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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.

I love reading, writing and the English language – I am such a grammar geek that I actually belong to a “grammar” blog. In writing, you want to make sure you are choosing your words wisely and appropriately – in other words, definitions matter. As we see in this quarter’s Medicare Compliance Newsletter, definitions also matter when billing for your services to Medicare, especially the definitions related to procedure and diagnosis codes.

Last week we addressed a couple of CERT issues from the January Medicare Quarterly Provider Compliance Newsletter that affected hospital inpatient claims. This week we will look at some deficiencies with outpatient records identified by the Recovery Auditors.

Extracorporeal Photopheresis – CPT 36522

Medicare covers extracorporeal photopheresis (drug and UVA light treatment of white blood cells) only for certain conditions per National Coverage Determination 110.4. This procedure is covered by Medicare for:

• Palliative treatment of skin manifestations of cutaneous T-cell lymphoma that has not responded to other therapy
• Patients with acute cardiac allograft rejection whose disease is refractory to standard immunosuppressive drug treatment
• Patients with chronic graft versus host disease whose disease is refractory to standard immunosuppressive drug treatment

Medicare claims for CPT 36522 must contain one of the following ICD-9 diagnosis codes for the above covered conditions to support medical necessity and be eligible for Medicare payment: 202.10-202.18 and 202.20-202.28, 996.83, or 996.85. A RAC automated review identified overpayments for claims with this service that did not contain an appropriate diagnosis code.

Facet Joint Injections

According to the newsletter, “Medicare will consider facet joint blocks to be reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint.” Due to findings from RAC reviews, Medicare reminds providers about the following facts of facet joint injections:

• It is expected that facet injections reported with CPT codes 64490-64495 will be performed under fluoroscopic guidance.
• Multiple nerves innervate each facet joint, but injections are to be reported per facet joint level, not per nerve. Facet joint levels refer to the joints that are blocked and not the number of medial branches that innervate them. For example, CPT codes 64490 and 64493 are used to report all of the nerves that innervate the first level paravertebral facet joint and not each nerve; CPT codes 64491, 64492, and 64494, 64495 report all nerves at the second and third additional levels and not each additional nerve.
• Codes 64490-64495 are unilateral procedures.
• Use modifier 50 to report bilateral injections (facet joint injections on both the right and left sides of one level of the spine). If multiple bilateral injections are performed, modifier 50 should accompany each facet CPT joint injection code that was performed on both sides of one level.
• Only one facet injection code should be reported at a specific level and side injected (e.g., right L4-5 facet joint), regardless of the number of needle(s) inserted or number of drug(s) injected at that specific level.

IV Infusion Units

Providers are to report only one “initial” intravenous infusion code for chemotherapy and therapeutic infusions (CPT codes 96413, 96365, and 96369) per day unless the patient has two different infusion sites or more than one visit on the same day. In the case of two infusion sites or multiple encounters, it is appropriate to append a -59 modifier to the second “initial” service. An initial infusion code is defined in MLN Matters Article MM3818 as the code that “best describes the key or primary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur." Also be sure to follow the CPT reporting hierarchy for drug administration codes in selecting the initial service.

Hospitals need to bear in mind that for drug administrations, observation services spanning more than one day are considered one encounter as explained in the Medicare Claims Processing Manual, Chapter 4, section 230:

“Drug administration services are to be reported with a line item date of service on the day they are provided. In addition, only one initial drug administration service is to be reported per vascular access site per encounter, including during an encounter where observation services span more than 1 calendar day.”

As always, it benefits providers to pay attention to the details when billing Medicare – such as the definitions of “initial” infusion and facet joint “level” versus nerve. In coding and billing, definitions matter!

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

Medical Management Plus enjoys acknowledging the various healthcare professionals with whom we work during their designated annual recognition times. October is National Physical Therapy month and we thank all of those who work diligently in the physical therapy occupation to improve the health of their patients. In association with this recognition, here are some questions and answers related to Medicare therapy services.

