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The Medicare Landscape and the Physicians Perspective Earl Berman, MD, FACP, MALPS-L Michael Montijo, MD, MPH, FACP James Szarzynski, Director of Medical.

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Presentation on theme: "The Medicare Landscape and the Physicians Perspective Earl Berman, MD, FACP, MALPS-L Michael Montijo, MD, MPH, FACP James Szarzynski, Director of Medical."— Presentation transcript:

1 The Medicare Landscape and the Physicians Perspective Earl Berman, MD, FACP, MALPS-L Michael Montijo, MD, MPH, FACP James Szarzynski, Director of Medical Review

2 Welcome Schedule for This Evenings Program Pre-test CMEs: AMA and OPMA PRA Category 1 credits (2.5) CEUs: check with specific organization; certificate provided upon conclusion of session Materials available on CGS website Questions and discussion Post-test and evaluations Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 2

3 Overview: Medicare as a defined benefit Challenges across disciplines and facilities Hospitalization challenges The home health benefit Physicians key role Medical review focus for CGS Future state and next steps Questions and discussion Agenda Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 3

4 Objectives Identify key data sources for errors in Medicare claims and documentation List topics and issues under increased scrutiny by Medicare contractors Define the role of physicians in responding to challenges regarding documentation and payment errors Name current and future areas of focus with respect to Medicare claims, documentation, and payment Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 4

5 Medicare as a Defined Benefit Setting the stage –Average monthly # of beneficiaries enrolled in Medicare A and/or B (estimated for FY 2013): 52 million Approx. 73% enrolled in FFS Medicare –Claims processed in CY 2012: Part A: 208,144,073 Part B: 1,022,408,206 –Medicare benefits estimated to be paid in FY 2013: $590.2 billion –Source: CMS Fast Facts (http://www.cms.gov/Research-Statistics-Data-and- Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts/index.html)http://www.cms.gov/Research-Statistics-Data-and- Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts/index.html Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 5

6 Medicare as a Defined Benefit Setting the stage –Ohio: 10 th largest state by beneficiary population (approx. 1.1 million) Allowed charges: over $111 million –Kentucky: 22 nd largest state by beneficiary population (approx. 609,000) Allowed charges: over $48 million Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 6

7 Medicare as a Defined Benefit Defined benefit: services and payment –Statutory: Social Security Act (medical necessity: section 1862(a)(1)(A)) –May limit number of covered days, frequency, setting, or types of services covered or not covered –May be irrespective of patient need –Payment vs. treatment/care Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 7

8 Medicare as a Defined Benefit Future state –Bundled payments –ACOs –Ability to flex benefits –Add additional resources – as deemed needed by the caregivers Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 8

9 Medicare as a Defined Benefit Requirements for payment –Statutory –Federal (CMS-level) –Local (Medicare contractors) Documentation as a condition for payment Purpose of documentation: treatment/orders vs. medicolegal vs. Medicare payment Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 9

10 Medicare as a Defined Benefit Reasonable and necessary standard: determined by treating physician unless –Treatment conflicts with clinical standards of care; or –Substantial scientific evidence of risk or ineffectiveness (i.e., sizeable number of studies published in peer-reviewed journals meeting professionally recognized standards of quality) Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 10

11 Medicare as a Defined Benefit Reasonable and necessary standard: AMA definition –"Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: In accordance with generally accepted standards of medical practice Clinically appropriate in terms of type, frequency, extent, site, and duration, and Not primarily for the convenience of the patient, physician, or other health care provider Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 11

12 Medicare as a Defined Benefit Documentation challenges and consequences –Impact on payment –Data analysis and involvement of multiple Medicare contractors –Further scrutiny: OIG, GAO, Congress, Recovery Auditors, MACs Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 12

13 Medicare as a Defined Benefit Why are we here? Key data sources: –Comprehensive Error Rate Testing (CERT) program: –CGS medical review outcomes –PEPPER reports –Comparative Billing Reports (CBRs): peer comparisons –OIG reports and workplans: Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 13

14 Medicare as a Defined Benefit Stats: setting the stage –Medicare receives approx. 4.8 million claims per day. –In 2011, the Comprehensive Error Rate Testing (CERT) program identified $28.8 billion in incorrect payments (calculated, adjusted error rate = 8.6%) Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 14

15 Medicare as a Defined Benefit Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 15

16 Improper Payments ($ in billions): 2011 CERT report Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 16

17 Challenges Across Disciplines & Facilities Documentation Signatures Specificity of orders/requests Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 17

