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Presentation on theme: "Disclaimer This resource is not a legal document. The presentation was prepared as a tool to assist providers and was current at the time of creation."— Presentation transcript:

0 Cahaba GBA’s 2014 Medicare Expo
August 6-7, 2014 – Chattanooga, TN Two Midnight Rule As directed a copy of the presentation is available for viewing or download on the Cahaba GBA website

1 Disclaimer This resource is not a legal document. The presentation was prepared as a tool to assist providers and was current at the time of creation. Responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited; providers are encouraged to share this education with staff. Let’s review the disclaimer, Our disclaimer states that this resource is not a legal document. The presentation was prepared as a tool to assist providers and was current at the time it was created. The responsibility for submitting correct claims lies with the provider of services. Reproduction of this material for profit is strictly prohibited; however, we do encourage providers to share this information with staff members. The American Medical Association CPT copyright and trademark is also noted on this slide anytime CPT or HCPCS codes are referenced.

2 Topics Medical Review Comprehensive Error Rate Testing (CERT)
Two Midnight Rule Resources Today we will cover: Medical Review CERT Two Midnight Rule And provide you with resources relevant to the content discussed today.

3 Preventing Improper Payments
The Affordable Care Act of 2010 Proposals to protect the Medicare Trust Fund Authority to recover overpayments Social Security Act Sections 1833(e), 1842(a)(2)(B), and 1862(a)(1)(A) Centers for Medicare and Medicaid Services (CMS) Protect the Medicare Trust Fund Identify inappropriate payments Take corrective actions Payment Accuracy: Medicare processes over one billion fee-for-service claims a year. The “Improper Payments Elimination and Recovery Act of 2010” requires Federal agencies to annually review programs that they manage and identify those that may be susceptible to improper payments. Under the Affordable Care Act: CMS has established Proposals to protect the Medicare Trust Fund and Authority to recover overpayments from providers Specific sections of the Social Security Act, require CMS to take measures in order to protect the Medicare Trust Fund against inappropriate payments that pose the greatest risk to the Trust Fund and take corrective actions accordingly. The payment accuracy website at the bottom of the slide is a wonderful resource to use for more information regarding improper payments. It contains FAQ’s as well as charts outlining the over and underpayments in It’s a wealth of information, so I do encourage you all to review it. NEXTTTTT

4 Medical Review Goal Reduce payment errors by identifying and addressing billing errors related to coverage and coding of services Data Driven Indentify vulnerabilities Identify questionable billing patterns Prevent and/or address provider errors Reduce paid claims error rate Publish Local Coverage Determinations (LCD) Medical Review and Education - Overview: Program Integrity Manual - Pub Medical Review Program: Now, I am going to discuss a little bit about our Medical Review program. The Medical Review Program was developed to assist with reducing of Medicare claim error rates. To accomplish this goal, patterns of inappropriate billing are identified by data analysis, medical review of claims and developing local policies to address program vulnerabilities. Our clinicians actively review medical records to ensure that the services billed meet Medicare guidelines, medical necessity and coding. If you do are contacted for a probe review, you do have 45 days to return all requested documentation listed on the Additional Documentation Request that is sent out. After the 45th day, if documentation is not received, the claim is automatically denied for lack of medical documentation. In addition, our reviewers do have 60 days to complete the review.   nexxt

5 Comprehensive Error Rate Testing (CERT)
Protect, Measure, Assess, Evaluate CERT Documentation Contractor Review Contractor CMS implemented the CERT program to measure improper payments in the Medicare fee-for-service (FFS) program in accordance with the Improper Payments Elimination and Recovery Act of The program produces national, contractor-specific, and service-specific paid claim error rates, as well as a provider compliance error rate. CERT has independent medical reviewers periodically reviewing random samples of Medicare claims that are identified as soon as they are accepted into the claims processing system. The independent reviewers medically review claims that are paid and any claims that are denied are validated to ensure that the decision was appropriate. There are two CERT contractor’s that manage the CERT program CERT Documentation - request Medical records CERT Review Contractor - Claims and records are reviewed for compliance Claims are randomly submitted from our system and providers do have 75 days to return all necessary documentation that is applicable to the claim. Unlike our Medical Review program, CERT will accept late documentation. Requests Medical Records Reviews Medical Records

6 Part A Review-All States: February 2014
Service Error Rate Denial Rationale Action Required Al , GA, TN-Short Term Hospitals- Condition Code 07 33.60% High Dollar Amount Per Pub , Ch. 11 Medicare Claims Processing Manual (Processing Hospice Claims) § 50 Billing and Payment for Services Unrelated to Terminal Illness. Services related to a hospice terminal diagnosis provided during a hospice period are included in the hospice payment and are not paid separately. Condition code 07 should be used for any Medicare covered services not related to the treatment of condition for which hospice was elected.