1. If a patient in a hospital setting (observation or inpatient) receives therapy services, do you have to follow the Part B (general considered outpatient) therapy guidelines?
2. outpatients receiving observatipon services
3. inpatients whose inpatient admission does not meet criteria so only Part B services are billed, and
4. inpatients who only have Medicare Part B coverage (patient does not have Medicare Part A or Part A benefits are exhausted).
   The 2014 IPPS Final Rule states “we (CMS) believe we also must apply the therapy caps and all other Part B coverage and payment rules to hospital inpatient therapy services paid under Part B. Accordingly, (therapy services) billed to Medicare Part B, … will be subject to the Part B therapy caps …, the therapy caps exceptions process, the manual medical review process, and all other requirements for payment and coverage of therapy services under Part B (for example, functional status reporting requirements).”
5. Is a discharge summary required for all Medicare patients receiving outpatient therapy services?Yes, the Medicare Benefits Policy Manual, Chapter 15, Section 220.3 states:
   “The Discharge Note (or Discharge Summary) is required for each episode of outpatient treatment. … The discharge note shall be a progress report written by a clinician, and shall cover the reporting period from the last progress report to the date of discharge. In the case of a discharge unanticipated in the plan or previous progress report, the clinician may base any judgments required to write the report on the treatment notes and verbal reports of the assistant or qualified personnel.”
6. If a patient discontinues outpatient therapy unexpectedly, must you report a discharge functional limitation HCPCS (G) code and modifier? What do you do if the same patient later returns to continue therapy?
   
   Per MLN Matters Special Article SE 1307: “Discharge reporting is required at the end of the reporting episode or to end reporting on one functional limitation prior to reporting on another medically necessary functional limitation. The exception is in cases where the beneficiary discontinues therapy expectantly. When the beneficiary discontinues therapy expectantly, we encourage clinicians to include discharge reporting whenever possible on the claim for the final services of the therapy episode.
   
   When a beneficiary discontinues therapy without notice, and returns less than 60 calendar days from the last recorded DOS to receive treatment for:
7. the same functional limitation, the clinician must resume reporting following the reporting requirements outlined in the “Required Reporting of Functional Codes” subsection; or
8. a different functional limitation, the clinician must discharge the functional limitation that was previously reported and begin reporting on a different functional limitation at the next treatment DOS.
9. NOTE: A reporting episode will automatically be discharged when it has been 60 or more calendar days since the last recorded DOS.
10. Is it appropriate to use modifier 59 to by-pass CCI edits for therapy services that are performed during the same session but at separate times?
11. Yes, per the NCCI manual, “Some NCCI edits pair a “timed” CPT code with another “timed” CPT code or a non-timed CPT code. These edits may be bypassed with modifier 59 if the two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter.”
12. Where can I find the information on the time reporting requirements for rehabilitative therapy services?
13. That information can be found in the,Medicare Claims Processing Manual, chapter 5 ,section 20.2and also -Medicare Therapy Billing Scenarios
14. Are Medicare contractors and affiliates still performing medical review of therapy services?
15. Yes, the RACs continue to perform manual medical review of therapy services exceeding the annual threshold amount and the OIG recently published areview of outpatient therapy services. Although this review focused on an independent therapy provider (not hospital outpatient), the findings are relevant to therapy in either setting. Findings included:
    
16. Plan of Care (POC) goals that were not measurable or pertinent to the patient’s functional limitation,
17. Problems with the therapist’s signature on the POC and treatment notes
18. Lack of specific skilled interventions in the treatment notes
19. Lack of documentation of time
20. Lack of medical necessity for therapy services
21. Progress notes not performed every 10th treatment day
22. Physician certifications not signed and/or dated
23. Other Medicare contractors such as the Medicare Administrative Contractors (MACs) and CERT reviewers may also review therapy records.

As always, therapists have more to worry about than just how their patients are progressing.

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.

Medicare has recently added yet another review contractor to audit your claims – the Supplemental Medicare Review Contractor (SMRC). So why does CMS need so many contractors to fight improper payments and ensure compliance? And what are the differences between the different contractors? I am not sure the answers are really clear, but here is some information from a recent transmittal about the various contractors and their functions.