18 Challenges Across Disciplines & Facilities Documentation –Demonstrate medical necessity (patients condition, care needed, setting) –Nature/type of service provided –Duration of the patient-physician relationship –Clear rationale –Consistency –Technical requirements (e.g., dated signature) –Must reflect care provided (not expected to precisely reflect every aspect of are provided) –Is not direct patient care but is a component of care Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 18

19 Challenges Across Disciplines & Facilities: Signatures Signatures –Problem area in all disciplines and all provider types –Acceptable electronic signatures – if using EMR, ensure your practice or facilitys system meets the requirements (complete list of requirements in CMS article MM6698,Signature Requirements for Medical Review Purposes)MM6698 –Legibility –Stamped signatures? – NO –Late signatures and attestations Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 19

20 Challenges Across Disciplines & Facilities: Signatures Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 20

21 Challenges Across Disciplines & Facilities: Signatures Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 21

22 Challenges Across Disciplines & Facilities: Specificity of Orders Specificity of orders/requests –Ambulatory Surgery Centers; Radiology; Clinical Laboratories; drugs & biologicals –Must demonstrate medical necessity of test/service/ procedure (ICD-9 code alone may not be sufficient) –Joint responsibility of testing/administering entity and ordering physician Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 22

23 Hospitalization Challenges Elective admissions One-day stays Medical necessity & reasonableness: ambulatory sensitive diagnoses Outpatient procedures Skilled Nursing Facility (SNF) qualifying stay Appropriate setting Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 23

24 Short-Term National Q1FY13 Report Top 20 Surgical DRGs for One-Day Stays Discharges for most recent 4 Quarters, ending Q1FY2013 In Descending Order by One-Day Stay Totals Per DRG DRGDRG Description One-Day Stay Count* Total Discharges for DRG Proportion of One-Day Stays to Total Discharges Average Length of Stay for DRG 247Perc cardiovasc proc w drug-eluting stent w/o MCC27,54598, % Extracranial procedures w/o CC/MCC21,45233, % Cervical spinal fusion w/o CC/MCC16,03427, % Back & neck proc exc spinal fusion w/o CC/MCC11,62330, % Major joint replacement or reattachment of lower extremity w/o MCC10,363415,8882.5% Major cardiovasc procedures w/o MCC9,21834, % Other vascular procedures w/o CC/MCC8,90227, % Perc cardiovasc proc w/o coronary artery stent w/o MCC7,76527, % Major joint & limb reattachment proc of upper extremity w/o CC/MCC7,30822, % Major male pelvic procedures w/o CC/MCC7,10112, % Spinal fusion except cervical w/o MCC6,84168,7709.9% Cardiac defibrillator implant w/o cardiac cath w/o MCC6,74715, % Uterine & adnexa proc for non-malignancy w/o CC/MCC5,94716, % Perc cardiovasc proc w non-drug-eluting stent w/o MCC5,44127, % Permanent cardiac pacemaker implant w/o CC/MCC5,29326, % Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC4,8266, % Extracranial procedures w CC3,84312, % Carotid artery stent procedure w/o CC/MCC3,7185, % Other vascular procedures w CC3,71638,4329.7% Laparoscopic cholecystectomy w/o CDE w/o CC/MCC3,66022, %3.2 Top 20 Surgical DRGs177,343971, %3.5 All Surgical DRGs300,3162,763, %6.4 *Excludes deaths, transfers, leaves against medical advice, and claims with prior observation of 24 hours or greater. One-Day Stays: Surgical DRGs Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 24

25 Short-Term National Q1FY13 Report Top 20 Medical DRGs for One-Day Stays Discharges for most recent 4 Quarters, ending Q1FY2013 In Descending Order by One-Day Stay Totals Per DRG DRGDRG Description One-Day Stay Count* Total Discharges for DRG Proportion of One-Day Stays to Total Discharges Average Length of Stay for DRG 313Chest pain37,12199, % Cardiac arrhythmia & conduction disorders w/o CC/MCC33,573107, % Esophagitis, gastroent & misc digest disorders w/o MCC27,139210, % Syncope & collapse24,623118, % Circulatory disorders except AMI, w card cath w/o MCC21,405102, % Transient ischemia20,29079, % Misc disorders of nutrition,metabolism,fluids/electrolytes w/o MCC19,585132, % Red blood cell disorders w/o MCC17,82388, % Cardiac arrhythmia & conduction disorders w CC16,478105, % Kidney & urinary tract infections w/o MCC14,915193,0587.7% Chronic obstructive pulmonary disease w/o CC/MCC11,94097, % Heart failure & shock w CC10,814201,8205.4% Chronic obstructive pulmonary disease w CC10,267137,2057.5% Poisoning & toxic effects of drugs w/o MCC10,00133, % Heart failure & shock w/o CC/MCC9,76678, % Renal failure w CC9,718154,5296.3% Intracranial hemorrhage or cerebral infarction w/o CC/MCC9,15859, % Signs & symptoms w/o MCC9,06751, % GI hemorrhage w CC9,050139,8086.5% Hypertension w/o MCC8,68331, %2.7 Top 20 Medical DRGs 331,4162,222, %3.6 All Medical DRGs704,3837,343,9669.6%4.8 *Excludes deaths, transfers, leaves against medical advice, and claims with prior observation of 24 hours or greater. One-Day Stays: Medical DRGs Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 25