7 Fiscal Year 2014 Inpatient Rule
2014 Hospital Inpatient Prospective Payment System (IPPS) Update for 2014 Medicare payment policies for inpatient stays General Acute Care Long Term Care Hospitals (LTACHs) Inpatient Psychiatric Hospitals Critical Access Hospitals (CAHs) Goal is to improve value and quality in hospital payments Provides clarification about when a patient should be admitted to the hospital Addresses concerns regarding extended Medicare Beneficiary stays in the hospital outpatient department Ok. Slide 15 begins our main topic for the webinar today, 2014 Inpatient Final Rule. (CMS) issued final rule 1599F  updating Fiscal Year 2014 Medicare payment policies and rates for inpatient admissions at General Acute Care, Critical Access Hospitals (CAH), Inpatient Psychiatric Hopsitals, and Long-Term Care Hospitals (LTCH) beginning on and after October 1, 2013. The purpose of this rule was to update 2014 Medicare payment policies and rates for inpatient stays at general acute care and Long-Term Care Hospitals (LTCHs). The rule aims at improving value and quality in hospital care and provides clarification about when a patient should be admitted to the hospital and responds to recent concerns about extended Medicare beneficiary stays in the hospital outpatient department.  NEXT

8 Two Midnight Rule Medicare Part A payment will be presumed appropriate if: Physician expects the patient’s treatment to require hospital stay exceeding a two midnight benchmark or requires a procedure on the inpatient only list Admits patient based on that expectation Formal physician order is required to begin inpatient status Physician Certification Clear Documentation supporting medical necessity of admission and expectation The 2-midnight presumption outlined in CMS-1599-F specifies that hospital stays spanning 2 or more midnights after the patient is formally admitted as an inpatient pursuant to a physician order for such admission will be presumed to be reasonably necessary for inpatient status based on the physicians expectation and the stay at the hospital is medically necessary. The order and Physician Certification must be present in the medical record certifying that the admission. In addition, Clear and concise documentation related to the patients illness must support the reason that the physician expected them to require inpatient care. I will speak further on the requirements regarding the elements of the physician order as well as the physician certification later on in the slide presentation.

9 Two Midnight Rule Any stay less than 2 midnights after inpatient order: Allows physician to consider all time patient has spent in the hospital as outpatient in guiding their two midnight expectation Observation Emergency Room Operating Room Other Treatment Area Applies to admissions with dates of service on or after October 1, 2013 CMS Issues FY 2014 Inpatient Payment Rule There are some caveats in meeting the two midnight benchmark for those patients that do not stay in the hospital past two midnights after the physician order is written. In addition to the patient’s medical condition, diagnosis, surgical procedures and/or diagnostic test, all time that the patient spent in the hospital as an outpatient receiving observation services or care in the emergency department, operating room, or other treatment area can be utilized in guiding their two-midnight expectation. This means that physicians can use this time to make a decision to admit the patient IF the patient doesn’t surpass 2 midnights after the order is written for inpatient, medical reviewers will review the time the patient in outpatient/observation in order to determine if the two midnight expectation was met. For example, If the patient spends 1 midnight in outpatient or observation status, CMS expects that the physician evaluate the patient on the 2nd day in order to make a decision whether it is reasonable and necessary to admit the patient. This way, the patient will meet that 2nd midnight as long as the order is written before that midnight.

