Objectives Receive an update on the NC Medicaid Recovery Audit Contractor program Understand the chosen “basics” of the NC RAC program Learn likely areas of NC RAC focus Appreciate clinical documentation tips and strategies to reduce RAC financial exposure
Medicaid RAC Provisions Section 6411 Affordable Care Act, Expansion of the RAC Program, required States to establish programs to contract with RACs by December 31,2010 Delay in implementation by April 2011 Implementation of program when Final Rule published
State Medicaid RAC Plan Section 1902 (a)(42)(B)(i) SSA-Title XIX of the SSA, NC Medicaid established RAC program State will make RAC payments contingency Contingency payments will not exceed highest rate paid under Medicare RAC $30 fee paid per underpayment identified Efforts of the Medicaid RAC(s) will be coordinated with other contractors or entities performing audits of entities receiving payments under the State plan or wavier in the State, and/or State and Federal law enforcement entities and the CMS Medicaid Integrity Program
Traditional Preparation RAC Committee formation Software application Adherence to record submission and appeal timelines Staffing to conduct appeals Financial reserves
Hospital Documentation Medical Record ERH & PConsult Progress Notes Ancillary Staff Discharge Summary
Medical Necessity Section 1862 (a)(1)(a) Social Security Act Title XVII “No payment can be made that is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve functioning of a malformed body member” Medical Necessity “Responsibility of the Physician” Medicare and other 3 rd party payer guidelines Screening criteria
Commercial Screening Criteria “CMS considers use screening criteria as only one tool that should be utilized by contractors “ Medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the beneficiary at anytime during the stay(Chapter 6, Section 6.5.2, of the Medicare Program Integrity Manual) Reviewer applies clinical judgment
Additional Criteria Admission criteria; Invasive procedure criteria; CMS coverage guidelines; Published CMS criteria; DRG validation guidelines; Coding guidelines; Other screens, criteria, and guidelines (e.g., practice guidelines that are well excepted by the medical community)
Signs & Symptoms Beneficiary must demonstrate signs and symptoms to warrant need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis Consider any pre-existing medical problems or extenuating circumstances that make admission of the beneficiary medically necessary Inpatient care rather than outpatient is required only if the beneficiary’s medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting
Physician’s Responsibility The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting. (Medicare Benefit Policy Manual Chapter 1 Section 10)
Factors to be Considered Factors to be considered when making the decision to admit include such things as: The severity of the signs and symptoms exhibited by the patient; The medical predictability of something adverse happening to the patient; The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and The availability of diagnostic procedures at the time when and at the location where the patient presents.
Lack of Focus Medical record documentation Severity signs and symptoms Portrayal of patient acuity Risk of morbidity and mortality Predictability of adverse outcomes Provisional diagnoses
Typical Case Mrs. Jones, a 78 year old woman presented to the Emergency Room in acute respiratory distress, with difficulty breathing that started about two hours prior to presentation to the ER. She has known COPD and continues to smoke, now requiring supplemental oxygen 2 liters round the clock. PMH: COPD, CHF, lung cancer status post lobectomy and chemo, hypertension. Vital signs: HR 120, RR 34, Temperature 99 F, oxygen sats 85%, appears in no respiratory distress, A & O x 3
Medical Necessity Physician lack of appreciation and understanding “This patient does not meet medical necessity criteria” “Please change the patient status to outpatient” “Please document for medical necessity”
Severity Clinical Impression Acute COPD Hypoxemia Morbidly obese Tobacco addiction Plan-admit and treat Acute exacerbation of COPD Acute on chronic respiratory failure Morbid obesity Tobacco addiction-continues to smoke Plan- will need to admit patient and improve patient’s oxygenation, currently she is on a 100% non-rebreather in the hopes of avoiding the vent. Last admission she was on the vent and had to be discharged to LTAC to wean her off the vent
Severity of Illness SOI Extent of organ system derangement or physiologic decompensation for a patient Gives medical classification: Minor Moderate Major Extreme Serves as basis for evaluating hospital resource use Assigned SOI based upon specific diagnoses and procedures performed
Severity of Illness Clinical Screening criteria Dyspnea and >= one: Respiratory rate >= 24/min Stridor Heart rate >=100/min Change in mental status Sputum smear/culture (+) for bacteria/fungi/protozoa
Medical Necessity Clinical Documentation Hospital Severity of Illness Risk of Mortality Physician Physician Judgment Medical Decision Making/Medical Necessity
