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©2014 Executive Health Resources, Inc. All rights reserved. Documentation Improvement for Medical Necessity Joydip Roy, MD Senior Medical Director, Audit,

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Presentation on theme: "©2014 Executive Health Resources, Inc. All rights reserved. Documentation Improvement for Medical Necessity Joydip Roy, MD Senior Medical Director, Audit,"— Presentation transcript:

1 ©2014 Executive Health Resources, Inc. All rights reserved. Documentation Improvement for Medical Necessity Joydip Roy, MD Senior Medical Director, Audit, Compliance and Education

2 ©2014 Executive Health Resources, Inc. All rights reserved. Agenda Objectives: –Get Physician Buy In, Why status matters –Documentation best practices and common errors –Documentation examples Medical Necessity 2 Midnight rule

3 ©2014 Executive Health Resources, Inc. All rights reserved. Why is Getting Patient Status Correct Such an Important Issue? Focus of Recovery Audit Contractors Potential False Claims issue if no complaint process is in place Potential recoupment of reimbursements during audit and loss of opportunity for appropriate OBS APC and ancillary charge payment Overuse of Inpatient Length of stay artificially elevated Mortality data artificially elevated Qualified stay impact on patient’s skilled care benefit Unexpected patient financial responsibility (self-administered medication charges, inflated co-payments) Overuse of Observation It’s about getting it right!

4 ©2014 Executive Health Resources, Inc. All rights reserved. Patient Deductible and Co-Pays Day 1-60: $1216 inpatient deductible per Benefit Period Day 61-90: $304/day Day : $608/day Inpatient (Part A) 2014: $147 per year deductible 20% coinsurance for all covered outpatient services 100% of non-covered outpatient services Outpatient (Part B) 2014: Source:

5 ©2014 Executive Health Resources, Inc. All rights reserved. National Exposure NBC Nightly News/MSNBC March 2014: –http://www.nbcnews.com/watch/nightly-news/why-going-under-observation-can-cost-you http://www.nbcnews.com/watch/nightly-news/why-going-under-observation-can-cost-you –http://www.nbcnews.com/watch/nightly-news/critical-advice-all-medicare-patients-should-hear http://www.nbcnews.com/watch/nightly-news/critical-advice-all-medicare-patients-should-hear FierceHealthcare, July 15, 2013 –http://www.fiercehealthfinance.com/story/study-hospitals-lose-money-observation-care/ ?utm_medium=nl&utm_source=internal 15?utm_medium=nl&utm_source=internal JAMA: July 8, Invited Commentary: Observation Status for Hospitalized Patients/Hospitalized but Not Admitted Kaiser News May 3, 2013 –http://www.kaiserhealthnews.org/Stories/2013/May/03/lawsuit-challenges-observation-rules-in- Medicare.aspxhttp://www.kaiserhealthnews.org/Stories/2013/May/03/lawsuit-challenges-observation-rules-in- Medicare.aspx Money August 2012; “This could Hurt—a lot” pg 70 NYTIMES: In the Hospital, but Not Really a Patient; June 22, 2012 USA Today April 17, 2012 –http://www.usatoday.com/money/industries/health/drugs/story/ /drugs-can-be-expensive-in- observation-care/ /1http://www.usatoday.com/money/industries/health/drugs/story/ /drugs-can-be-expensive-in- observation-care/ /1 Washington Post 2010: Patients held for observation can face steep drug bills

6 ©2014 Executive Health Resources, Inc. All rights reserved. CMS Transmittal 540 Issued on September 4, 2014 –Effective date: September 8, 2014 MACs and ZPICs may deny “related” claims, either after review or automatically Medicare’s example: –When the Part A Inpatient surgical claim is denied as not reasonable and necessary, the MAC may recoup the surgeon's Part B services. For services where the patient’s history and physical (H&P), physician progress notes or other hospital record documentation does not support the medical necessity for performing the procedure, post payment recoupment may occur for the performing physician’s Part B service.