10 Two Midnight Rule Inpatient Order Requirements
Required for inpatient coverage and Part A payment Inpatient status begin when order is written Must specify admission to inpatient status No retroactive orders allowed Who may write the order? Physician or other practitioner Licensed by State to admit patients Granted admitting privileges in the hospital Knowledgeable about the hospital course, medical plan of care, and current condition at the time of admission Non-Physician practitioner would still need co-signature if incident to ordering physician There are elements that must be met along with the two midnight benchmark It should be noted that inpatient status does not begin until the formal order is written by the practitioner. The order should be written by a physician or other practitioner who is licensed by the state to admit patients to the hospital, granted privileges by the hospital and is involved with the patients care or knowledgeable of about the patients hospital course, plan of care, and current condition at the time of admission. The physician is not required to write the order, but is required to sign the order indicating that he or she made the decision to admit the patient. Further, the ordering physician is not required to be the certifying physician. A NP, PA, or Medical Resident may write the inpatient order if they have admitting privileges, but they cannot full fill the certification requirements. It is strongly suggested that the ordering physician to indicate in the language of the order the intent to admit as inpatient. Such as Admit to inpatient, inpatient services, inpatient care versus admit to 3W, which may be unclear to others. In addition, Cahaba will treat orders such as “Admit to outpatient, Admit to Obs (Type of Service) as such.

11 Two Midnight Rule Non-Physician Practitioners/Residents
No admitting privileges May under state laws or hospital by laws write initial orders to initiate inpatient admission Order must be documented following collaboration with ordering physician Must identify the qualified physician Qualified physician must co-sign order before discharge Authenticated order by qualified physician will satisfy order part of the physician certification as long as he/she meets requirements for a certifying physician Example: Admit to inpatient per Dr. Smith Admit to inpatient v.o./t.o. Dr. Smith For non-physician practitioners at the hospital without admitting privileges, it is acceptable to document the order following a verbal discussion with the ordering physician as long as the transcription of the order is in accordance with their state law, which includes scope of practice laws, hospital policies and medical staff bylaws, rules and regulations. In this particular event, the order must be documented as soon as it is received and must identify the ordering physician. It should also be co-signed by that physician promptly or prior to the patient’s discharge. This also applies to Emergency Physicians that do not have admitting privileges but are authorized by the hospital to write temporary or bridge inpatient orders. Listed at the bottom of the slide, there are two examples that can be used to help get an idea of the order requirements under these circumstances. For these verbal orders, the order must be signed, dated and timed by the ordering physician in the medical record before the patient leaves the hospital unless the hospital policy required an earlier time frame. An authenticated verbal order would satisfy the order part of the physician certification as long as the ordering physician meets the requirements for a certifying physician, which I will go over in the next few slides.

12 Two Midnight Rule Physician Certification Condition of payment Content
Required for Part A payment under section 1814(a) of the Social Security Act Indicates that inpatient services were medically necessary Content Authentication of physician order Reason for inpatient services Estimated time required in hospital Plan for post-hospital care if appropriate Physician Order and Certification Requirements As a condition of payment for hospital inpatient services under Medicare Part A, Section 1814 under the Social Security Act requires a physician certification to establish the medical necessity that services should be provided on an inpatient basis. There has not been any significant changes with the certification, except the addition of including the physician order as a critical element for inpatient coverage, and it is part of the physician certification. The order to admit begins the certification process. The physician certification along with the order to admit is considered along with the documentation in the medical record as an indicating factor that the services provided as inpatient were reasonable and medically necessary. So let’s talk about what type of content should be provided in the physician certification. As previously stated, the physician order should be authenticated indicating that the inpatient services were ordered according to Medicare guidelines. This can be done either by the ordering physician signing the order or by co-signature. The reason for the inpatient services should be clearly stated. For example, hospitalization of the patient for inpatient medical treatment or medically required diagnostic study. Documentation of an admitting diagnosis can full fill this element of the certification process as long as all of the documentation in the medical record supports it. Further, the estimated time needed in the hospital should be included. Estimated or actual length of stay is most commonly reflected in the progress notes where the practitioner discusses the assessment. For the purposes of meeting the requirement for certification, expected or actual length of stay may be documented in the order or a separate certification or recertification form, but it is also acceptable if discussed in the progress notes assessment and plan or as part of routine discharge planning. If the reason an inpatient is still in the hospital is that they are waiting for availability of a skilled nursing facility (SNF) bed, 42 CFR (c) and (e) provide that a beneficiary who is already appropriately an inpatient can be kept in the hospital as an inpatient if the only reason they remain in the hospital is they are waiting for a post-acute SNF bed. The physician may certify the need for continued inpatient admission on this basis. However, a patient cannot be admitted as inpatient for the sole purpose of meeting the SNF requirement. And lastly, any plans for post hospital care. On a side note, for Critical Access Hospitals: the physician must certify that the patient may reasonably be expected to be discharged or transferred to a hospital within 96 hrs after admission to the CAH. The physician certification must be completed, signed, dated, and documented in the medical record prior to the patient discharging. And while we are talking about discharge, the time of discharge is when the effectuation of activity specified in the d/c order. For example, “D/c after dinner”. So with this being said, the D/C can, but not always coincide with the time the physician order was written.