Disconnect Clinical indicators Physician Documentation Severity of Illness
Different Perspective Clinical Documentation Medical Necessity Hospital/Physician admission and continued stay Severity of Illness Screening criteria Physician clinical judgment, medical decision making, admission & discharge Revenue Cycle Denials avoidance and appeals Strategy to minimize denials/financial exposure
Clinical Documentation Today Required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes Chronologically, documents the care of the patient and is an important element contributing to high quality care
The “Great Facilitator Medical record facilitates: the ability of the physician and other healthcare professionals to evaluate and plan the patient's immediate treatment, and to monitor his/her healthcare over time; communication and continuity of care among physicians and other healthcare professionals involved in the patient's care;
The “Great Facilitator accurate and timely claims review and payment; appropriate utilization review and quality of care evaluations; and collection of data that may be useful for research and education
The Great Blender
Reducing that “Hassle Factor” An appropriately documented medical record can reduce many of the "hassles" Associated with claims processing and may serve as a legal document to verify the care provided, if necessary. Associated with retrospective queries from Health Information Management coding
“Clinical Documentation-Why the Fuss” Providing services consistent with standards of medical care, evidenced based medicine, and insurance coverage Site of service Medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or Services provided have been accurately reported 33
Documentation Purposes Outlines and highlights patient’s clinical presentation History of Present Illness and context Constellation of signs and symptoms Recording of physical findings Assimilating historical data and physical findings in into clinical context Formulation of Working Hypotheses
Documentation Purposes Justification for diagnostic workup Development and documentation of clinical diagnoses Development and implementation of care plan Adherence to best practice, evidence based medicine Quality measurement
Documentation Purposes Support of outcome studies Risk of mortality and morbidity, severity of illness Risk adjusted readmissions Promotes continuity of care Measurement of efficiency/value Represents clinical judgment and medical decision-making in support of medical necessity depiction for hospital and physician Provisions of clinical data for research and education Supports and justifies resource consumption and research
Measurement of Efficiency Efficiency “Providing and ordering a level of services that is sufficient to meet a patient’s health care needs but is not excessive, given the patient’s health status”
Documentation Deficiencies Result of Documentation Deficiencies Appearance of unnecessary use of resources Appearance of inefficient practice of medicine Non-support of medical necessity Reporting of nonspecific diagnoses/symptoms versus definitive diagnoses Inaccurate reporting of patient outcomes Poor, inadequate communication between providers Increased risk of hospital readmissions
Principles of Medical Record Documentation Medical should be complete and legible Documentation of each patient encounter should include: Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
Principles of Medical Record Documentation The documentation of each patient encounter should include: assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the observer Documentation should support intensity of patient evaluation and/or treatment, including thought processes and the complexity of medical decision-making as it relates to the patient’s chief complaint for the encounter
Principles of Medical Record Documentation Past and present diagnoses should be accessible to the treating and/or consulting physician. Appropriate health risk factors should be identified.
Principles of Documentation The documentation should support the intensity of the patient evaluation and/or the treatment, including thought processes and the complexity of medical decision-making as it relates to the patient's chief complaint for the encounter.
Principles of Documentation The patient's progress, including response to treatment, change in treatment, change in diagnosis, and patient non-compliance should be documented
Nature of Presenting Problem Ensure the nature of the patient’s presentation corresponds to CPT’s contributory factors of the nature of the presenting problem and/or patient’s status descriptions for the code reported.
Nature of Presenting Problem For instance: – “Usually the patient is stable, recovering or improving.” – “Usually the patient is responding inadequately to therapy or has developed a minor complication.” – “Usually the patient is unstable or has developed a significant complication or a significant new problem.”
Importance of Proper and Accurate Documentation Services billed to the Medicare program are the sole responsibility of the Medicare provider. Documentation needs to be unique, specific, and should accurately reflect the services you are billing.