26 Short-Term Acute Care PEPPER Visit PEPPERresources.org PPS Hospitals for Demo Jurisdiction (DMSTR) 1DS Top Medical DRGs Jurisdiction Top 20 Medical DRGs for One-Day Stay Disch., Most Recent 4 Qtrs. In Descending Order by One-Day Stay Totals Per DRG DRGDescription One-Day Stay Count* Total Dis-charges for DRG Proportion of One- Day Stays to Total Dis-charges for DRG Jurisdict. Average Length of Stay for DRG 313 Chest pain 3,0457, % Esophagitis, gastroent & misc digest disorders w/o MCC 2,27414, % Cardiac arrhythmia & conduction disorders w/o CC/MCC 2,1637, % Syncope & collapse 1,9899, % Circulatory disorders except AMI, w card cath w/o MCC 1,6867, % Transient ischemia 1,6176, % Misc disorders of nutrition,metabolism,fluids/electrolytes w/o MCC 1,4058, % Cardiac arrhythmia & conduction disorders w CC 1,0877, % Red blood cell disorders w/o MCC 1,0765, % Kidney & urinary tract infections w/o MCC 1,06011,8139.0% Chronic obstructive pulmonary disease w/o CC/MCC 9096, % Chronic obstructive pulmonary disease w CC 90810,6468.5% Heart failure & shock w CC 81613,8095.9% Poisoning & toxic effects of drugs w/o MCC 7732, % Atherosclerosis w/o MCC 7132, % Renal failure w CC 68610,6696.4% Seizures w/o MCC 6803, % GI hemorrhage w CC 6629,5816.9% Signs & symptoms w/o MCC 6303, % Heart failure & shock w/o CC/MCC 6204, %4.0 Top Medical DRGs Jurisdiction-wide 24,799152, %3.5 All Medical DRGs Jurisdiction-wide50,404490, %4.7 *Excludes deaths, transfers, leaves against medical advice, and claims with prior observation of 24 hours or greater. Note: DRGs will display if they had at least 11 one-day stay discharges in the most recent four quarters. Short-Term Acute Stays: Med Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 26

27 Short-Term Acute Care PEPPER Visit PEPPERresources.org PPS Hospitals for Demo Jurisdiction (DMSTR) 1DS Top Surgical DRGs Jurisdiction Top 20 Surgical DRGs for One-Day Stay Disch., Most Recent 4 Qtrs. In Descending Order by One-Day Stay Totals Per DRG DRGDescription One-Day Stay Count* Total Dis-charges for DRG Proportion of One-Day Stays to Total Dis- charges for DRG Jurisdict. Average Length of Stay for DRG 247 Perc cardiovasc proc w drug-eluting stent w/o MCC 2,7447, % Extracranial procedures w/o CC/MCC 1,6112, % Major joint replacement or reattachment of lower extremity w/o MCC 1,41426,4715.3% Other vascular procedures w/o CC/MCC 9672, % Cervical spinal fusion w/o CC/MCC 9051, % Back & neck proc exc spinal fusion w/o CC/MCC 7271, % Perc cardiovasc proc w/o coronary artery stent w/o MCC 6411, % Major cardiovasc procedures w/o MCC 6152, % Perc cardiovasc proc w non-drug-eluting stent w/o MCC 5322, % Major male pelvic procedures w/o CC/MCC % Major joint & limb reattachment proc of upper extremity w/o CC/MCC 5171, % Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC % Cardiac defibrillator implant w/o cardiac cath w/o MCC 4731, % Uterine & adnexa proc for non-malignancy w/o CC/MCC 4651, % Spinal fusion except cervical w/o MCC 3724,7967.8% Other vascular procedures w CC 3522, % Permanent cardiac pacemaker implant w/o CC/MCC 3421, % Carotid artery stent procedure w/o CC/MCC % Other skin, subcut tiss & breast proc w/o CC/MCC % Extracranial procedures w CC %3.8 Top Surgical DRGs Jurisdiction-wide 14,56064, %3.1 All Surgical DRGs Jurisdiction-wide22,491176, %6.0 *Excludes deaths, transfers, leaves against medical advice, and claims with prior observation of 24 hours or greater. Note: DRGs will display if they had at least 11 one-day stay discharges in the most recent four quarters. Short-Term Acute Stays: Surg Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 27