7 ©2014 Executive Health Resources, Inc. All rights reserved. Documentation Tips for Medical Necessity

8 ©2014 Executive Health Resources, Inc. All rights reserved.

9 What the Auditors Expect

10 ©2014 Executive Health Resources, Inc. All rights reserved. What typically is Provided

11 ©2014 Executive Health Resources, Inc. All rights reserved. “Foreign Body Removed #!” Name Protected, MD

12 ©2014 Executive Health Resources, Inc. All rights reserved. Physician Documentation Uses Before: Communication with physician partners and consultants Reminder notes for self use Possible use by nurses Now: Audit defense Billing justification Malpractice defense Quality of Care Measurement Government investigations

13 ©2014 Executive Health Resources, Inc. All rights reserved. Limited or no physician documented info (consult, ED note or H & P) –Only information available is a list of symptoms/ lab work –No documentation until several hours after “admission” No plan of care or clear impression in the H & P –Common with mid-level providers, medical students and residents OP note/H & P for procedures that do not address/include any risk from past medical history –Frequently occurs from using office notes as history and physical Lack of discharge summary for a readmission review and no mention of stability on discharge/return to baseline in the discharge note Prolonged stays frequently do not include the current progress note or orders to indicate why the patient requires continued acute care Common Documentation Problem Areas

14 ©2014 Executive Health Resources, Inc. All rights reserved. Common Documentation Problem Areas Using a symptom rather than a diagnosis for the impression or assessment ─N/D/V vs. bowel obstruction ─SOB, chest pain, headache, back pain ─Listing the diagnosis as an intractable symptom (vertigo, abdominal pain, vomiting) without noting the potential diagnosis Using a lab value or treatment plan with no diagnosis Documentation for medical necessity is different than for billing level or coding

15 ©2014 Executive Health Resources, Inc. All rights reserved. General Documentation Takeaways 5 key pieces of documentation for Medicare cases and determining medical necessity of Inpatient: –Medical history –Current medical needs –Severity of signs and symptoms –Facilities available for adequate care –Predictability of an adverse outcome Source: CMS Medicare Benefit Policy Manual, Chapter 1, §10

16 ©2014 Executive Health Resources, Inc. All rights reserved. Key Words What is your suspicion of what is going on, i.e. impression? SUSPECTS PREDICTABLE RISK CONCERNS Given the patient’s history and current presentation, what kind of adverse outcomes are likely and what are the chances What are your concerns of the situation?

17 ©2014 Executive Health Resources, Inc. All rights reserved. IP Documentation Review Custodial Delay Convenience Any “kill the case” statements? –Can go home from ER but the family cannot take care of the patient “The patient was about to be discharged, but apparently she did/does not have much help at home and she is unable to take care of herself…” –Contradiction of IP order and certification IP order and “I anticipate 1 midnight in the hospital and hence she will be admitted under observation.” –Here for placement –Home in AM after lab result

18 ©2014 Executive Health Resources, Inc. All rights reserved. IP Documentation Review “Case Killer” statement: –“The patient was about to be discharged (from ER), but apparently she did/does not have much help at home and she is unable to take care of herself…” –Instead consider: –86 y/o female with hx CABG, valve replacement and two hip replacements, had a ground level trip and fall, resulting in an acute left humerus fx and left sup and inf pubic rami fx. She was treated with IV morphine and had an episode of hypotension. Pt lives by herself and was being worked up as an outpt (for frequent falls). In addition, she is on IV antibiotics for a resistant organism after failing outpt treatment.