13 Two Midnight Rule Physician Certification (cont)
Authorization to sign certification A physician who is a doctor of medicine or osteopathy A dentist in the circumstances specified in 42 CFR (d) A doctor of podiatric medicine if his or her certification is consistent with the functions he or she is authorized to perform under State law All of which are responsible for case or by another physician with knowledge of the case and is authorized by the responsible physician or hospital’s medical staff On slide 15, lists who is authorized to sign the certification of services. The following physicians listed here on the slide should either be responsible for the patient’s care or is knowledgeable of the case to serve as the certifying physician. In addition, Medicare considers only the following physicians, podiatrists or dentists to have sufficient knowledge of the case to serve as the certifying physician: The admitting physician or physician on call for him/her The surgeon responsible for the surgical procedure or the surgeon on call A dentist functioning as the admitting physician of record or the surgeon responsible for the major dental procedure, And in specific case, on a non-physician non-dentist admitting practitioner licensed by the state and granted privileges by the facility. It should be noted that there is not a specific format required for cert statements. That is for the provider’s discretion on which type of form or method to utilize as long as it contains all of the criteria. With this being said, cert statements may be entered on notes, records or individual forms specially developed for certification purposes. All physician certification’s should be signed by the authorized health professional before the time of discharge. Medicare does not require the certifying physician to have admitting privileges at the hospital. However, non-physician practitioners such as Nurse Practitioners and Physician Assistants are not permitted to complete the certification. The physician certification and physician order are not to be considered by CMS to be conclusive evidence that the inpatient hospital admission was medically necessary. Those elements must be met along with good documentation in the medical record.

14 Medical Record Documentation
All entries in the medical record must be complete in order to: Justify admission Justify continued hospitalization Support the diagnosis Describe the patient’s progress Describe the patient’s response to medications; and medical intervention All entries in the medical record must be legible Illegible entries in the medical record may be misread or misinterpreted Misread or misinterpretation could lead to medical errors or other adverse patient events All entries in the medical record must be dated, timed, and signed By the individual that provided or evaluated the service Handwritten or electronically So you have all the required elements met, Expectation that the patient will require a stay past two midnights, the physician order and certification certifying that expectation is reasonable and necessary. Cahaba will continue to follow longstanding guidance to review the reasonableness of the inpatient admission decision based on the information known to the physician at the time of admission. CMS does expect that sufficient documentation will be rooted in good medical practice. Since the medical record is a legal document, it should be complete and legible at all times. Documentation is extremely important because it paints the picture of the scenario. The expected length and the determination of the underlying need for medical or surgical care at the hospital must be supported by complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event, which Medicare review contractors will expect to be documented in the physician assessment and plan of care. All information listed in the medical record must support the services provided. To completely authenticate the record, it should always be date, timed and signed, either handwritten or electronically by the provider of service. NEXXXXXXT 

15 Two Midnight Rule Reviewing Hospital Claims for Inpatient Status
General Rule for 0-1 Midnight stays Inappropriate for inpatient admission if estimated length is between 0-1 midnight stays regardless of the time the patient arrived or if they used a bed Exception Inpatient only List Unforeseen Events Rare and Unusual Circumstances Medicare Administrative Contractor will deny these inappropriate admissions as directed by CMS unless these exceptions apply. Generally, inpatient services and Part A payment are inappropriate if the patient is expected to stay in the hospital between 0-1 midnight stays regardless of the time the patient arrived or if they used a bed unless they entered the hospital for a surgical procedure listed as inpatient only. CMS has instructed Cahaba to deny these inappropriate admissions unless they apply to the exceptions listed below. Services on the Inpatient only lists are Part A appropriate regardless of how long the patient is in the hospital. CMS has directed Cahaba to approve these cases as long as the order and documentation requirements are met. Other exceptions such as unforeseen events and rare and unusual circumstances will be discussed on the next slide.