28 Short Term Acute Care PEPPER Visit PEPPERresources.org Chronic Obstructive Pulmonary Disease Hospital Q1 = Oct-Dec Q2 = Jan- Mar Q3 = Apr-Jun Q4 = Jul-Sep Time Periods Target Area Discharge Count (Numerator)Denominator Count Percent (Numerator / Denominator) Target Area Average Length of Stay (ALOS) Denominator Average Length of Stay (ALOS) Target Average Medicare Payment Target Sum Medicare Payments Q2 FY %3.45.2$5,103$219,450 Q3 FY %3.34.6$5,134$256,705 Q4 FY %3.84.5$4,878$180,480 Q1 FY %3.85.4$5,147$180,157 Q2 FY %4.14.5$5,183$331,715 Q3 FY %3.94.7$4,912$235,781 Q4 FY %3.14.5$4,807$192,289 Q1 FY %3.43.9$5,287$338,366 Q2 FY %3.74.5$5,328$255,729 Q3 FY %3.74.0$5,628$185,732 Q4 FY %3.34.5$5,173$165,539 Q1 FY %3.25.1$5,193$259,665 Need to audit? When reviewing this information, you may want to consider auditing a sample of records if you identify: Percents (4 th column in the table below) that are consistently red (high outlier) A trend of increasing Percents over time resulting in outlier status Your Percent is above the national 80th percentile (see graph on the following worksheet) Short-Term Acute Stays: COPD Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 28

29 Short-Term Acute Care PEPPER Single CC or MCC (New target area as of Q1FY13) Q1 = Oct-Dec Q2 = Jan- Mar Q3 = Apr-Jun Q4 = Jul-Sep Time Periods Target Area Discharge Count (Numerator)Denominator Count Percent (Numerator / Denominator) Target Area Average Length of Stay (ALOS) Denominator Average Length of Stay (ALOS) Target Average Medicare Payment Target Sum Medicare Payments Q2 FY %3.65.3$5,755$1,116,408 Q3 FY %3.54.8$5,811$1,284,128 Q4 FY %3.44.8$6,701$1,259,802 Q1 FY %3.75.1$6,093$1,163,806 Q2 FY %3.74.9$6,079$1,386,008 Q3 FY %3.85.0$6,693$1,378,843 Q4 FY %3.55.0$6,067$1,201,249 Q1 FY %3.34.5$6,374$1,376,693 Q2 FY %3.35.0$5,943$1,051,967 Q3 FY %3.24.9$5,878$946,417 Q4 FY %2.94.6$6,233$1,134,421 Q1 FY %3.14.9$6,853$1,171,783 Need to audit? When reviewing this information, you may want to consider auditing a sample of records if you identify: Percents (4 th column in the table below) that are consistently red (high outlier) or green (low outlier) A trend of increasing or decreasing Percents over time resulting in outlier status Your Percent is above the national 80th percentile (see graph on the following worksheet) Your Percent is below the national 20th percentile (see graph on the following worksheet) Short-Term Acute Stays: Single CC or MCC Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 29

30 Short-Term Acute Stays Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 30

31 Medical Necessity & Reasonableness: Recovery Auditor Quarterly Stats Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 31 Region B Top Error: Cardiovascular Procedures –Medical necessity for cardiovascular procedures performed inpatient hospital are not supported in medical record

