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The Medicare Landscape and the Physician’s Perspective

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Presentation on theme: "The Medicare Landscape and the Physician’s Perspective"— Presentation transcript:

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

2 Welcome Schedule for This Evening’s 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

3 Agenda 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 Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

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

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) Provides scope & context Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

6 Medicare as a Defined Benefit
Setting the stage Ohio: 10th largest state by beneficiary population (approx. 1.1 million) Allowed charges: over $111 million Kentucky: 22nd largest state by beneficiary population (approx. 609,000) Allowed charges: over $48 million Timeframe for the data: July 2012-December 2012, source is CMS Focused Medical Review report (formerly BESS report) Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

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

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

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

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

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

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

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

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

15 Medicare as a Defined Benefit
CGS Administrators - Medicare Part B 6/24/2013 Medicare as a Defined Benefit This table, from FY 2011 CERT report, displays the improper payment amounts and rates for the top 10 states, as well as the breakdown by overpayments and underpayments. As you can see, Ohio is among the top states with 1.3 billion in improper payments and an 11.6% improper payment rate. These figures are unadjusted (does not consider reversals due to appeals submitted after the amounts were calculated). Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

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

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

18 Challenges Across Disciplines & Facilities
Documentation Demonstrate medical necessity (patient’s 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

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

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

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

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

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

24 Total Discharges for DRG
One-Day Stays: Surgical DRGs 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 DRG DRG Description One-Day Stay Count* Total Discharges for DRG Proportion of One-Day Stays to Total Discharges Average Length of Stay for DRG 247 Perc cardiovasc proc w drug-eluting stent w/o MCC 27,545 98,291 28.0% 2.7 039 Extracranial procedures w/o CC/MCC 21,452 33,758 63.5% 1.9 473 Cervical spinal fusion w/o CC/MCC 16,034 27,589 58.1% 2.1 491 Back & neck proc exc spinal fusion w/o CC/MCC 11,623 30,688 37.9% 2.5 470 Major joint replacement or reattachment of lower extremity w/o MCC 10,363 415,888 2.5% 3.9 238 Major cardiovasc procedures w/o MCC 9,218 34,729 26.5% 4.2 254 Other vascular procedures w/o CC/MCC 8,902 27,053 32.9% 3.0 251 Perc cardiovasc proc w/o coronary artery stent w/o MCC 7,765 27,618 28.1% 3.2 484 Major joint & limb reattachment proc of upper extremity w/o CC/MCC 7,308 22,793 32.1% 708 Major male pelvic procedures w/o CC/MCC 7,101 12,887 55.1% 2.0 460 Spinal fusion except cervical w/o MCC 6,841 68,770 9.9% 4.0 227 Cardiac defibrillator implant w/o cardiac cath w/o MCC 6,747 15,861 42.5% 3.4 743 Uterine & adnexa proc for non-malignancy w/o CC/MCC 5,947 16,955 35.1% 2.3 249 Perc cardiovasc proc w non-drug-eluting stent w/o MCC 5,441 27,011 20.1% 3.1 244 Permanent cardiac pacemaker implant w/o CC/MCC 5,293 26,473 20.0% 627 Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC 4,826 6,950 69.4% 1.8 038 Extracranial procedures w CC 3,843 12,060 31.9% 3.7 036 Carotid artery stent procedure w/o CC/MCC 3,718 5,107 72.8% 1.6 253 Other vascular procedures w CC 3,716 38,432 9.7% 5.9 419 Laparoscopic cholecystectomy w/o CDE w/o CC/MCC 3,660 22,216 16.5% Top 20 Surgical DRGs 177,343 971,129 18.3% 3.5 All Surgical DRGs 300,316 2,763,240 10.9% 6.4 *Excludes deaths, transfers, leaves against medical advice, and claims with prior observation of 24 hours or greater. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