19 ©2014 Executive Health Resources, Inc. All rights reserved. Admission Review – Key Considerations Physicians Order Medical Necessity Expectation of 2-Midnight Stay Documentation and Certification

20 ©2014 Executive Health Resources, Inc. All rights reserved. Medical Necessity Example 1 76 y/o male with central intermittent chest pain for 2 days which lasts about 20 minutes, few episodes Awoke in the morning with left arm tingling that quickly resolved Past Hx includes MI, DM2, CABG and prior cardiac stents PE BP 90/65 HR 105 RR 24 – Tachycardiac with bilateral crackles EKG besides for Sinus Tach is unchanged and cardiac enzymes non-diagnostic, Cr 1.5, Bld Glc 220 g/dL Pain is relieved by NTG, then recurs and feels just like his prior MI Chest Pain THIS PATIENT PROBABLY DOES NOT MEET INPATIENT CRITERIA

21 ©2014 Executive Health Resources, Inc. All rights reserved. Documentation Keys: Chest Pain The common term "chest pain" does not necessarily refer to cardiac disease and is often misunderstood Documentation of your clinical judgment (e.g., cardiac ischemia, recurrent or worsening angina, chest wall pain, non-cardiac, GERD) is important –What is the rationale or factors you considered in your judgment? “Atypical chest pain” does not exclude ischemic disease – document suspected cause regardless of typical or “atypical” pattern Acute Coronary Syndrome encompasses UA, NSTEMI, or STEMI –UA - rest angina (usually lasting >20min), new onset (<2months) duration of angina, or crescendo pattern of occurrence Symptoms similar to past events? EKG baseline vs. current if known and Cardiac Enzymes Hypotension, Diaphoresis, CHF, Pulmonary Edema?

22 ©2014 Executive Health Resources, Inc. All rights reserved. Medical Necessity Example 2 72 y/o male sudden onset of slurred speech and right arm weakness witnessed by wife Past History: HTN, DM2 BP 170/95 by EMS, in ED BP 135/85 Symptoms present on EMS arrival PE in ED HR 120 – irreg irreg EKG by EMS showed Atrial Fibrillation Normal neuro exam (back to baseline) in ED TIA THIS PATIENT PROBABLY DOES NOT MEET INPATIENT SCREENING CRITERIA

23 ©2014 Executive Health Resources, Inc. All rights reserved. Documentation Keys: TIA/CVA Similar previous episodes? Atrial Fibrillation/other source for potential cardio embolism? ABCD2 score (0 -7 score) ─Age over 60 ─Blood pressure (systolic > 140 or diastolic > 90) ─Clinical features of TIA (1 or 2 points) ─Unilateral weakness with/without speech impairment ─Duration (1 or 2 points) ─10-59 min or over 60 min ─Diabetes ABCD2 score and 2-day stroke risk ─Score of 0-3 = 1% risk of stroke in 2 days ─Score of 4-5 = 4.1% risk of stroke in 2 days ─Score of 6-7 = 8.1% risk of stroke in 2 days

24 ©2014 Executive Health Resources, Inc. All rights reserved. 2 Midnight Example 1 Symptoms: 80 year old female admitted with chest pain, positive biomarkers and EKG changes in the emergency room, urgently taken to catheterization lab OrderAdmit as inpatient Expectation of LOS “I expect this patient to remain in the hospital for a time greater than 2 midnights” Medical NecessityDocumentation present to support inpatient admission CertificationAll elements of certification present per document review Follow up necessary Patient does not remain for 2 MN ⁻Was (presumption not met) due to: death, transfer, AMA, inpatient- only procedure or “recovery faster than anticipated”? ⁻Evaluate based on start of service to see if benchmark met

25 ©2014 Executive Health Resources, Inc. All rights reserved. 2 Midnight Example 2 Symptoms: 65 year old male, no previous cardiac history, presents with shoulder pain after exertion, physician suspects musculoskeletal, biomarkers below detection threshold, no EKG changes. Monitor overnight if telemetry, enzymes and EKG’s remain negative, anticipate discharge in am. No planned stress test or further evaluation during hospitalization. OrderAdmit as inpatient Expectation of LOS 23 hour monitoring Medical NecessityDocumentation does not support inpatient admission – observation Certification Order and physician expectation of 2 midnights are in conflict Order and medical necessity are in conflict Follow up necessary Consider Condition Code 44 if requirements are met If patient remains in hospital or new information available, re-review for medical necessity at inpatient level If patient discharged – cannot do Condition Code 44, if within rebilling timeframe, consider for Part B rebilling

