Knowledge Base Category -

Q:

Where can I find the new QIO contact information that we should put on the Important Message from Medicare (IM) letter?

A:

As of August 1st, the QIO Program began its 11th Scope of Work (SOW). The newly created Beneficiary and Family Centered Care – Quality Improvement Organizations (BFCC-QIOs) are responsible for managing discharge appeals.

There are two BFCC-QIOs for the nation. CMS awarded the two BFCC-QIOs contracts to Livanta, LLC located in Annapolis Junction, Maryland and KePRO located in Seven Hills Ohio. The 50 states, DC, Puerto Rico and the Virgin Islands have been divided into Five (5) Areas.

CMS has provided a 2014 QIO Program Transition Fact Sheet for Providers and Suppliers. In this fact sheet CMS instructs Providers that a list of current BFCC-QIOs as well as the Quality Innovation Network (QIN) QIOs can be found at http://www.qioprogram.org under Locate Your QIO.

Q:

How do you determine the level of physician supervision required for hospital outpatient therapeutic and diagnostic services?

A:

The answer is sort of like putting together a jigsaw puzzle. There is a piece here and a piece there. Terms defined in one place, then defined further in another place, codes in the physician RVU file, and a new type of service supervision designation altogether. Let’s see if we can put the pieces in place.

Definitions

Definitions of the levels of supervision can be found in the Code of Federal Regulations at 42 CFR 410.32 (b).

• General supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure.
• Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. CMS has further defined direct supervision for services provided in a hospital in the Medicare Benefit Policy manual, chapter 6, sections 20.4 and 20.5 as noted below.
• Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

This section of the CFR also discusses some exceptions to diagnostic supervision requirements such as mammography services, audiology tests, laboratory tests, and a few other exceptions.

In the Medicare Benefit Policy manual, CMS clarifies the definition of “direct supervision” as it relates to hospital services performed during or after CY 2011 – “whether directly or under arrangement in the hospital or in an on-campus or off-campus outpatient department of the hospital as defined at 42 CFR 413.65, “direct supervision” means that the physician must be immediately available to furnish assistance and direction throughout the performance of the procedure. As discussed below, the physician is not required to be present in the room where the procedure is being performed or within any other physical boundary as long as he or she is immediately available…. Immediate availability requires the immediate physical presence of the supervisory physician. CMS has not specifically defined the word “immediate” in terms of time or distance; however, an example of a lack of immediate availability would be situations where the supervisory physician is performing another procedure or service that he or she could not interrupt. Also, for services furnished on-campus, the supervisory physician may not be so physically distant on-campus from the location where hospital outpatient services are being furnished that he or she could not intervene right away. The hospital or supervisory physician must judge the supervisory physician’s relative location to ensure that he or she is immediately available… The supervisory physician must have, within his or her State scope of practice and hospital-granted privileges, the knowledge, skills, ability, and privileges to perform the service or procedure… The supervisory responsibility is more than the capacity to respond to an emergency, and includes the ability to take over performance of a procedure or provide additional orders.”

Hospital Outpatient Diagnostic Services

The supervision requirements for hospital outpatient diagnostic services can be found in the Medicare Benefit Policy manual, chapter 6, section 20.4. Section 20.4.4 explains that supervision levels for individual diagnostic tests are listed in the quarterly updated Medicare Physician Fee Schedule (PFS) Relative Value File which can be found on the Medicare Physician RVU File webpage. After selecting the year and quarter (quarters identified by A (January), B (April), C (July), etc.), download the zip files, select the PPRRUV14 spreadsheet and locate the “Physician Supervision of Diagnostic Procedures” column (column Z in this year’s spreadsheets). Hospitals are interested in the designation for the technical component (TC) of diagnostic services. The supervision levels are listed by codes, the definitions of which can be found in the Medicare Benefit Policy manual, chapter 15, section 80. The main designations are:

• 1 - Procedure must be performed under the general supervision of a physician.
• 2 - Procedure must be performed under the direct supervision of a physician.
• 3 - Procedure must be performed under the personal supervision of a physician.
• 9 - Concept does not apply.

Certain diagnostic tests performed personally by non-physician practitioners (NPPs) do not require physician supervision but NPPs may not supervise diagnostic tests when performed by other hospital staff.

Hospital Outpatient Therapeutic Services

Section 20.5.2 of chapter 6 of the Benefit Policy Manual describes the supervision requirements for therapeutic services - all therapeutic services provided to hospital outpatients generally require direct supervision by an appropriate physician or NPP although CMS may assign a different level of supervision to some therapeutic services. In addition to physicians and clinical psychologists, licensed clinical social workers, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives may furnish the required supervision of hospital outpatient therapeutic services that they may personally furnish in accordance with State law and all additional rules governing the provision of their services. However, pulmonary and cardiac rehab services require that a physician provide the direct supervision.

CMS may designate certain services to general or personal supervision or beginning in 2011, as non-surgical extended duration therapeutic services. Extended duration services require direct supervision during the initiation of the service followed by general supervision for the remainder of the service at the discretion of the supervising practitioner. The service can transition to general supervision after the beginning portion of the service when the supervising practitioner decides the patient is stable enough for general supervision. The point of transition to general supervision must be documented in the patient’s progress notes or medical record. A list of “Hospital Outpatient Therapeutic Services Designated as General or NSEDTS” is available in the downloads section on the Hospital OPPS webpage.