CMS Transmittal 508 updates the Medicare Program Integrity Manual to include information about the Supplemental Medicare Review Contractor. According to the manual update, SMRCs, along with CERT contractors, Medicare Administrative Contractors (MACs), and Recovery Auditors (RAs) are contracted by CMS to fight improper payments and promote provider compliance in the Medicare fee-for-service program.

CERT Contractors

The CERT program establishes error rates and estimates of improper payments (implemented as part of the Improper Payments Elimination and Recovery Improvement Act).

Medicare Administrative Contractors (MACs)

MACs prevent improper payments through initiatives to help providers comply with Medicare’s coverage, coding and billing rules. This is accomplished through provider education; pre-and post-payment claim review; and local coverage determinations (LCDs), articles, and coding instructions. The MACs use error rates and vulnerabilities identified through the CERT and RA programs to target their efforts.

Recovery Auditors

Because of the large volume of claims that Medicare processes and the difficultly with catching all improper payments, the RAs provide additional review to detect and correct improper payments to help protect the Medicare Trust Funds.

Supplemental MR Contractor (SMRC)

The SMRCs are a centralized medical review (MR) resource that can perform large volume MR nationally. They perform and/or provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs. The focus of SMRC reviews may include but are not limited to issues identified by CMS internal data analysis, the CERT program, professional organizations and other Federal agencies, such as the OIG/GAO and comparative billing reports. Their primary duties include:

• Serving as a readily available source of medical information to provide guidance in questionable situations, including questionable claim review situations
• Providing the clinical expertise and judgment to develop LCDs and internal MR guidelines
• Keeping abreast of medical practice and technology changes that may result in improper billing or program abuse
• Providing clinical expertise and judgment to effectively focus MR on areas of potential fraud and abuse

Are the differences between the contractors clear as mud? Yes, I thought so. But even so, you need to know who the Medicare contractors for your region are. You can find that information by using the Review Contractor Directory.

Is your hospital continuing to struggle to comply with Final Rule CMS-1599-F that went into effect on October 1, 2013? Are you still seeking any and all of the additional information that you can find to help comply with the new rules? If the answer is yes, you are not alone.

In the past couple of weeks CMS has been busy providing additional guidance. First, was the release of MLN Matters® Number: MM8586. This article provides guidance for the new use of Occurrence Span Code 72 to identify outpatient time associated with an inpatient hospital admission. Next, they posted updated guidance regarding the Hospital Inpatient Admission Order and Certification and an updated Reviewing Hospital Claims for Patient Status download to their Inpatient Hospital Review webpage. They also held yet another “Special Open Door Forum” (ODF) to discuss the Hospital Inpatient Admission Order and Certification; 2 Midnight Benchmark for Inpatient Hospital Admissions on February 4th.

As the question and answer portion of the ODF became more of a question being asked and CMS requesting that you submit that question to IPPSAdmissions@cms.hhs.gov, it became apparent that no big “aha” moments were going to be happening. It was at this point that all I could think about was the chorus to the Sonny and Cher 1967 hit song The Beat Goes On. For those old enough to remember this one sing along:

“The beat goes on, the beat goes on

Drums keep pounding

A rhythm to the brain

La de da de de, la de da de da.”

Now that this song is firmly stuck in your head, let’s take a look at the new and updated guidance from CMS.

Occurrence Span Code 72; Identification of Outpatient Time Associated with an Inpatient Hospital Admission and Inpatient Claim Payment:MLN Matters(R) Number: MM8586

Effective Date: December 1, 2013

Implementation Date: February 24, 2014

Why is this being implemented?

• “The redefinition of occurrence span code 72 allows providers to voluntarily identify those claims in which the 2-midnight benchmark was met because the beneficiary was treated as an outpatient in the hospital prior to the formal inpatient admission order. In other words, it permits providers and subsequently review contractors to identify the “contiguous outpatient hospital services (midnights) that preceded the inpatient admission,” as well as the total number of midnights after formal inpatient order and admission, on the face of the claim.”