32 Short-Term Acute Care PEPPER Visit PEPPERresources.org Three-day Skilled Nursing Facility-qualifying Admissions Hospital H0904 Q1 = Oct-Dec Q2 = Jan- Mar Q3 = Apr-Jun Q4 = Jul-Sep Time Periods Target Area Discharge Count (Numerator)Denominator Count Percent (Numerator / Denominator) Target Area Average Length of Stay (ALOS) Denominator Average Length of Stay (ALOS) Target Average Medicare Payment Target Sum Medicare Payments Q2 FY %3.06.5$7,219$267,087 Q3 FY %3.05.9$6,445$212,695 Q4 FY %3.05.8$6,819$259,123 Q1 FY %3.05.6$7,090$304,877 Q2 FY %3.05.8$6,604$264,155 Q3 FY %3.06.3$6,744$188,830 Q4 FY %3.06.0$7,223$223,907 Q1 FY %3.05.7$6,977$300,021 Q2 FY %3.06.1$6,255$237,694 Q3 FY %3.06.3$7,796$288,466 Q4 FY %3.05.7$7,849$353,184 Q1 FY %3.06.5$8,499$271,969 Need to audit? When reviewing this information, you may want to consider auditing a sample of records if you identify: Percents (4 th column in the table below) that are consistently red (high outlier) A trend of increasing Percents over time resulting in outlier status Your Percent is above the national 80th percentile (see graph on the following worksheet) Three-Day SNF Qualifying Admissions Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 32

33 Three-Day SNF Qualifying Admissions Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 33

34 Hospitalization Challenges: Appropriate Setting Observation vs. inpatient –Patients medical history and current medical needs –Types of facilities available –Hospital by-laws and admission policies –Relative appropriateness of treatment in each setting –Severity of signs and symptoms exhibited by the patient –Medical predictability of something adverse happening to the patient –Need for diagnostic studies that appropriately are outpatient services to assist in assessing whether the patient should be admitted –Availability of diagnostic procedures at the time and location where the patient presents Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 34

35 Hospitalization Challenges: Appropriate Setting Observation vs. inpatient –An order simply documented as admit will be treated as an inpatient admission. –A clearly worded order such as inpatient admission or place patient in outpatient observation will ensure appropriate patient care and prevent hospital billing errors. –Order for observation must include rationale. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 35

36 Hospitalization Challenges: Appropriate Setting Inpatient vs. outpatient –More than 20% of 2011 improper payments: inpatient claim denied, yet would have been payable in outpatient setting (source: 2011 CERT report) –Resulted in A/B Rebilling Demonstration (now ended) Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 36

37 Hospitalization Challenges: Appropriate Setting Readmission rates –For conditions with both large numbers of stays and high readmission rates, Medicare and especially Medicaid patients were more likely to be readmitted than privately insured or uninsured patients. For example, congestive heart failure readmission rates were 30.1% for Medicaid, 25.0% for Medicare, 19.5% for privately insured, and 17.1% for uninsured. –Source: AHQR Statistical Brief #153, April 2013 Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 37

38 Hospitalization Challenges: Appropriate Setting Changing scene –Although diagnostic cardiac catheterizations was the fifth most common procedure in 2010, the rate of hospitalization with this procedure decreased 23 percent since –Rates of hospitalization with knee replacement and spinal fusion approximately doubled between 1997 and –Source: AHQR Statistical Brief #149, February 2013 Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 38

39 Home Health Benefit In 2012: –Number of beneficiaries that received home health services: 3.5 million –Number of home health agencies involved in providing this care: approx. 12,000 –Cost to the Medicare program for these home health services: approx. $18.2 billion Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 39

40 Home Health Benefit Requirements for payment/coverage: CMS Pub , chapter 7, section : –… payment can be made only if a physician certifies the need for services and establishes a plan of care. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 40

41 Home Health Benefit Requirements for payment/coverage: Social Security Act (section 1814(a)(2)(C) and 1835(a)(2)(A)) - beneficiary must: –Be confined to the home; –Be under the care of a physician; –Be receiving services under a plan of care established and periodically reviewed by a physician; –Be in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology; or –Have a continuing need for occupational therapy. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 41

42 Home Health Benefit Physician must certify that patient is confined to his/her home. This means: –Does not have to be bed-ridden –Has normal inability to leave home, so leaving home would require a considerable and taxing effort Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 42

43 Home Health Benefit Physician must certify that patient is confined to his/her home. This means: –May still be considered homebound if absences from home are infrequent or for periods of relatively short duration, or are attributable to the need to receive health care treatment, including: Adult day center, to receive medical care Ongoing outpatient dialysis Outpatient chemotherapy or radiation therapy –Occasional absences permissible (e.g., visit to barber, walk around the block, attend wedding) Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 43

44 Home Health Benefit Physician (or allowed NPP) must document face-to- face encounter with patient Documentation requirements (Pub , chapter 7, section ): –Date of face-to-face encounter and brief narrative by physician to describe how the patients clinical condition as seen during that encounter supports the patients homebound status and need for skilled services –Document, sign and date encounter OR on addendum to certification –May be dictated or generated from EMR –May NOT be dictated to home health agency then signed by physician Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 44

45 Home Health Benefit Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 45

46 Home Health Benefit Codes to consider for reimbursement for physicians time (must maintain documentation): –Care Plan Oversight: HCPCS codes G0181, G0182 Billing guidelines: CMS Medicare Claims Processing Manual (Pub ), chapter 12, sections 80 and 80.1CMS Medicare Claims Processing Manual (Pub ), chapter 12, sections 80 and 80.1 –Transitional Care Management: CPT codes Billing guidance: CMS FAQs for transitional care managementCMS FAQs for transitional care management Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 46 CPT only copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use.