Q:Should physician queries be part of the legal medical record? 

A:

At MMP we have seen facilities maintain queries as part of the legal medical record and other facilities maintain the query forms within the CDI Department. Ultimately, this is a hospital specific decision.

Below are excerpts from two complimentary AHIMA Practice Briefs where they have provided guidance regarding query retention.

Query Retention

Retention of the query varies by healthcare organization. First, an organization must determine if the query will be part of the health record. If the query is not part of the health record, then the organization must decide if the query is kept as part of the business record or only the outcome of the query is maintained in a database.

Before this decision is made a discussion with the facility compliance and legal staff may be beneficial. Regardless, the query should be retained indefinitely if it contains information not documented in the health record. Auditors may request copies of any queries in order to validate the query wording, even if they are not considered part of the legal medical record.

With the current culture of governmental audits (e.g., RACs and MACs), it is helpful to keep the query a permanent part of the health record to demonstrate compliant and ethical CDI practices. The permanent query demonstrates the CDI professional’s attempt to seek clarification. It also can demonstrate to the administration the CDI professional’s efforts to communicate to the medical staff.

Keeping the query as part of the health record can also refute a healthcare provider’s assertion that he or she was unaware of the need for additional documentation. Finally, a permanent document in the health record serves to reduce redundancy and decrease the risk of a duplicate, retrospective query.

Article Citation: AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010); expanded web version.

Link to Guidance: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_047343.hcsp?dDocName=bok1_047343

Develop Query Retention Policies

Each organization should develop internal policies regarding query retention. Ideally, a practitioner’s response to a query is documented in the health record, which may include the progress notes or the discharge summary. If the record has been completed, this may be an addendum and should be authenticated. As noted in AHIMA’s toolkit, “Amendments in the Electronic Health Record,” “the addendum should be timely, bear the current date, time, and reason for the additional information being added to the health record, and be electronically signed.”

Organizational policies should specifically address query retention consistent with statutory or regulatory guidelines. The policy should indicate if the query is part of the patient’s permanent health record or stored as a separate business record. If the query form is not part of the health record, the policy should specify where it will be filed and the length of time it will be retained. It may be necessary to retain the query indefinitely if it contains information not documented in the health record. Auditors may request copies of any queries in order to validate query wording, even if they are not considered part of the legal health record.

An important consideration in query retention is the ability to collect data for trend analysis, which provides the opportunity for process improvement and identification of educational needs.

Article Citation: AHIMA. “Guidelines for Achieving a Compliant Query Practice.” Journal of AHIMA 84, no.2 (February 2013): 50-53.

Link to Guidance: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_050018.hcsp?dDocName=bok1_050018

Q:

What discharge disposition do I use if one of our patients is transferred to a swing bed in another hospital since the description for discharge disposition (61) is entitled, “Discharged/Transferred Within This Institution to a Hospital-Based Medicare Approved Swing Bed?”

A:

Discharge disposition (61) may also be used for patients who are transferred to a Medicare-approved swing bed located in another facility. CMS notes that there has been confusion with this discharge disposition and refers us to MedLearn Matters, article SE0408, March 10, 2004 for further review. Please note the two additional references below, Medicare State Operations Manual and the Uniform Billing Editor by Optum also states a patient may be transferred to a Medicare-approved swing bed in another facility.

Medicare State Operations Manual

§482.66 Special Requirements for Hospital Providers of Long-Term Care Services (“Swing-Beds”)

The change in status from acute care to swing-bed status can occur within one facility or the patient can be transferred to another facility for swing-bed admission.

Uniform Billing Editor by Optum

For Medicare, this code is used to report patients who have been discharged/ transferred to a SNF level of care within the hospital’s approved swing-bed arrangement, or to another Medicare-approved swing bed in another location.

Q:

Is it appropriate for a testing laboratory to provide a copy of lab results directly to the patient or their representative?
 

A:

Yes. On February 6, 2014, CMS released a final rule that allows laboratories, upon the patient’s request (or upon the request of the patient’s personal representative), to provide access to completed lab tests results directly to the patient or their personal representative under the Clinical Laboratory Improvement Act (CLIA) and HIPAA privacy regulations. Laboratories that are HIPAA covered entities (i.e. conduct covered health care transactions electronically) are required to provide patients with access to their lab results upon request under this new rule. This final rule is effective April 7, 2014 and HIPAA covered entity laboratories have until October 6, 2014 to comply with the new rule. Prior to this new regulation, CLIA regulations limited the release of laboratory tests results to persons authorized under state law to order and/or receive test results, the person responsible for using the test results in the treatment context, and the laboratory that initially requested the test.

Hospital-based laboratories have a big advantage over independent laboratories in the implementation of this rule. Most hospital laboratories will likely handle the new requirement by directing patients to the Hospital HIM Release of Information (ROI) department. These hospital ROI departments are already knowledgeable concerning the HIPAA regulations and have processes in place to address the requirements of HIPAA, such as positive identification of the person requesting a copy of the medical record, pricing for copies, documentation of the release, etc.