25 Total Discharges for DRG
One-Day Stays: Medical DRGs 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 DRG DRG Description One-Day Stay Count* Total Discharges for DRG Proportion of One-Day Stays to Total Discharges Average Length of Stay for DRG 313 Chest pain 37,121 99,318 37.4% 2.2 310 Cardiac arrhythmia & conduction disorders w/o CC/MCC 33,573 107,281 31.3% 2.4 392 Esophagitis, gastroent & misc digest disorders w/o MCC 27,139 210,577 12.9% 3.6 312 Syncope & collapse 24,623 118,979 20.7% 3.0 287 Circulatory disorders except AMI, w card cath w/o MCC 21,405 102,126 21.0% 3.3 069 Transient ischemia 20,290 79,595 25.5% 2.7 641 Misc disorders of nutrition,metabolism,fluids/electrolytes w/o MCC 19,585 132,034 14.8% 3.7 812 Red blood cell disorders w/o MCC 17,823 88,757 20.1% 3.5 309 Cardiac arrhythmia & conduction disorders w CC 16,478 105,815 15.6% 3.4 690 Kidney & urinary tract infections w/o MCC 14,915 193,058 7.7% 4.0 192 Chronic obstructive pulmonary disease w/o CC/MCC 11,940 97,328 12.3% 292 Heart failure & shock w CC 10,814 201,820 5.4% 4.6 191 Chronic obstructive pulmonary disease w CC 10,267 137,205 7.5% 4.3 918 Poisoning & toxic effects of drugs w/o MCC 10,001 33,820 29.6% 2.8 293 Heart failure & shock w/o CC/MCC 9,766 78,011 12.5% 3.2 683 Renal failure w CC 9,718 154,529 6.3% 066 Intracranial hemorrhage or cerebral infarction w/o CC/MCC 9,158 59,692 15.3% 948 Signs & symptoms w/o MCC 9,067 51,182 17.7% 378 GI hemorrhage w CC 9,050 139,808 6.5% 305 Hypertension w/o MCC 8,683 31,672 27.4% Top 20 Medical DRGs 331,416 2,222,607 14.9% All Medical DRGs 704,383 7,343,966 9.6% 4.8 *Excludes deaths, transfers, leaves against medical advice, and claims with prior observation of 24 hours or greater. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

26 Short-Term Acute Stays: Med
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 DRG Description 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 3,045 7,282 41.8% 2.1 392 Esophagitis, gastroent & misc digest disorders w/o MCC 2,274 14,697 15.5% 3.4 310 Cardiac arrhythmia & conduction disorders w/o CC/MCC 2,163 7,037 30.7% 2.4 312 Syncope & collapse 1,989 9,212 21.6% 3.0 287 Circulatory disorders except AMI, w card cath w/o MCC 1,686 7,560 22.3% 3.2 069 Transient ischemia 1,617 6,063 26.7% 2.6 641 Misc disorders of nutrition,metabolism,fluids/electrolytes w/o MCC 1,405 8,381 16.8% 3.3 309 Cardiac arrhythmia & conduction disorders w CC 1,087 7,278 14.9% 812 Red blood cell disorders w/o MCC 1,076 5,359 20.1% 3.5 690 Kidney & urinary tract infections w/o MCC 1,060 11,813 9.0% 4.1 192 Chronic obstructive pulmonary disease w/o CC/MCC 909 6,723 13.5% 191 Chronic obstructive pulmonary disease w CC 908 10,646 8.5% 4.2 292 Heart failure & shock w CC 816 13,809 5.9% 4.4 918 Poisoning & toxic effects of drugs w/o MCC 773 2,368 32.6% 303 Atherosclerosis w/o MCC 713 2,344 30.4% 2.3 683 Renal failure w CC 686 10,669 6.4% 4.5 101 Seizures w/o MCC 680 3,541 19.2% 3.1 378 GI hemorrhage w CC 662 9,581 6.9% 3.9 948 Signs & symptoms w/o MCC 630 3,447 18.3% 293 Heart failure & shock w/o CC/MCC 620 4,941 12.5% 4.0 Top Medical DRGs Jurisdiction-wide 24,799 152,751 16.2% All Medical DRGs Jurisdiction-wide 50,404 490,830 10.3% 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. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

