2 Short Stay Acute Care Facilities Traditionally known as “hospitals”Can offer a variety of services by order of a credentialed physician/provider who has privileges at the facility“inpatient”“outpatient”
3 Short Stay Acute Care Facilities Hospitals that accept CMS beneficiaries agree to inpatient care reimbursement under the Inpatient Perspective Payment System (IPPS) and outpatient care reimbursement under the Outpatient Perspective Payment System (OPPS)
4 Medicare Reimbursement It is the responsibility of the hospital to know when to bill Medicare Part A (IPPS) for inpatient services and when to bill Medicare Part B (OPPS) for outpatient servicesHOWEVER the hospital can only bill CMS (Medicare/Medicaid) based on the services ordered by the physician
5 Inpatient ServicesTraditionally referred to as an “admission” or “Admit to”Most patients who spend the night in the hospital believe they are “admitted”However, spending the night in the hospital does not automatically qualify for inpatient services
6 Inpatient Services Uses a day as its basic unit Day begins at midnight Any part of a day = 1 dayPatient admitted at 11:30 pm = 1 dayCount first day of admission but not last dayDischarge patients as early as possible the day of dischargeTime of discharge are when services are complete not when the order is written
7 The Good and Bad of IPPSInpatient services are only a “covered” CMS benefit when medically necessary e.g., when the services could not have been safely provided in a lesser settingHospitals must verify the medical necessity of all inpatient stays/ episodes of careShort stay admissions are vulnerable to scrutiny
8 The Good and Bad of IPPSThe IPPS uses a “bundled” payment system differentiated by MS-DRGThe MS-DRG payment covers all services rendered by the hospital during an inpatient stay regardless of the length of stay* (LOS)
9 IPPS PaymentThe bulk of the cost associated with an inpatient stay is room & boardCMS bases reimbursement on the G/LOS95% confidence interval for LOS based on all associated claimsAlways rounded up to whole number as inpatient claims are paid per day
10 RAC AuditsThe IPPS (MS-DRG) payment includes coverage for several days of tx, the potential for overpayment occurs when IPPS payment is made for a 1 or 2 day stayTheoretical . . .if a patient is discharged in fewer days than the associated GLOS the hospital makes $if a patient stays longer than the associated GLOS the hospital loses $
12 High Risk Admission DRG Hospital A will receive payment of $6,249 regardless of the services provided and how long the patient stayed in the hospital under the IPPS rulesWhen patients in MS-DRGs like this have a one-day inpatient stay CMS evaluates the possibility of overpaymentIPPS payment rather than OPPS payment
13 Purpose of Utilization Review (UR) To ensure patients are receiving the correct level of hospital services based on medical necessityProcedure Only/same day surgeryObservation/Outpatient servicesInpatient servicesBilling at the incorrect level of care is Medicare fraud so a hospital does not bill for services that don’t meet medical necessity
14 Step Two What type of hospital service was ordered by the provider? InpatientAppropriate for hemodynamic instabilityPatients who need immediate intervention/txObservationWhen in doubt this is probably the right level of careAppropriate for stable patients with negative diagnostics who are receiving additional diagnostics
15 Is the Order Valid per CMS Guidelines? Not only must an order be present, but it must be unambiguous“admit to OBS” is no longer considered a valid order by Medicare as of April, 2009The term “admit” = inpatient settingThe term “OBS” = outpatient setting
16 Is the Order Valid? The term “23 hours admission” is NOT valid 23 hour observation is an antiquated termAn inpatient admission is billed per day, a patient can be an inpatient AND remain hospitalized for less than 24 hoursObservation patients DON’T automatically “rollover” to inpatient status after 23 hours the physician must write a new order to cover care past the 23rd hour
17 Step ThreeIn order to verify medical necessity, CMS mandates the use of a “screening tool”UR staff screen for medical necessity by performing an admission reviewIs the ordered level of care supported by documentation in the medical record?