For complete information, please see the CLIA Program and HIPAA Privacy Rule; Patients’ Access to Test Reports; Final Rule.

Q:

When we perform a self-audit after a patient has been discharged and the documentation does not support a 2-Midnight expectation do we have to notify the beneficiary of the change from a Part A claim to a Part B claim?

A:

This question was addressed on pages 50913 – 50914 of the 2014 IPPS Final Rule.

Commenters asked that CMS clarify whether or not they were “proposing a self-audit process that would have to conform to the utilization review rules under the CoPs, notably physician concurrence, beneficiary notification, and other aspects related to continuation of an inpatient stay.”

CMS’s response was that “we did not propose and are not finalizing a policy that would allow hospitals to bill Part B following an inpatient reasonable and necessary self audit determination that does not conform to the requirements for utilization review under the CoPs. We do not agree with the commenters that beneficiaries need not be notified of a hospital’s determination that the inpatient admission was not reasonable and necessary. Part B billing pursuant to such a determination may result in an increase in financial liability for some beneficiaries which hospitals may not be able to ‘‘waive’’ or forego attempting to collect (we refer readers to sections XI.B.5 and B.6. of the preamble of this final rule). We believe that the CoP rules for beneficiary notification and physician involvement in hospital utilization review decisions are important for maintaining beneficiary rights, consistent with 42 CFR 482.13.”

§482.30 Condition of participation: Utilization Review

This CoP instructs that if after review the Utilization Review Committee determines that a stay was not medically necessary, written notification must be provided to the hospital, patient and MD responsible for the patient’s care, within 2 days of the decision being made.

Question:

Were there any changes to the Post-Acute Transfer and Special Payment Policy in the 2014 IPPS Final Rule?

Answer:

MLN Matters® Number: MM8421 (Effective Date: October 1, 2013) indicates that no changes were made to the Post-acute and Special Post-acute payment policy or applicable DRGs for FY 2014.

This article goes on to “note that the new Patient Status codes (81-95) that refer to ‘Planned Readmissions’ have been mapped to their non-planned readmission counterparts and are included in the transfer policy.

The entire MLN Matters® article can be found at: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8421.pdf

2-Midnight Benchmark and Psychiatric Services

Question:

Does the new 2-Midnight Benchmark apply to Inpatient Psychiatric Services?

Answer:

Yes, per the excerpt from the 2014 IPPS Final Rule below, the 2-Mignight Benchmark does apply to Inpatient Psychiatric Services.

“Comment: Commenters questioned the applicability of the proposed rule to differing types of hospital facilities. Commenters specifically requested clarity regarding application of the rule to IRFs and IPFs. Commenters further asserted that this distinction may conflict with State laws requiring inpatient admissions post 24 hours, and such States should be granted exception.

Response: In the proposed rule, our reference to section 1861(e) of the Act was intended to specify that CAHs were included in the proposed policies, not that we were proposing that IPFs or other non-IPPS hospitals should be excluded. Having considered the public comments to the proposed rule, we believe that all hospitals, LTCHs, and CAHs, with the exception of IRFs, would appropriately be included in our final policies regarding the 2-midnight admission guidance and medical review criteria for determining the general appropriateness of inpatient admission and Part A payment. Due to the inherent differences in the operation of and beneficiary admissions to IRFs, such providers must be excluded from the aforementioned admission guidelines and medical review instruction. We disagree with the commenters’ assertion that the 2-midnight admission and medical review policies conflict with existing state laws regarding observation. The 2-midnight benchmark does not prohibit physicians from ordering inpatient admission in accordance with state law; rather, this policy indicates when Medicare payment will be deemed appropriate. To the extent that State law requires admission in situations where Medicare payment would not be appropriate, providers should work with their States to resolve those discrepancies.”

Source: Federal Register / Vol. 78, No. 160 / Monday, August 19, 2013 / Rules and Regulations 50949

Question:

If there is no stop time for an infusion, how is this to be reported?

Answer:

If there is no stop time for an infusion, it should be reported as an IV push.

However, be sure to look for other documentation that might support the duration of the infusion service, such as:

• Periodic drug titrations
• Nurse’s notes that the infusion is still in progress
• Nurse’s notes that the infusion continued at the time of transfer
• Documentation of the total hours infused (the most recent guidelines from Cahaba GBA indicate they will accept documentation of “total hours infused”)

Remember, the time the IV is discontinued or removed is not necessarily the same as the infusion stop time.

Case Mix Index

Question:

What is Case Mix Index (CMI)?

Answer:

CMI is the sum of the relative weights of all DRGs assigned to Medicare inpatient cases, billed by the hospital in a given time-frame, divided by the total number of cases.

Formula for CMI:Total Relative Weights ÷ Total DRGs Coded = CMI

CMI:

•Measures the cost or resources needed to treat patients

•Calculated from billed data

•Reveals how sick your patients really are

•The higher the CMI the more complex the patients are, indicating that they have utilized costly and/or complex resources