27 Short-Term Acute Stays: Surg
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 DRG Description 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 2,744 7,737 35.5% 2.5 039 Extracranial procedures w/o CC/MCC 1,611 2,337 68.9% 1.7 470 Major joint replacement or reattachment of lower extremity w/o MCC 1,414 26,471 5.3% 3.3 254 Other vascular procedures w/o CC/MCC 967 2,188 44.2% 473 Cervical spinal fusion w/o CC/MCC 905 1,612 56.1% 2.0 491 Back & neck proc exc spinal fusion w/o CC/MCC 727 1,834 39.6% 2.3 251 Perc cardiovasc proc w/o coronary artery stent w/o MCC 641 1,885 34.0% 3.2 238 Major cardiovasc procedures w/o MCC 615 2,140 28.7% 4.0 249 Perc cardiovasc proc w non-drug-eluting stent w/o MCC 532 2,220 24.0% 2.9 708 Major male pelvic procedures w/o CC/MCC 890 59.8% 484 Major joint & limb reattachment proc of upper extremity w/o CC/MCC 517 1,498 34.5% 2.1 627 Thyroid, parathyroid & thyroglossal procedures w/o CC/MCC 500 629 79.5% 1.4 227 Cardiac defibrillator implant w/o cardiac cath w/o MCC 1,051 45.0% 3.4 743 Uterine & adnexa proc for non-malignancy w/o CC/MCC 465 1,166 39.9% 460 Spinal fusion except cervical w/o MCC 372 4,796 7.8% 3.7 253 Other vascular procedures w CC 352 2,683 13.1% 5.8 244 Permanent cardiac pacemaker implant w/o CC/MCC 342 1,755 19.5% 3.1 036 Carotid artery stent procedure w/o CC/MCC 315 398 79.1% 1.5 581 Other skin, subcut tiss & breast proc w/o CC/MCC 269 564 47.7% 2.4 038 Extracranial procedures w CC 267 825 32.4% 3.8 Top Surgical DRGs Jurisdiction-wide 14,560 64,679 22.5% All Surgical DRGs Jurisdiction-wide 22,491 176,430 12.7% 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. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

28 Short-Term Acute Stays: COPD
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 2010 43 185 23.2% 3.4 5.2 $5,103 $219,450 Q3 FY 2010 50 163 30.7% 3.3 4.6 $5,134 $256,705 Q4 FY 2010 37 114 32.5% 3.8 4.5 $4,878 $180,480 Q1 FY 2011 35 134 26.1% 5.4 $5,147 $180,157 Q2 FY 2011 64 188 34.0% 4.1 $5,183 $331,715 Q3 FY 2011 48 158 30.4% 3.9 4.7 $4,912 $235,781 Q4 FY 2011 40 122 32.8% 3.1 $4,807 $192,289 Q1 FY 2012 146 43.8% $5,287 $338,366 Q2 FY 2012 3.7 $5,328 $255,729 Q3 FY 2012 33 121 27.3% 4.0 $5,628 $185,732 Q4 FY 2012 32 136 23.5% $5,173 $165,539 Q1 FY 2013 132 37.9% 3.2 5.1 $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 (4th 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) Note: Data for hospitals with fewer than 11 discharges in the numerator of a target area have been suppressed due to confidentiality requirements. Note: Target area discharge count (numerator) = total discharges for DRGs 190, 191 and 192 (see Definitions worksheet for complete definitions Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

29 Short-Term Acute Stays: Single CC or MCC
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 2010 194 547 35.5% 3.6 5.3 $5,755 $1,116,408 Q3 FY 2010 221 508 43.5% 3.5 4.8 $5,811 $1,284,128 Q4 FY 2010 188 459 41.0% 3.4 $6,701 $1,259,802 Q1 FY 2011 191 486 39.3% 3.7 5.1 $6,093 $1,163,806 Q2 FY 2011 228 584 39.0% 4.9 $6,079 $1,386,008 Q3 FY 2011 206 467 44.1% 3.8 5.0 $6,693 $1,378,843 Q4 FY 2011 198 470 42.1% $6,067 $1,201,249 Q1 FY 2012 216 518 41.7% 3.3 4.5 $6,374 $1,376,693 Q2 FY 2012 177 604 29.3% $5,943 $1,051,967 Q3 FY 2012 161 522 30.8% 3.2 $5,878 $946,417 Q4 FY 2012 182 539 33.8% 2.9 4.6 $6,233 $1,134,421 Q1 FY 2013 171 495 34.5% 3.1 $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 (4th 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) Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

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

31 Medical Necessity & Reasonableness: Recovery Auditor Quarterly Stats
CGS Administrators - Medicare Part B 6/24/2013 Medical Necessity & Reasonableness: Recovery Auditor Quarterly Stats Cardiovascular Procedures: (Medical Necessity) Medicare pays for inpatient hospital services that are medically necessary for the setting billed. Medical documentation for patients undergoing cardiovascular procedures needs to be complete and support all services provided in the setting billed. Region B Top Error: Cardiovascular Procedures Medical necessity for cardiovascular procedures performed inpatient hospital are not supported in medical record Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