Importance of Proper and Accurate Documentation Documentation not only must reflect necessity and the services provided but also must be consistent among the providers involved in an episode of care. Medicare payment for services may be denied if the supporting documentation is not thorough.
Clinical Case Study 48 H & P Assessment HD #3 Right Lower Lobe Infiltrate- start IV Zosyn and Levaquin Pulmonary edema- diurese H & H decreased- watch closely and transfuse if necessary Cardiac arrhythmia- continue Rythmol and Coumadin
Clinical Case Study Cont. H & P Assessment HD #3 Right Lower Lobe Infiltrate- start IV Zosyn and Levaquin Pulmonary edema- diurese H & H decreased- watch closely and transfuse if necessary Cardiac arrhythmia- continue Rythmol and Coumadin
New & Improved H & P Assessment HD #3 Aspiration pneumonia-continue IV Zosyn and Levaquin, patient’s respiratory status improving but still somewhat short of breath, chest X-ray still shows some consolidation, slowly improving, may need a few days more of IV antibiotics Acute on chronic systolic CHF- diuresing nicely, will consider step down therapy to PO tomorrow Chronic blood loss anemia due to slowly bleeding AV malformation- H & H decreased- watch closely and transfuse if necessary. Will have to transfuse judiciously if necessary given the patient’s precarious CHF with tendency to fluid overload
Congruence 51 Clinical Doc Med Necessity Quality Efficienc y ACO
Widespread Probe Review Trailblazer widespread review MS-DRG 690- Urinary Tract Infection Post-payment sample of 100 claims Paid claims error rate percent Records reviewed for: Verification of Medicare coverage for billed services Determination of medical necessity Determination of appropriateness of care setting Validation of the MS-DRG 52
Lack of Medical Necessity Examples lack of medical necessity denials: Physicians writing admission orders for acute inpatient care for a patient documented as stable, receiving oral medications, without fever, and with normal laboratory values Admission orders are written for acute inpatient care for a condition or complication not substantiated by supporting documentation from members of the interdisciplinary team 53
Lack of Medical Necessity The documentation of admission assessment was insufficient The documentation did not support an inpatient level of care 54
Key Elements of Medical Record Documentation “Reasonable and Medically Necessary” and “Supporting Documentation” are key elements of medical record documentation Interdisciplinary team documentation of assessment, intervention, and outcomes provides a picture of patient’s clinical condition and response to treatment 55
The Sum of the Components Each component is useful in determining “reasonable and medically necessary” services are provided and billed to the contractor for reimbursement Objective clinical documentation solidifies admission/continued stay medical necessity 56
RAC Related Denials Lack of consistency in entry in medical record Assessments, treatment plans, physician orders, nursing notes, medication and treatment records, etc., and other facility documents such as admission and discharge data, pharmacy records, etc. Provider’s failed to adequately document significant changes in the patient’s condition or care issues that in some instances impacted the review determination 57
Added Value Ancillary Provider Documentation supports and facilitates provider patient status decisions: The severity of signs and symptoms exhibited by the patient; The medical predictability of something adverse happening to the patient ; The need for diagnostic studies; The availability of diagnostic procedures at the time when and at the location where the patient presents 58
A “Few” More Words During medical review, the medical reviewer considers any pre-existing medical problems or extenuating circumstances that make the admission of the beneficiary medically necessary. Inpatient care rather than outpatient care is required only if the beneficiary's medical condition, safety or health would be significantly and directly threatened if care was provided in a less intensive setting. 59
The “Last Word” Inpatient care rather than outpatient care is required only if the beneficiary's medical condition, safety or health would be significantly and directly threatened if care was provided in a less intensive setting. Objective account of assessment, interventions, and outcomes, response to treatment. 60
Medical Necessity & Diagnosis For a service to be considered medically necessary, it must be all of the following: Appropriate in duration and frequency Meets but does not exceed patient’s medical needs Provided in accordance with accepted standards of medical practice Not experimental or investigational Performed by qualified personnel in an appropriate setting 61
Relevant Note Medicare requires the informational content (the facts about the patient’s condition) in the medical record to demonstrate all of the above. The facts, not just conclusory statements, must demonstrate that the patient has the diagnosis reported on the claim and that the patient’s condition fulfills all coverage provisions of all Medicare rules and policies. 62