47 Physicians Key Role Coding Clinical review judgment Consistency across disciplines Cloning, EMR, templating, and scribing Certification: PT/OT/SLP plans of care, ambulance transport Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 47

48 Physicians Key Role Coding –Importance of being there –Role of coders: select CPT/HCPCS codes and modifiers and ICD-9 codes based on physicians documentation and with physicians input –Medical necessity as the overarching criterion –Weight/preponderance of documentation vs. physicians assessment of the patients condition and appropriateness of care –Documentation paints the picture; reviewer must be able to follow your rationale Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 48

49 Physicians Key Role Reasonable and necessary standard: AMA definition –"Health care services or products that a prudent physician would provide to a patient for the purpose of preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: In accordance with generally accepted standards of medical practice Clinically appropriate in terms of type, frequency, extent, site, and duration, and Not primarily for the convenience of the patient, physician, or other health care provider Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 49

50 Physicians Key Role Eddy, et. al. Benefit language, JAMA 275(8): ) Eisenberg et. al., Ten lessons for evidence-based technology assessments, JAMA 282(19): l CriteriaReasonableNecessary Safe and effective/not investigational++ Appropriate duration & frequency:++++ Accepted standards of medical practice++++ Appropriate setting+++ Qualified personnel (order/perform)+++ Meets, but does not exceed, medical need ++++ As beneficial as existing and available medically appropriate alternative +++ Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 50

51 Physicians Key Role Consistency across disciplines: challenges –Multidisciplinary environments: review and oversight of documentation –Disconnects: patient assessments Condition varies by day or time of day PT/OT vs. nurse Hospital discharge summary vs. evaluation by speech pathologist –Conflicting documentation: problematic Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 51

52 Physicians Key Role Documentation –Challenges around electronic medical records: cloned documentation, use of scribes, role of electronic medical records –Timeliness, changes, and addenda –Who gathers and copies documentation? – trained staff, timeline for responses, what to send and to whom, quality control –Definition of an order for Medicare purposes – specificity, signature Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 52

53 Cloning –Medical documentation is exactly the same from beneficiary to beneficiary. –It would not be expected that every patient had the exact same problem, symptoms, and required the exact same treatment. –This "cloned documentation" does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. Physicians Key Role Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 53

54 Cloning –All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. –Considered a misrepresentation of the medical necessity requirement for coverage of services. –Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made. Physicians Key Role Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 54

55 Templating –Medical necessity is key –Coding Manager DOES NOT = MN –Do NOT preset visit template –Adapt template to patient, NOT the reverse Physicians Key Role Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 55

56 Scribes –Living recorder," documenting actions and words of physician in real time –The real time transcription must be clearly documented as noted, by both the scribe and the physician. –Scribe does not act independently –No separate payment –Physician is ultimately accountable for the documentation, and should sign and note after the scribe's entry the affirmation above, that the note accurately reflects work done by the physician. Physicians Key Role Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 56

57 Involvement of ancillary staff: –CGS is seeing components of E/M services completed or updated by nursing or other medical staff in the EMR. For example: in the Past Medical or Family/Social History sections, there is an electronic note stating "updated by Nancy Jones, Medical Technician" or an electronic statement of "medication list updated by Mary Smith RN." –Physician must also review and address these components. –Nurse or medical technician entry without physician review and documentation: may not be used in determining the level of E/M service provided as they do not reflect the work of the physician. Physicians Key Role Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 57

58 Timeliness, changes, and addenda –We strongly encourage all health care providers to enter information into the patients medical record at the time the service is provided to the patient; that is, contemporaneously. Physicians Key Role Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 58

59 In all cases, regardless of whether the documentation is maintained or submitted in paper or electronic form, any medical records that contain amendments, corrections, or addenda must: –Clearly and permanently identify any amendment, correction or delayed entry as such, and –Clearly indicate the date and author of any amendment, correction, or delayed entry, and –Not delete, but instead, clearly identify all original content. Physicians Key Role Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 59