16 Two Midnight Rule Reviewing Hospital Claims for Inpatient Status
Short Stay Admissions Less than two midnights May be appropriate for Part A payment if unforeseen circumstances results in a shorter stay than the physician’s reasonably expectation of two midnights Death Transfer to another hospital Discharged against medical advice (AMA) Clinical Improvement Hospice Election Rare and unusual circumstances If an unforeseen circumstance results in a shorter beneficiary stay than the physician’s reasonable expectation of at least 2 midnights, the patient may be considered to be appropriately treated on an inpatient basis and hospital inpatient payment may be made under Medicare Part A. Such circumstances must be documented in the medical record in order to be considered upon medical review. Examples of unforeseen circumstances are: death, transfer to another hospital, departure against medical advice, sudden clinical improvement, and most recently election of hospice care in lieu of continued treatment in the hospital . If any of these events occur before the patient meets the two midnight benchmark, then it is still appropriate for Part A Payment. Since documentation plays a significant role in identifying the medical necessity of less than two midnight stays, it must be fully documented in the medical record of these reasons. Rare and Unsual Circumstances are another exception in meeting the two midnight bench mark, which I will discuss on the next slide.

17 Two Midnight Rule Rare and Unusual Circumstances
Newly Initiated Mechanical Ventilation Excludes anticipated intubations related to minor surgical procedures or other treatment CMS does recognize that additional rare and unusual circumstances exist that have not been identified For suggestions to additional rare and unusual circumstances, please CMS at Subject: “Suggestion exceptions to the two midnight rule” Care in an ICU setting ALONE is not an exception to meeting the 2 midnight benchmark. However, CMS has identified newly initiated mechanical ventilation (excluding anticipated intubations related to minor surgical procedures or other treatment) as its first rare and unusual exception to the two midnight rule. This “rare and unusual circumstance would support an inpatient admission and Part A payment. CMS believes a physician will generally expect beneficiaries with newly initiated mechanical ventilation to require 2 or more midnights of hospital care, but if the physician expects that the beneficiary will only require one midnight of hospital care, inpatient admission and Part A payment is nonetheless generally appropriate. CMS does recognize that there could be additional rare and unusual circumstances that have not been identified. So, while they will continue to work with facilities and physicians to identify these situations, they would like to emphasize that they do expect these situations to be rare and unusual exceptions to the general rule. If additional situations are identified, they will be included in the sub-regulatory instruction.. If providers have any suggestions to additional rare and unusual circumstances that would require inpatient care vs. outpatient care can CMS at with “suggestion exceptions to the two midnight rule” in the subject line. These situations should be appropriately documented as to why these situations require inpatient care

18 Scenario Example 70 y.o. male enters the emergency room for shortness of breath on 01/03/2014. Patient is triaged and placed in one of the ED rooms at 11:00 p.m. Shortly after, patient is evaluated by physician at 11:15 p.m. Physician writes the order to admit patient as IP after a chest x-ray determined patient has a dx of pneumonia. MD expects patient to be in the hospital past two midnights. He receives IP services and is discharged on 01/07/2014. Since the MD expects patient to receive medical necessary services for at least two midnights based on his condition, then Part A payment for inpatient will be presumed appropriate. (Notice: Patient stayed past two midnights after IP order was written).

19 Scenario Example 45 y.o. female went to the emergency room on 1/2/2014 with complaint of chest pain. Hx of HTN, Smoking and Stents. She was triaged and placed in a ED room at 03:00 p.m. Began receiving services. Cardiac enzymes were ordered. Physician wrote an order to admit patient as observation to the unit at 05:00 p.m. Patient is receiving observation services on floor past midnight. The next morning, 1/03/2014, physician evaluates patient and decides to admit her as IP based on results of cardiac panel. The patient was in observation status for one midnight. Per CMS guidelines, Physician appropriately assessed her condition the following day and determined she needed IP care, in which he wrote the order for admission. This way, the two midnight benchmark will be met when reviewed if she stays past the 2nd midnight.