Evaluation and Management 63 History HPI ROS PFSH Physical Exam Medical Decision Making Number of Diagnoses and Management Options Amount and Complexity of Data Table of Risk
Elements of E & M 64 Six Major Elements History Physical Exam Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem
Key vs. Contributing Components 65 Key History Physical Exam Medical Decision Making Contributing Nature of Presenting Problem Counseling Coordination of Care
Documentation Requirements 66 Documentation must meet following criteria Must be legible Clearly identify patient, date of service, and who performed the service Accurately report all pertinent facts, findings, and observations Include appropriate diagnosis for the service provided Documentation must have hand written or an electronic signature
What are the Payers Looking For ? 67 Require reasonable documentation that services consistent with the insurance coverage provided May request record to validate: The site of service; The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or That services provided have been accurately reported
Documentation Documentation for each patient encounter should include: reason for encounter and relevant history, physical examination findings, and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and date and legible identity of the observer. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred
Documentation Past and present diagnoses should be accessible to the treating and/or consulting physician Appropriate health risk factors should be identified. The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented. The CPT and International Classification of Diseases 9th Revision Clinical Modification (ICD-9- CM) codes reported on the health insurance claim form should be supported by the documentation in the medical record.
E & M 70 Evaluation of patient with exchange of clinically reasonable and necessary information Use of the clinical information in the management of the patient Cardinal Rule of E & M coding No evidence of face-to-face visit →→ NO E & M No diagnosis documented →→ No E & M Specific, Accurate and Detailed Documentation fundamental to E & M
Basics of E & M Assignment 71 Chief Complaint (CC) CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter. Every progress note must have clearly documented CC HPI- chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.
HPI 72 HPI consists of following: Location Quality Severity Duration Timing Context Modifying factors; and Associated signs and symptoms
Take Note 73 The extent of HPI, ROS and PFSH that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem (Chief Complaint) Two levels HPI Brief HPI consists of 1 -3 elements Extended HPI consists of 4 or more elements H & P- strive for 4 or more elements HPI
Role of HPI HPI drives: Extent of PFSH, ROS and physical exam performed Medical necessity for amount work performed and documented Medical necessity for E & M assignment Medical necessity of an Evaluation and Management (E/M) encounter is often visualized only when viewed through the prism of its characteristics captured in specific History of Present Illness (HPI) elements
Speaking of Medical Necessity Federal law requires that all expenses paid by Medicare, including expenses for Evaluation and Management services, are medically reasonable and necessary
Medical Necessity Medical necessity of E/M services is generally expressed in two ways: frequency of services and intensity of service (CPT level). Medicare’s determination of medical necessity is separate from its determination that the E/M service was rendered as billed.
Medical Necessity Medicare determines medical necessity largely through the experience and judgment of clinician coders along with the limited tools provided in CPT and by CMS. At audit, Medicare will deny or downcode E/M services that, in its judgment, exceed the patient’s documented needs
Elements of Medical Necessity Medical necessity of E/M services is based on the following attributes of the service that affected the physician’s documented work: Number, acuity and severity/duration of diagnoses/ problems addressed through history, physical and medical decision-making.
Elements of Medical Necessity The context of the encounter among all other services previously rendered for the same problem Complexity of documented comorbidities that clearly influenced physician work. Physical scope encompassed by the problems (number of physical systems affected by the problems).
Medical Necessity & Diagnosis For medical necessity, services must meet the following: Appropriate in duration and frequency Meet but does not exceed patient’s medical needs Provided in accordance with accepted standard of medical practice Not experimental or investigational Performed by qualified personnel in appropriate setting
Qualifying Factor Medicare requires the informational content (the facts about the patient’s condition) in the medical record to demonstrate all of the above. The facts, not just conclusory statements, must demonstrate that the patient has the diagnosis reported on the claim and that the patient’s condition fulfills all coverage provisions of all Medicare rules and policies.