Hospital Inpatient Admission Order and Certification (January 30, 2014)

CMS’s attempt to clarify the September 5th Guidance fell a little short. However, there were a few key pieces of information to point out to you.

• If you have a Medicare beneficiary waiting on a skilled nursing facility (SNF) bed, CMS indicates that “a beneficiary who is already appropriately an inpatient can be kept in the hospital as an inpatient if the only reason they remain in the hospital is they are waiting for a post-acute SNF bed. The physician may certify the need for continued inpatient admission on this basis.”
• Residents, non-physician practitioners and ED physicians who do not have admitting privileges can make the initial admission decision. “In countersigning the order, the ordering practitioner approves and accepts responsibility for the admission decision.” This counter-signature would “satisfy the order part of the physician certification, as long as the ordering practitioner also meets the requirements for a certifying physician.”
• “If the physician or other practitioner responsible for countersigning an initial order or verbal order does not agree that inpatient admission was appropriate or valid (including an unauthorized verbal order), he or she should not countersign the order and the beneficiary is not considered an inpatient. The hospital stay may be billed to Part A as a hospital outpatient encounter.”

The entire update can be found at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf

Highlights from the February 4, 2014 Special Open Door Forum

• CMS has extended the MAC Probe and Educate Period through September 30, 2014. CMS verified (at a caller’s request) that they have not cancelled or delayed the implementation of the new rule.
• In response to a question about whether or not there had to be a statement indicating the expected length of stay in the record, CMS indicated that there are no “magical words” that need to appear saying the physician certifies the stay. CMS would expect to find “regular good documentation” in the record, not a separate “I certify” statement.
• Another caller asked if the MD does not sign a verbal admit order until after the patient is discharged can we bill for anything? CMS responded that as far as the letter of the law you need the order to submit a Part A claim. If the order was not co-signed then you could submit a Part B Outpatient claim (a 13x type of bill).
• One hospital indicated that they were under the impression that they would receive a letter from their MAC after their records had been reviewed under the Probe & Educate program. CMS indicated that they had asked MACs to hold on letters until additional guidance was released regarding the Inpatient Admission Order and Certification. They went on to indicate that this information was released last week and the MACs should no longer be holding letters.

Reviewing Hospital Claims for Patient Status: Admissions On or After October 1, 2013 (Last Updated: 01/31/14)

There were two specific clarifications made to this Guidance that I would like to point out to you. Prior to this update CMS had indicated that “it is not necessary for a beneficiary to meet an inpatient “level of care,” as may be defined by a commercial screening tool, in order for Part A payment to be appropriate.” In this updated version they further indicate that “In addition, meeting an inpatient “level of care,” as may be defined by a commercial screening tool, does not make Part A payment appropriate in the absence of an expected length of stay of 2 or more midnights.” Once again, CMS is making the point that good physician documentation supportive of a 2 or more midnight admission is the key to the decision to admit a patient as an inpatient.

The other clarification is about the documentation that the MACs would expect to find to support the 2-midnight expectation. CMS indicates that “physicians need not 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.”

National Provider Call: 2-Midnight Benchmark: Discussion of the Hospital Inpatient Admission Order and Certification

CMS is already planning additional education through a National Provider Call on Thursday February 27, 2014 from 2:30 PM – 4:00 PM Eastern Time. The target audience for this call includes hospitals, physicians and non-physician practitioners, case managers, medical and specialty societies, and other healthcare professionals. Topics to be covered in this call are the order and certification guidance with case examples, transfers and a question and answer session.

Registration is open and those interested in participating can sign up at the CMS MLN Connects Upcoming Callsregistration website.

It appears that the truism that best applies with the new regulations and guidance is that “The only constant is change.” MMP continues to be on the lookout for updated guidance and education opportunities to pass along to you so, stay tuned.

What do Probe Reviews, the start time for when the 2 midnight benchmark begin, Physician Documentation, automatic denials and Occurrence Span Code 72 have in common? All of these issues were addressed in the CMS Frequently Asked Questions (FAQs) December 23, 2013 update. Let’s break it down be each updated FAQ.