26 ©2014 Executive Health Resources, Inc. All rights reserved. 2 Midnight Example 3 Symptoms: 78 year old female admitted for atrial flutter, stabilized in Emergency Room. Although expected to be discharged after medication adjustments, patient developed heart block requiring additional adjustments and possible pacemaker OrderPlace in observation Expectation of LOSAnticipate short stay, 23 hour monitoring Medical NecessityDelayed review suggests that inpatient may be appropriate CertificationAll elements of certification would need to be completed prior to discharge Follow up necessary EHR would recommend inpatient level of service Call with physician to discuss medical necessity in light of order change requirement Call with case manager to discuss order change and expectation documentation with regard to certification requirements Inpatient order, documentation of expectation and all other elements of certification would need to be addressed prior to discharge

27 ©2014 Executive Health Resources, Inc. All rights reserved. 2 Midnight Example 4 Symptoms: 76 year old woman with UTI, treated with intravenous antibiotics. Fevers continue with tachycardia and hypotension requiring fluid support. Immunosuppressed due to post kidney transplant status. OrderAdmit for inpatient services Expectation of LOS Admission orders include order for “discharge in am” Medical Necessity Would meet for inpatient by criteria, but documentation clearly violates 2 midnight expectation Certification Depending on follow-up activity, if inpatient supported confirm all elements of certification prior to discharge Follow up necessary Although historically inpatient medical necessity would be met, the documentation does not support 2 MN expectation Resolve conflict between order/medical necessity and expectation Update documentation if patient not discharged as planned Consider Condition Code 44 if expectation of discharge remains

28 ©2014 Executive Health Resources, Inc. All rights reserved. 2 Midnight Example 5 Symptoms: 68 year old male, with a history of stroke, known carotid stenosis, and previous neck irradiation making carotid end-arterectomy high risk. Patient scheduled for carotid angiography and stent placement. OrderObservation Expectation of LOS Less than 2 midnights Medical Necessity Procedure appropriate for inpatient based on inpatient-only status Certification All elements of certification except the 2 MN expectation would be required to be documented prior to discharge to support inpatient claim Follow up necessary Order should be corrected for procedure on CMS inpatient-only procedure list For procedures on the inpatient-only list, order must be present on the medical record prior to the initiation of the procedure Inpatient-only procedures are exempted from the 2 midnight expectation, but all other certification requirements remain

29 ©2014 Executive Health Resources, Inc. All rights reserved. Summary Excellent patient care is top priority Regardless of the payer: –Admission order –Expected LOS –History and Physical/Procedure note –Progress note each hospital day –Discharge summary and plan –Above signed prior to discharge Make the obvious, obvious

30 ©2014 Executive Health Resources, Inc. All rights reserved. Questions? Joydip Roy, MD Senior Medical Director, Audit, Compliance and Education

31 ©2014 Executive Health Resources, Inc. All rights reserved. EHR has been awarded the exclusive endorsement of the American Hospital Association for its leading suite of Clinical Denials Management and Medical Necessity Compliance Solutions Services. EHR received the elite Peer Reviewed designation from the Healthcare Financial Management Association (HFMA) for its suite of medical necessity compliance solutions, including: Medicare and Medicaid Medical Necessity Compliance Management; Medicare and Medicaid DRG Coding and Medical Necessity Denials and Appeals Management; Managed Care/Commercial Payer Admission Review and Denials Management; and Expert Advisory Services. EHR was recognized as one of the “Best Places to Work” in the Philadelphia region by Philadelphia Business Journal for the past six consecutive years. The award recognizes EHR’s achievements in creating a positive work environment that attracts and retains employees through a combination of benefits, working conditions, and company culture. AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product. About Executive Health Resources

32 ©2014 Executive Health Resources, Inc. All rights reserved. ©2014 Executive Health Resources, Inc. All rights reserved. No part of this presentation may be reproduced or distributed. Permission to reproduce or transmit in any form or by any means electronic or mechanical, including presenting, photocopying, recording and broadcasting, or by any information storage and retrieval system must be obtained in writing from Executive Health Resources. Requests for permission should be directed to


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