20 Scenario Example Patient comes into ED and is observation from 9am to 12 noon. Patient is admitted inpatient and then discharged later that day. The UR reviews and determines that this needs to be a re-bill. How are we supposed to bill when it is the same date of service? Under A/B rebilling, you can bill a 121 and 131 with the same date of service.  You will need to bill the 121 claim first and let it finish processing.  Once it has completed processing, then bill the 131 TOB. 

21 Updates Two Midnight Benchmark for: Hospital to Hospital Transfers
Off Campus Emergency Department There are some updates within the guidance provided by CMS on 01/30/2014 pertaining to hospital to hospital transfers and care in an offcampus ED. For the purpose of determining whether the 2-midnight benchmark was met for hospital to hospital transfers, Cahaba will take into account the pre-transfer time and care provided to the patient at the initial hospital. What I am saying by this statement is that the start clock for transfers begins when the care begins in the initial hospital. Any excessive wait times or time spent in the hospital for non-medically necessary services shall be excluded. So, the receiving hospital can utilize the time spent in the transferring facility to meet the two midnight benchmark. Of course, that patient would still need to be evaluated physically as well as from the medical records from the transferring facility to ensure that it is medically necessary to continue inpatient admission. If so, then it is an inpatient to inpatient transfer. CMS will allow Cahaba to request records from the transferring hospital to support the medical necessity of the services provided and to verify when the beneficiary began receiving care to ensure compliance and deter gaming or abuse. Claim submissions for transfer cases will be monitored and any billing aberrancy identified by CMS or the Medicare review contractors may be subject to targeted review. The initial hospital should continue to apply the 2-midnight benchmark based on the expected length of stay of the beneficiary for hospital care within their facility. Now for the second update, If the ED is established as a provider-based/practice location of the hospital, CMS does not pay to move the patient from an off-campus location of the Medicare hospital to the campus of the same Medicare hospital. Moving the patient within the hospital that participates in Medicare under a single CMS Certification Number (CCN) from a provider-based off-campus ED to a separate on-campus unit, or moving the bene from an on-campus ED to a specified floor on the same campus would be considered the same from a Medicare perspective. The provider-based or practice location (off-campus) ED is subject to all of the hospital Conditions of Participation (COPs) and is considered an integral part of the Medicare participating hospital. Therefore, if a hospital ED is either an on-campus ED or an off-campus provider-based ED/practice location of a Medicare-certified hospital, the ED is considered part of that hospital for purposes of the 2-midnight rule, and therefore the total time in the hospital should be counted for purposes of the 2 midnight benchmark. On the other hand, if the ED is not established as an off-campus provider based/practice location (unrelated to that hospital’s CCN), then the beneficiary movement would be considered a transfer and the rules outlined in H1 are applicable.

22 Updates Three Day Qualifying Stay-SNF Bed not available at SNF
If patient is receiving medically necessary services: Appropriate for the patient to remain in hospital Bed available at SNF Not appropriate to hold patient for the sole purpose of qualifying for 3 day qualifying SNF stay if patient is not receiving medically necessary care Bed not available at SNF It is appropriate for patient to remain in hospital until bed is available There have been numerous questions concerning the 3 day qualifying stay, which is separate from the 2 midnight rule. If a patient no longer requires inpatient medical necessary services, the guidance specifies that it is not appropriate to hold the patient to meet that 3 day stay, if a SNF bed is available. The exception to this is, if the patient is already appropriately an inpatient, then they may remain in the hospital if the sole reason is waiting on a post-acute SNF bed that is currently unavailable. The physician may certify the need for continued inpatient care on this basis. But, I must emphasize that is inappropriate to keep the patient in the hospital for purpose of qualifying for 3 day qualifying SNF stay while a bed is available at the SNF unless the patient is still receiving medically necessary services for their condition .