32 Three-Day SNF Qualifying Admissions
Short-Term Acute Care PEPPER Visit PEPPERresources.org Three-day Skilled Nursing Facility-qualifying Admissions 000904 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 2010 37 195 19.0% 3.0 6.5 $7,219 $267,087 Q3 FY 2010 33 147 22.4% 5.9 $6,445 $212,695 Q4 FY 2010 38 161 23.6% 5.8 $6,819 $259,123 Q1 FY 2011 43 175 24.6% 5.6 $7,090 $304,877 Q2 FY 2011 40 207 19.3% $6,604 $264,155 Q3 FY 2011 28 152 18.4% 6.3 $6,744 $188,830 Q4 FY 2011 31 153 20.3% 6.0 $7,223 $223,907 Q1 FY 2012 170 25.3% 5.7 $6,977 $300,021 Q2 FY 2012 209 18.2% 6.1 $6,255 $237,694 Q3 FY 2012 148 25.0% $7,796 $288,466 Q4 FY 2012 45 185 24.3% $7,849 $353,184 Q1 FY 2013 32 155 20.6% $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 (4th 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) Note: Data for hospitals with fewer than 11 discharges in the numerator of a target area have been suppressed due to confidentiality requirements. Note: Target area discharge count (numerator) = total discharges to a SNF with a three-day length of stay (see Definitions worksheet for complete definitions). Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

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

34 Hospitalization Challenges: Appropriate Setting
Observation vs. inpatient Patient’s 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

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

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

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

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 1997.” “Rates of hospitalization with knee replacement and spinal fusion approximately doubled between 1997 and 2010.” Source: AHQR Statistical Brief #149, February 2013 Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

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

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

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. Intermittent = provided or needed on fewer than 7 days each week or <8 hours of each day for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional care is finite and predictable). Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

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” Intermittent = provided or needed on fewer than 7 days each week or <8 hours of each day for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional care is finite and predictable). Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

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) Intermittent = provided or needed on fewer than 7 days each week or <8 hours of each day for periods of 21 days or less (with extensions in exceptional circumstances when the need for additional care is finite and predictable). Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

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 patient’s clinical condition as seen during that encounter supports the patient’s 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

45 Home Health Benefit Total errors for 2014 CERT report: 73. FTF errors = 67. Other errors = 6. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

46 Home Health Benefit Codes to consider for reimbursement for physician’s time (must maintain documentation): Care Plan Oversight: HCPCS codes G0181, G0182 Billing guidelines: CMS Medicare Claims Processing Manual (Pub ), chapter 12, sections 80 and 80.1 Transitional Care Management: CPT codes Billing guidance: CMS FAQs for transitional care management Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 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 Physician’s 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

48 Physician’s Key Role Coding Importance of “being there”
Role of coders: select CPT/HCPCS codes and modifiers and ICD-9 codes based on physician’s documentation and with physician’s input Medical necessity as the overarching criterion Weight/preponderance of documentation vs. physician’s assessment of the patient’s 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

49 Physician’s 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

50 Physician’s Key Role Criteria Reasonable Necessary
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 Eddy, et. al. Benefit language, JAMA 275(8): ) Eisenberg et. al., Ten lessons for evidence-based technology assessments, JAMA 282(19): l Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

51 Physician’s 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

52 Physician’s 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 Footnote: we have received information from the CERT contractor about providers sending records for additional patients (in addition to the one requested). Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

53 Physician’s Key Role 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. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

54 Physician’s Key Role 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. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

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

56 Physician’s Key Role 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. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

57 Physician’s Key Role 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. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

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

59 Physician’s Key Role 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. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

60 Physician’s Key Role 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. Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

61 Physician’s Key Role 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 Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

62 Physician’s Key Role Medical records staff:
Requests from multiple contractors/entities and timeline for responses: CGS job aid – “Medical Record Requests: Keys to Success” 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; patient’s name; signed/dated notes Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

63 Physician’s 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

64 Physician’s 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

65 Physician’s 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

66 Physician’s 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 Delayed certification: see Pub , chapter 15, section D Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

67 Physician’s Key Role Ambulance: “Medical necessity is established when the patient’s 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 individual’s 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

68 Physician’s Key Role Non-emergency transport (from CFR):
Bed-confinement or beneficiary’s 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

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

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

71 MR Strategy Development: Tools, Evaluation, & Interventional Strategy
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

72 MR Strategy Development: Tools, Evaluation, & 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

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

74 Medical Review Pre-payment Post-payment Automated vs. complex
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 Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

75 J-15 Evolution of Corrective Action
Corrective Actions J-15 Evolution of Corrective Action 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 Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 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.

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

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

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

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

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

81 Medical Review Current areas of focus Future 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 Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC

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 Revised 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 Consider inserting somewhere Revised July 18, 2013 © Copyright 2013, CGS Administrators, LLC 83

84 Medical Review Predictive Modeling
How is this different from the current process? Traditional Approach New 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 supplier’s 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 84

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

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


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