18 Observation Following Surgery/Procedure Requires medical necessity validationObservation is only justified if something occurs during the procedure and/or during recovery to necessitate an additional episode of careRequire 4-6 hours of recovery“monitoring” does not justify observation careThe observation principal diagnosis isn’t the same as that to justify surgery
19 How Do You Justify Patient Status? Document, document, documentNot only does a hospital need justification for the patient status, BUT the hospital is also dependent upon physician documentation for their CMS Quality Indicators and reimbursement
20 Documentation BasicsObservation care is for diagnostic workup so inpatients should have “evidence of” a concerning disease process to be admitted.Always provide the underlying etiology of a symptom i.e., chest pain, syncope, abdominal pain, documented in the H&P in the discharge summaryA diagnosis can be “possible” or “probable” in the discharge summary if additional evaluation will occur in the outpatient setting
21 History and PhysicalSpecify in your “history of present illness” the following:Onset of the new/ acute symptomIs it an exacerbation of a chronic conditionHow is the patient’s current condition different from baseline?
22 History & PhysicalSpecify the current status of all co-morbid conditionsState if resolvedHistory of pneumonia dx by PCP resolvedRemains acuteHistory of pneumonia dx by PCP remains acuteIs a chronic condition
23 Coding GuidelinesThe principal diagnosis is the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospitalNot the admitting symptomLink the symptoms to the underlying disease processFluid volume overload 2/2 ESRD
24 Documentation Guidelines Avoid perpetuating the admitting complaint as the Pdx, update your diagnoses each progress note/dailyClearly state when the etiology of the admitted complaint is determined if it’s symptomology was present on admission (POA)Disease processes like pneumonia, SIRS, and sepsis should always be noted if the symptoms were POA
25 Documentation Guidelines Clearly state when a differential or working diagnosis is ruled out or confirmed in the progress note and/or discharge summaryUnstable angina secondary to CAD remains likely cause of the CPPneumonia ruled out, abx stopped
26 Documentation Guidelines There can still be “evidence of” a disease based on presenting complaints even when not confirmed with diagnosticsAborted stroke 2/2 TPA interventionEvidence of gram negative pneumonia (HCAP) 2/2 recent hospitalization and dialysis
27 The Value of a Concurrent Condition Medicare identifies diagnoses (by ICD-9 codes) that require additional resources during hospitalization when not intrinsic to the PDx These diagnoses are separated into those that minimally resource use (CC) and those that greatly resource use (MCC) this stratification creates the “tiers”
28 What is The Clinical Documentation Improvement (CDI) Program? Because clinical terms don’t often correspond to ICD-9 codes, many hospitals have a CDI program. RNs and/or coders who work collaboratively with providers and coders to bridge the gap between the data contained in the medical record i.e., test results, nurses notes, consultant notes, etc., and what is available for coding.
29 How Does CDI Work?The CDI nurse establishes and updates a working MS-DRG based on the principal diagnosis, principal procedure (if applicable), and any concurrent conditions that are classified as a CC or MCC based on documentation by treating providers i.e., H&P, progress notes, discharge summary, etc.
30 Chart QueriesWhenever there is clinical evidence suggestive of a more definitive Pdx and/or the presences of an incomplete or missing diagnosis, i.e., a potential CC and/or MCC, the CDI specialist will “query” the physician to interpret the clinical evidence.NOTE: Queries aren’t only to reimbursement
31 Chart QueriesAs with direct patient care, the CDI nurse presents relevant findings to the physician for reviewCDI staff don’t evaluate the “quality of care”The focus of CDI is ensuring provider documentation reflects the clinical evidence in the medical record and can be “captured” by ICD-9 codes
32 Chart QueriesCDI staff are not allowed to “lead” a physician to a particular responseCDI staff can’t pose yes/no questionsCDI staff can’t tell you what diagnosis to writeWhen possible, CDI staff will give the provider the diagnosis commonly associated with the clinical evidence that can be captured by ICD-9 code
33 Chart QueriesCoders can’t infer or assume so sometimes CDI staff must ask for documentation that seems obvious to the provider and/or to “link” a symptom to a diagnosisA provider can always disagree or state the condition isn’t clinically significant or is an incidental finding
34 RemindersProvide rationales/medical necessity for all orders justify the complexity of your patientRefer to the H & P to address ALL presenting signs/symptoms with known, suspected or possible diagnosesState when a differential dx has been confirmed or ruled out