23 Probe Review Two Midnight Benchmark Review:
For stays less than two midnights after formal inpatient order is written: Subject to Medical Review BUT Cahaba GBA Medical Reviewers will consider the time the patient spent receiving ER, Outpatient, or Observation services in determining if two midnight benchmark was met Clock begins when patient begins receiving services Triage activities such as checking vital signs does not count Waiting period in the ER does not count Must be receiving medically necessary services responsive to the patient’s clinical presentation As stated on the previous slides, Any time spent in the outpatient setting prior to the order written will not be considered inpatient time, but will be considered during the medical review process for the sole purpose of determining whether the two midnight benchmark was met and making the admission appropriate for Part A payment. Medical Reviewers will take in consideration the patient’s clinical presentation, prognosis and expected treatment to support the need for hospital care spanning past two midnights. It should be noted that the clock begins when the patient enters the emergency room and begins receiving services or is directly receiving inpatient services, such as an elective admission or transfer to another hospital. In the event of a direct admission or transfer, the time begins when they receive services after arrival to the hospital. Waiting times and triage activities in the emergency room will not be considered. While we are speaking about transfers, For the purpose of determining whether the 2-midnight benchmark was met, Cahaba will take into account the pre-transfer time and care provided to the patient at the initial hospital. IN other words, the start clock for transfers begins when the care begins in the initial hospital. Any excessive wait times or time spent in the hospital for non-medically necessary services will be excluded. Cahaba may request records from the transferring hospital to support the medical necessity of the services provided and to verify when the beneficiary began receiving care to ensure compliance and deter gaming or abuse. Claim submissions for transfer cases will be monitored and any billing aberrancy identified by CMS or Cahaba may be subject to targeted review. The initial hospital should continue to apply the 2-midnight benchmark based on the expected length of stay of the beneficiary for hospital care within their facility.

24 Probe and Educate Patient Status Reviews Pre-Payment Review
Extended until March 31, 2015 Pre-Payment Review 10 claims for most hospitals 25 claims for larger hospitals ADR letters will be sent out via mail or electronically in FISS Edit number 5Pxxx will be listed on the ADR Providers will receive a summary letter explaining each denial Cahaba GBA will offer 1:1 education and will repeat the probe process if necessary Probe and Educate Process-Article Now, CMS issued an updated guidance on 05/12/2014 on their website regarding the probes and educate process. Protecting Access to Medicare Act of 2014 was recently signed into law, which will permit CMS to continue the Probe & Educate process through March 31, 2015, and will continue to prohibit Recovery Auditor inpatient hospital patient status reviews for dates of admission occurring between October 1, 2013 and March 31, However, Recover Auditors are still permitted to conduct CMS-approved claim reviews, unrelated to the appropriateness of the inpatient admission. In addition, other contractors may still complete reviews. The Comprehensive error rate testing contractor that is responsible for doing a subsample of reviews to calculate the improper payment rate can still select their very small sample of inpatient claims for that purpose and Some fraud units can conduct reviews as appropriate. The probe and educate process for Cahaba will remain the same. A 10 claim sample for most hospitals will be selected, 25 for larger ones. The medical review department will send these ADR letters out via mail or electronically in FISS. To distinguish these probes from other ones, you will see edit number 5Pxxx on the ADR. After the probe review is complete, providers will receive a summary letter outlining each reason for the denial via mail along with an offer of 1 on 1 education. I must mention, that there has been some confusion concerning the extension and the two midnight rule. The two midnight rule has not been placed on hold. It is still in full effect as it was since October 1, Please continue to apply these rules and regulations for your inpatient stays. An article pertaining to this matter and the extension was placed on our website. You may access it at the link provided below.

25 Probe and Educate Patient Status Reviews
Reviews conducted by MAC’s to determine hospital’s compliance with new rule Focuses on appropriateness of inpatient treatment versus outpatient treatment Hospital’s compliance will be assessed by the following three criteria: Admission order requirements Certification requirements Two midnight benchmark When reviewing medical records, Cahaba will assess the hospital’s compliance with the final rule using the following criteria: Admission Order, Physician Certificate and whether the inpatient admission met the two midnight benchmark. Documentation will also be considered in the medical record to ensure that it supports the physician’s expectation of admission. Therefore, it is extremely important to thoroughly document all information pertaining to the patient’s condition and health status.

