalate your appeal because the ALJ ruling timeframe passed, you may request a Medicare Appeals Council review.”

It is also at this level that it would be easy for depression to set in due to the fact that even though you continue to believe in the medical necessity of the case you are appealing you also realize that by now you have spent countless hours and more than likely at least two years or more championing your appeal.

Level 5: Judicial Review a.k.a. Acceptance

Escalation to this level can happen when “you disagree with the Appeals Council decision, or you wish to escalate your appeal because the Appeals Council ruling timeframe passed.” At this level, win or lose, you should be prepared that this is the end of the line for the case you have been defending.

Resources:

Transmittal 543: Defending Medical Review Decisions at Administrative Law Judge (ALJ) Hearings: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R543PI.pdf

Link to OIG November 2012 Report – Improvements are Needed at the Administrative Law Judge Level of Medicare Appeals: http://oig.hhs.gov/oei/reports/oei-02-10-00340.pdf

Link to Statement of Nancy J. Griswold, Chief Administrative Law Judge to the United States House Committee on Oversight & Government Reform: http://oversight.house.gov/wp-content/uploads/2014/07/CMS-Griswold-OMHA-Final.pdf

Link to Medicare Learning Network’s Medicare Appeals Process Fact Sheet (ICN 006562 August 2014): http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedicareAppealsprocess.pdf

Link to Statistical Sampling Initiative: http://www.hhs.gov/omha/statistical_sampling_initiative.html

Link to Settlement Conference Facilitation Pilot: http://www.hhs.gov/omha/settlement_conference_facilitation_pilot.html

Medicare Appeals Settlement: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html

Coders probably sometimes feel as if they are searching for the proverbial needle in the haystack. They must evaluate an entire medical record to pick out the key condition responsible for a patient’s admission and other conditions that affect the patient’s treatment. Not easy considering the issues with incomplete, illegible, and conflicting documentation that may be present. And then there are the numerous coding rules of which coders must be aware and stay current. Our hats off to coders everywhere.

Last week, we reviewed the CERT findings from the July 2014 Medicare Compliance Quarterly Newsletter which focused on documentation deficiencies. This week we will look at some coding errors identified by the Recovery Auditors (RACs) detailed in the July Compliance Newsletter. These are brief summaries of the examples given in the newsletter. I encourage everyone to carefully review the examples in the newsletter for complete understanding.

Heart Failure and Shock (MS-DRGs 291, 292 and 293)

The RACs identified errors for these DRGs in both the sequencing of the principal diagnosis and in improper coding of the secondary diagnosis.

• The patient presented with decompensated congestive heart failure (CHF) and a pleural effusion with pulmonary edema. The physician did not state the cause of the pleural effusion so this should be coded as pleural effusion not otherwise specified (NOS) (511.9), instead of pleural effusion not elsewhere classified (NEC) (511.8). Coding Clinic has noted that pulmonary effusions are often seen with CHF with and without pulmonary edema and may be reported as an additional diagnosis. In this case the change in the secondary diagnosis changes the DRG assignment from 291 to 292, resulting in an overpayment.
• In the second example provided, a patient is diagnosed with CHF and an acute myocardial infarction. The reason for admission as determined after study was the acute MI (410.71), not the heart failure (428.20) also changing the DRG assignment to a lower weighted DRG.

NOTE

Medical Management Plus Inpatient Coders offer the following comments concerning pleural effusions with CHF: Coders assume a relationship between pleural effusions and CHF unless stated otherwise. Pleural effusion is considered to be integral to the CHF disease process and will normally clear with treatment for the CHF. It would not typically be assigned its own diagnosis code. Pleural effusions may only be reported as an additional diagnosis if the condition is specifically evaluated or treated, but reporting is not required. Evaluation may involve special x-rays such as decubitus views or diagnostic thoracentesis and it may be necessary to address the effusion by therapeutic thoracentesis or chest tube drainage.

Effective 2009, ICD-9 code 511.8 required a 5th digit and was removed from the MCC list. Both 511.8x and 511.9 are now CCs.

Postoperative or Posttraumatic Infections with Operating Room (OR) Procedure with Complications and Comorbidities (CC) (MS-DRG 857)

Both examples given for this DRG involve improper diagnosis code assignment in cases where the infection and complications were associated with implanted devices and not with the surgical procedure itself. In these examples, code 998.59 (postoperative infections) should not have been assigned as the principal diagnosis code because it excludes infections due to implanted devices.

• The first involved a total knee prosthesis which should have been coded with a principal diagnosis code of 996.66, Infection and inflammatory reaction due to internal prosthetic device implant and graft. The secondary diagnosis code of 998.12, hemorrhage or hematoma complicating a procedure, was replaced with ICD-9 diagnosis code 997.77 other complication due to internal joint prosthesis. This resulted in a DRG change from 857 to 487.
• The second patient was treated surgically for a pocket infection of a pacemaker. A correct principal code assignment of 996.61, Infection and inflammatory reaction due to cardiac device, implant, and graft changed the MS-DRG from DRG 857 to DRG 261.

Amputations (MS-DRGs 239, 240, 241, 474, 475, and 476)

The final inpatient coding errors involved secondary diagnoses coded with amputation DRGs. The code assignments were not supported by the physician documentation for acute heart failure or acute renal failure. Removing or correcting these diagnosis codes removed the MCC resulting in lower weighted DRGs.

Coders have a difficult task of reviewing an entire medical record and selecting the appropriate principal and secondary diagnoses. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care” but careful consideration must be used in making this determination, such as what was the actual reason for the admission and the focus of treatment. Also, secondary diagnoses must be clearly supported by the physician’s documentation in the medical record and correctly selected based on coding guidelines. Errors in code sequencing and selection can easily lead to an overpayment.