60 For paper medical records: –Making corrections, in keeping with these principles, generally entails using a single line strike-through (like this) so the original content is still legible. –The author of the alteration must sign and date the revision. –Amendments or delayed entries must also be signed and dated by the author upon entry. Physicians Key Role Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 60

61 For electronic medical records: –Amendments, corrections, and delayed entries must be distinctly identified as such, and –The record must provide a reliable means of clearly identifying the original content, the modified content, and the date and author of each modified record. –More info: CMS Change Request 8105, which updates the CMS Program Integrity Manual (Pub ), chapter 3, section Change Request 8105Program Integrity Manual (Pub ), chapter 3, section Physicians Key Role Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 61

62 Physicians Key Role Medical records staff: –Requests from multiple contractors/entities and timeline for responses: CGS job aid – Medical Record Requests: Keys to SuccessCGS job aid –What to send: only what is relevant and all of what is relevant –Quality control: legibility, two-sided records, highlighting and holes punched, review requirements (signatures, orders, test results, plans of care, prior encounters) –Basics: Date of service; patients name; signed/dated notes Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 62

63 Physicians Key Role Certification: PT/OT/SLP –Basis: Code of Federal Regulation (42 CFR (c)) –Requirements: patient is under your care; needs treatment –Must relate to treatment during interval on claim –Certification: Applies to duration of plan of care or 90 calendar days from initial treatment date, whichever is less Timely: signed w/in 30 days of first treatment day Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 63

64 Physicians Key Role Code of Federal Regulation (42 CFR (c)) language: (c) Outpatient physical therapy and speech-language pathology services –(1) Content of certification. (i) The individual needs, or needed, physical therapy or speech pathology services. (ii) The services were furnished while the individual was under the care of a physician, nurse practitioner, clinical nurse specialist, or physician assistant. (iii) The services were furnished under a plan of treatment that meets the requirements of § of this chapter. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 64

65 Physicians Key Role Code of Federal Regulation (42 CFR (c)) language: (2) Timing. The initial certification must be obtained as soon as possible after the plan is established. (3) Signature. –(i) If the plan of treatment is established by a physician, nurse practitioner, clinical nurse specialist, or physician assistant, the certification must be signed by that physician or nonphysician practitioner. –(ii) If the plan of treatment is established by a physical therapist or speech-language pathologist, the certification must be signed by a physician or by a nurse practitioner, clinical nurse specialist, or physician assistant who has knowledge of the case. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 65

66 Physicians Key Role Recertification: PT/OT/SLP –Can be by different physician from certification –Required whenever significant modification to plan is evident or at least every 90 days after initiation of treatment under that plan Provisions for delayed certification Certification/recertification by DPMs – must be consistent w/ scope of practice, as defined by state Chiropractors not permitted to certify/recertify therapy plans of care Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 66

67 Physicians Key Role Ambulance: Medical necessity is established when the patients condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individuals health, whether or not such other transportation is actually available, no payment may be made for ambulance services. –CMS Pub , chapter 10, section –See also: Code of Federal Regulations, 42 CFR (d) Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 67

68 Physicians Key Role Non-emergency transport (from CFR): –Bed-confinement or beneficiarys condition is such that transportation by ambulance is medically required –CFR defines bed confinement; not sole criterion for coverage –Nonemergency, scheduled, repetitive services: Physician Certification Statement (PCS) required before service is furnished; dated no earlier than 60 days prior to transport. –Other guidelines apply to PCS for nonemergency unscheduled or nonemergency non-repetitive transports –PCS: ICD-9 codes, statement bed confined, or list of conditions not sufficient Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 68

69 Physicians Key Role Know what youre being asked to sign and why –Question about the guidelines? – call our Provider Contact Center ( ) Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 69

70 MR Strategy Development Purpose –Protect Medicare Trust Fund –CERT Error Rate Driven by data: quantitative and qualitative –Sources Claims data – raw data, probes, edit effectiveness CERT Reports PEPPER Reports OIG Reports Other external reports – IOM, Kaiser, etc. Medical literature – emerging trends, issues Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 70

71 MR Strategy Development: Tools, Evaluation, & Interventional Strategy Tools: –Statistical analytics: trending, significance –Predictive models: clustering, targeting Evaluation: –Periodic review for effectiveness, review –New data drill downs –Decision process to amend strategy (add or e- focus) Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 71