26 Probe and Educate Updated Guidance-01/30/2014
Inpatient Probe and Educate Claims Re-Openings Appeals CMS issued guidance on 01/30/2014 requesting that all Medicare Administrative Contractors (MACs) re-review all claim denials made under the Probe & Educate process between October 1, 2013 and January 31, 2014 to ensure the claim decision and subsequent education is consistent with the most recent clarifications. With this guidance, Cahaba may reverse the original decision and issue payment outside of the appeals process if it is determined that a claim is payable upon re-review. To ensure that the re-review process does not affect the ability of a provider to file a timely appeal of a denied claim, CMS will waive the 120 day timeframe for filing redetermination requests received before September 30, 2014 for claim denials under the Probe & Educate process that occurred on or before January 30, 2014. Claim denials under the Probe & Educate process that occurred on or before January 30, 2014 for which an appeal has been filed will also be subject to re-review. Claims determined payable following re-review will be adjusted accordingly. Claims for which the denial is affirmed following re-review will be transferred to appeals automatically for a redetermination.

27 Probe and Educate Common issue with compliance
Documentation of expectation of two midnight stay Documentation related to patient’s illness that caused the physician to expect that inpatient admission Remember: Document, Document, Document “If it is was not documented, then it was not done” Denial

28 Denials Inpatient Admission Part B Billing Timely Billing Guidelines
Not reasonable and necessary Part B Billing Inpatient Outpatient 3 day payment window Timely Billing Guidelines 1 year from date of service In the final rule, when a Medicare Part A claim for hospital inpatient services is denied because the inpatient admission was determined not reasonable and necessary, or if a hospital determines through utilization review after a beneficiary is discharged that his or her inpatient admission was not reasonable and necessary, the hospital may be paid for the Part B services that would have been reasonable and necessary if the beneficiary had been treated as a hospital outpatient rather than admitted as an inpatient, provided the beneficiary is enrolled in Medicare Part B. Hospitals may bill services furnished after the time of the inpatient admission (the order) on a Part B inpatient claim, except observation services, hospital outpatient visits and outpatient diabetes self-management training services as these services require an outpatient status. The policy for payment of services furnished prior to the inpatient admission in the 3-day (1-day for non-IPPS hospitals) payment window in the regulations remains unchanged: the hospital may submit a Part B outpatient claim for payment of these services under Part B (including those requiring an outpatient status) as the outpatient services that they were. Part B coverage and payment rules must be met. Timely filing restrictions to the billing of all Part B inpatient services still apply, is within 1 year from the date of service.

29 Probe and Educate Here is a copy of the graph of the probe and educate program. You may not be able to see it clearly on your power point handout, but this should be included in your handout that I sent via . It just explains the process of the probe and education following the probe reviews depending on the results.

30 Please Take Our Survey Some of you may have seen our Fore See Survey pop up while visiting our website. We do encourage you all to take this survey when you see it. We are constantly looking for ways to improve our website and your feedback is valuable to us as it gives us an idea on the direction that we need to take in order to tailor to provider’s need. When you take the survey, we do ask that you be as specific as possible when informing us of what is helpful as well as any improvements that are suggested. As always, we do appreciate any and all of your feedback

31 Resource Centers for Medicare and Medicaid Services: Inpatient Hospital Review This page is the golden resource for the final rule. If you place the link in your browser, It will take you to the CMS website, which is titled Inpatient Hospital Review. Listed on that page is all the information pertaining to the two midnight rule. CMS does update this information periodically. You will have access to FAQ’s, The Review Process, and all updated information that applies to the rule. I highly suggest utilizing this resource as it will provide further understanding regarding the rules.

32 Questions This does conclude the presentation….
We are now ready to open the lines for questions. As a reminder, ensure you are dialed in by telephone to ask a question. Please remember HIPAA guidelines when asking your questions, so that you do not release any protected health Information. For claim specific questions, please contact the Provider Contact C enter at ,so they can review your claim to discuss with you. _______________, please open the phone lines…….

33 Provider Contact Center: 1-877-567-7271
Thank You The Part A Provider Outreach and Education staff would like to thank you for participating in today’s event. Provider Contact Center: We appreciate you taking time out of your busy schedule to join us today. Please take a moment to complete the evaluation at the close of the webinar. As a second option, you may access the evaluation by clicking on the link available on the slide. Your feedback is very important to us in helping improve our educational efforts. Once again, Thank you and Enjoy the rest of your day!

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