Q1.1: “Will CMS direct the Medicare review contractors to apply the 2-midnight presumption-that is, contractors should not select Medicare Part A inpatient claims for review if the inpatient stay spanned 2 midnights from the time of formal admission?”

• Yes, when a patient has been in your hospital for two midnights AFTER the inpatient order was written review contractors are to presume that the Medicare Part A inpatient admission was reasonable and necessary.
• New to this answer is that for inpatient admissions from October 1, 2013 through March 31, 2014 “CMS will not permit Recovery Auditors to conduct patient status reviews on inpatient claims with dates of admission between October 1, 2013 and March 31, 2014. These reviews will be disallowed permanently; that is, the Recovery Auditors will never be allowed to conduct patient status reviews for claims with dates of admission during that time period.”
• Caution: These same admissions CAN be reviewed for other issues (i.e. medical necessity of a surgical procedure or coding validation).

Q2.1: “Can CMS clarify when the 2 midnight benchmark begins for a claim selected for medical review, and how it incorporates outpatient time prior to admission in determining the general appropriateness of the inpatient admission?

• All time that a Medicare beneficiary is receiving outpatient services at the hospital will be considered in whether or not the 2-midnight benchmark was met.
• Note: “The Medicare review contractor will count only medically necessary services responsive to a beneficiary’s clinical presentation as performed by medical personnel.”
• Services to be included: observation services, treatments in the Emergency Department, and procedures provided in the operating room or other treatment area
• Services not to be included: treatment received in an outlying Emergency Department or in an ambulance en-route to your hospital.

Q4.1: “What documentation will Medicare review contractors expect physicians to provide to support that an expectation of a hospital stay spanning 2 or more midnights was reasonable?”

• Physician complex medical decision making: The expectation of a 2-midnight stay “must be 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.”
• Documentation: Medicare review contractors will expect the Physician’s decision making factors to be documented in the physician assessment and plan of care. “CMS does not anticipate that physicians will include a separate attestation of the expected length of stay, but rather that 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.”

Q4.9: “Under the new guidance, will all inpatient stays of less than 2 midnights after formal inpatient admission be automatically denied?”

• Medicare does anticipate that most stays less than 2 midnights would be as an outpatient. However, “because this is based upon the physician’s expectation, as opposed to a retroactive determination based on actual length of stay, we expect to see services payable under Part A in a number of instances for inpatient stays less than 2 total midnights after formal inpatient admission.”
• CMS has provided specific exceptions to the 2-midnight benchmark when inpatient would still be appropriate:
• Beneficiary death,
• Beneficiary transfer to another acute inpatient facility,
• Beneficiary leaving against medical advice (AMA),
• Beneficiary was admitted for a medically necessary service on the Inpatient-Only List,
• Mechanical ventilation initiated during the present visit (Note: is not intended to apply to anticipated intubations related to minor surgical procedures or other treatment),
• Or a Beneficiary unexpectedly improves and was discharged in less than 2 midnights.
• New to this answer: “Lastly, there may be rare and unusual cases where the physician did not expect a stay lasting 2 or more midnights but nonetheless believes inpatient admission was appropriate and documents such circumstance. The MACs are being instructed to deny these claims and to submit these records to CMS Central Office for further review. If CMS believes that such a stay warrants an inpatient admission, CMS will provide additional subregulatory instruction and the Part A contractors will review any claims that are subsequently submitted for payment in accordance with the most updated list of rare and unusual situations in which an inpatient admission of less than 2 midnights may be appropriate.”

Q5.2: “Is there a way for providers to identify any time the beneficiary spent as an outpatient prior to admission on the inpatient claim so that Medicare review contractors can readily identify that the 2-midnight benchmark was met without conducting complex review of claim.”

• “Effective December 1, 2013, Occurrence Span Code 72 was refined to allow hospitals to capture ‘contiguous outpatient hospital services that preceded the inpatient admission’ on inpatient claims.”
• For now, “Occurrence Span Code 72 is a voluntary code, but may be evaluated by CMS for medical review purposes.”