Case Study “Demonstrating Medical Necessity” The patient s a 61-year old male with a history of peripheral vascular disease, who has had multiple vascular surgeries on his right lower extremity, which included an aortobifemoral, a right profunda to politeal bypass, a jump graft from the common femroal to the profunda, and a redo fem below knee popliteal bypass. The patient presented to Ziosville approximately 5 PM the day prior to presentation, complaining of increased right lower extremity pain that started below his knee. The patient does have a significant history of claudicating, however, this pain was at rest.
Case Study Continued She described it as crampy, has been increasing in intensity since its onset, and he also reports that his foot is cold. Currently the patient does not have any sensation below the mid calf on his right lower extremity and has decreased strength at his ankle, and little to no motor function in his toes. Pain is rated at 9 out of 10 pain scale, took some Motrin this morning with no improvement, can’t hardly walk due to the pain.
Case Study Continued PMH: Hypertension-labile and not well controlled Coronary artery disease with episodes of unstable angina relieved with nitro for the most part. CABG x 5 Diabetes Type II uncontrolled. Patient noncompliant with diet and medication regimen
Case Study Continued Assessment & Plan The patient is a 61-year old male with a history of peripheral vascular disease who presents with acute on chronic limb ischemia Admit the patient to the peripheral vascular service under Dr Denial We will schedule the patient for an emergent right lower extremity thrombectomy and possible femoral to tibia bypass and possible fasciotomies We will need to reverse the patient’s Coumadin with fresh frozen plasma We will make appropriate plans for the OR including chest x-ray, electrocardiogram, type and cross, and preoperative antibiotics
What’s the Big Deal Why the focus upon specific, accurate and detailed clinical documentation? CERT Program RAC Program Medicare Administrative Contractor reviews Medicaid Integrity Contractor Goal to reduce Medicare paid claims error rate by 50% by 2012
Clear, concise, and complete clinical documentation essential for business success Physician Feedback Program Physician Quality Reporting System Pay-for-Performance Bundled Payments (ACE Project) Accountable Care Organizations Shared savings, Gain sharing ICD-10 October 2013 Alternate Care Contracts Looking Ahead Once Again
Healthcare Quality Reporting Healthgrades.com Whynotthebest.org HospitalCompare.gov Medicare.gov New feature Physician Compare allows physician look-up Indicates participation in PQRS Indicates participation in prescribing medicines electronically
Modifier JW Palmetto requires use of modifier JW HCPS Modifier JW-drug/biological amount discarded/not administered to any patient Not used when actual drug dose administered less than billing unit Billing unit 10 mg, if administer 7 mg, bill one unit w/o JW modifier Coverage limited to single use vials. Multiple use vials not subject to payment
Modifier JW Drug wastage must be documented in the patient’s medical record with date, time, amount wasted and reason for wastage. Upon review, any discrepancy between amount administered to the patient and amount billed will be denied as non-rendered unless the wastage is clearly and acceptably documented. The amount billed as “wasted” must not be administered to another patient or billed again to Medicare.
Documentation Requirements All doses must be drawn by a licensed professional whose scope of practice includes administration of parenteral medications and knowledge of aseptic technique. All doses from a given vial should be drawn and administered within the time period specified on the package insert. Only one vial of a given concentration of the medication should be opened and used by the administering professional at any given time. A second vial of the same medication must not be opened until the previous vial is discarded.
Documentation Requirements Any opened vials or filled syringes must be discarded if not used within the specified time frame of the first puncture of the vial. Vials must be labeled to document the time of first entry and maintained at a temperature specified on the package insert during non-use. Residual amounts of these medications (either in the vial or syringes) must never be pooled with medication from another vial or syringe. If a patient requires more medication than is in a single, drawn syringe, then medication from a separate vial should be drawn into a separate syringe for administration
Quality Assurance Each facility should have in place a process- monitoring (quality assurance) program, which ensures compliance with these policies and procedures. This program should include: Recording data on infections in treated patients. Unannounced practice audits involving quality assurance staff observing performance of reuse techniques.
Of Note Modifier JW not used when billing unit already includes amount administered as well as amount wasted. Example- J1275- meperidine hydrochloride, per 100 mg. If 75 mg injected, bill one unit J1275 J mg includes administered amount as well as wastage. Do not use modifier “JW”