72 MR Strategy Development: Tools, Evaluation, & Interventional Strategy Interventional strategy: –Educational Webinars, web postings, articles, Carrier Advisory Committee, periodic meetings with compliance officers –Provider-specific Face to face (Provider Outreach & Education team, CMDs), brainstorming, comparison to peers reports, edit rates) Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 72

73 Medical Review Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 73

74 Pre-payment –Conversion to prepayment review Significant increase in prepayment review –Changing behavior with targeted audit/educational activities Post-payment Automated vs. complex Clinical review judgment Reviewer guidance, QA, reliability Medical Review Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 74

75 Corrective Actions Data Analysis Identified utilization outlier of home visits (CPT codes ) Submitted CPT modifier 25 with each and every E/M code Data also indicated billing debridements in patients homes (CPT code 11721) Data showed beneficiaries were not homebound and were attending other appointments Prepay Probe Conducted prepay probe, error rate was 100% No documentation to support medical necessity Prepay Review Began altering billing 3 months after review Stopped billing E/M, added additional codes Changed place of service ZPIC Referral Referred to accepted by ZPIC Notified HHH MR of situation and referring agencies for possible data analysis Fraudulently billed $92,000 in 4 months before acceptance by ZPIC J-15 Evolution of Corrective Action CPT only copyright 2012 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable FARS\DFARS Restrictions Apply to Government Use. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 75

76 Medical Review Clinical review judgment –Synthesis of information to create a longitudinal clinical picture; considers many factors –Medicare guidelines: foundation (e.g., CMS/AMA Evaluation & Management Documentation Guidelines) –May require clinician to make clinical judgments about a claim based on his/her clinical knowledge and/or experience Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 76

77 Medical Review Clinical review judgment –Role of clinical review judgment at CGS: Efforts to reduce the paid claims error rate Fewer claims denied inappropriately; fewer claims appealed Fewer dead-end referrals to the Zone Program Integrity Contractor (ZPIC) Reduce the hassle factor for providers Not forgiveness for poor/inadequate documentation Does not include re-interpretation or reinvention of existing policy to cover the care provided Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 77

78 Review criteria: –Code of Federal Regulations –CMS Rulings –National Coverage Determinations (NCDs) –CMS Guidance: Internet-Only Manuals (IOM) –Local Coverage Determinations (LCDs) –Peer-reviewed publications –Compendia –Gold standards Medical Review Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 78

79 Assumptions: –Medical Review believes in the honor system –The provider delivered the service billed and the documentation is accurate –The provider submits the claim honestly –Clinical judgment should be applied appropriately to pay the claim when payable Medical Review Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 79

80 Determines whether a service is: –A covered benefit –Reasonable and necessary –Accurately coded Is not: –A means to deny claims –Fraud investigation –Street justice Medical Review Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 80

81 Current areas of focus –Highest level office visits –One day stays Future areas of focus –Cross-claim review –Elective surgeries –SNF qualifying admissions –SSOE –Predictive modeling Medical Review Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 81

82 MR Tools Statistical Sampling with Overpayment Estimation (SSOE) –What is SSOE? Define universe of claims Select statistically valid random sample Review claims post-payment and extrapolate denial % to universe –Use Large providers too big to prepay Repeated education fails Biggest stick in contractor toolbox 1 claim denied may represent $$$ Protracted appeals process –Goal Dramatic change in provider behavior 82Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

83 MR Innovations/Enhancements Predictive Modeling –A statistical, customized model for J15 based on providers billing behavior within a specific policy group (instead of randomly targeting individual claims at the HCPCS level) –Based on the premise of the providers profit motives Providers will try to maximize their profits but not intentionally defraud Medicare –Combines clinical necessity with statistical guidance 83Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

84 Medical Review Predictive Modeling How is this different from the current process? 84 Traditional ApproachNew CGS Approach Randomly selects and evaluates individual claims for clinical necessity documentation Evaluates a single HCPCS code for improper billing Approaches the issue solely from clinical necessity Does not account for common abusive billing patterns Examples: code shifting, location shifting, and bundling Creates a risk score to identify abusive patterns at the supplier level Identifies providers based on their overall billing pattern; the model includes multiple HCPCS codes Probe reviews and education will focus on multiple codes to address the suppliers overall billing pattern, not just a single HCPCS code Models supplier behavior, but also integrates clinical necessity and guidelines, using LCDs and NCDs Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

85 Go Forth Consider internal compliance audits –Corrective Action Plans (CAPs) Monitor widespread data relevant to your practice Practice-specific findings (from internal or external sources): implications for internal processes? Tools available for your staff: staying informed Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 85

86 Questions? Please complete: –Post-test –Participant evaluation Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 86


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