The entire FAQ download can be found at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/QuestionsandAnswersRelatingtoPatientStatusReviews_12232013_508Clean.pdf With the MAC Probe and Educate program just getting underway, you can expect there to be several additional updates to the FAQs.

On November 12th CMS hosted a third, follow-up Special Open Door Forum (ODF) to allow hospitals and practitioners to ask questions regarding the Hospital Inpatient Admission Order and Certification and the 2 Midnight Benchmark for Inpatient Hospital Admissions. While you wait for CMS to post the transcript here is a run down from the Question and Answer (Q&A) portion of the call:

Question(s): More than one caller sought clarification on when care started in the Emergency Department for the 2 Midnight Benchmark. Specific “scenarios” provided by callers:

• What if a triage nurse does more than simply take vital signs and begins to initiate orders and/or treatment protocols that were designed by Physicians. Is this when care starts?
• What if a patient begins receiving treatment in an Ambulance prior to reaching the hospital at the direction of an Emergency Department Physician? Is this when care starts?

Answer: Pre-hospital care time does not count towards the 2 Midnight Benchmark. To meet the spirit of the regulation a Provider (MD, NP or PA) would need to initiate the care to start the time. Of note, CMS is currently considering when a triage nurse initiates a treatment protocol designed by a Physician.

Question: Will claims submitted with date of service from October 1, 2013 through March 31, 2014 later be audited by Recovery Auditors?

Answer: These claims are “off the table” for Recovery Auditors to perform “patient status reviews.” CMS went on to remind callers that they can request claims from this time for Coding Validation and Medical Necessity of Surgical Procedure reviews. This caller asked when this would be put in writing. CMS indicated that this was answered in the first question of the most recently released Questions and Answers on the CMS website.

Question: Regarding the Probe and Educate Program, a caller asked what would happen if the records were not reviewed timely and based on those findings the MAC requests additional records for review.

Answer: CMS indicated that the initial sample will be complete in entirety from October 1 – December 31 dates of service claims. After a review is complete the MACs will identify the denial rate and provide education. The Goal with the program is that a follow up sample would be from claims with dates of services after education had been provided to a hospital.

Question: A caller recognized that in recent information made available on the CMS website it was unclear whether or not Critical Access Hospitals would be part of the Probe and Educate Program and asked for clarification.

Answer: CAHs are not included in the Probe and Educate Program but are still subject to the rules.

Question: A caller provided an example of a patient presenting to the Emergency Department at 10:00 pm who was subsequently admitted as outpatient with observation services. The following morning the patient was no better, no sicker and not safe for discharge. At this point would it be appropriate to write the Inpatient order?

Answer: Yes, update to an Inpatient status.

Question: In regards to the medical review process, will MACs and RAs consider that a verbal order for inpatient admission written by a Nurse Practitioner or Resident that is co-signed by the Attending meets the Physician Certification Requirement?

Answer: Yes, as long as the Inpatient admission is conducted pursuant to an Inpatient order.

Question: One caller requested additional guidance regarding how to treat patient transfers to their hospital in regards to the 2 Midnight Rule.

Answer: CMS indicated that they are still working on this guidance and did note that they are excluding transfer cases from the Probe and Educate Review until the further guidance has been issued.

CMS has identified “rare and unusual” (exceptions) circumstances when a patient would not remain in the hospital greater than 2 Midnights but still be appropriate as an Inpatient. Current exceptions include patient death, patient transfer, patient left AMA or a patient who rapidly improves and is stable for discharge. The last call to be accepted during the ODF was an additional suggestion for an exception. When a patient is admitted and is receiving medically necessary inpatient services but the family requests Hospice care prior to the 2nd Midnight and the patient is discharged home with Hospice. CMS requested that this suggestion be sent to them to take a closer look at this.

CMS indicated during the ODF that they will soon be adding additional guidance regarding the patient order and certification to the website. MMP strongly recommends that you read these two downloads and continue to check the Inpatient Hospital Review page on the CMS website frequently for updates.

Link to Inpatient Hospital Review page:  http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/InpatientHospitalReviews.html

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