Provider Potter and the Chamber of Invalid Orders Medicare CMP Audit Anguish Barbara Dumont, RN, CPHRM St. John’s Lutheran Hospital Libby, Montana

Background  February 2010: St. John’s notified by Noridian that we had been selected for a Probe Audit of Comprehensive Metabolic Panel testing (CMP’s) and venipunctures.  May 2010: Our error rate was found to be 18% and Noridian notified us that they moved us to Provider on Review (POR) status until our error rate is  5%.

7 tests on CMP/not on BMP that must meet med necessity  Total Protein  Albumin  A/G Ratio  AST (SGOT)  ALT (SGPT)  Alkaline Phosphatase  Total Bilirubin

Types of Denials  More than one venipuncture billed per day.  Patient symptomatology and/or documentation did not support medical necessity for the service billed.  Patient symptomatology and/or documentation for a repeat CMP in a short time frame did not support medical necessity.

Denials  Documentation did not support a physician order per Medicare guidelines: Physician signature on the order Legible physician name Physician signature dated and timed Order dated  Pre-op screening CMP not allowed.

Medical Necessity Denials  Examples of what we have seen…. * CMP order with Dx of pernicious anemia * CMP order with Dx of hyperlipidemia * CMP order with Dx of screening PSA * CMP order with Dx of rheumatoid arthritis  Documentation must state medical necessity for the test. (i.e. – if patient is on a medication that justifies the test.)

St. John’s Valid Order Policy  Patient name  Service ordered  Diagnosis or sign/symptom (not ICD-9 code)  Physician signature, with legible first and last name and credentials, that is dated and timed  Date of order

Write Offs  We had to write off a 2 day observation stay and a 4 day inpatient stay due to telephone orders not signed within 48 hours per Medicare regulations.  To date we have written off $39,132 total.

Actions  Developed a physician signature log and submitted it with all claims chosen for audit. However, as of April 1, 2011, logs are no longer allowed by Medicare.  Educated the providers and office staff regarding our policy and Medicare regulations regarding what is a valid order.  Shared results of the audit for individual providers collectively and individually.

Actions  Educated all of our Department Managers and the staff of Outpatient Departments, ED, and Acute Care regarding valid orders.  Developed a report in Meditech that we run pre-bill to remove duplicate venipuncture charges.  Distributed a memo to providers and department managers informing them that St. John’s will no longer accept requisitions that do not have a valid order. We notify the provider and perform the test when we receive a valid order.

Actions  Consulted with Eide Bailly and our Corporate Compliance Attorney and they stated we could legally write off claims prior to submission if not in compliance with CMS regulations.  Implemented back-end internal audit of 100% of CMP’s before the claims are billed.

And more actions!  Implemented front-end internal audit of outpatient orders. OP departments wait to obtain valid orders before performing the test. We wanted to know which providers were the biggest offenders and what parts were missing from their orders.  Requested all departments to attach a copy of the original order with each standing order test done.  Requested our ED and chemo staff to attach a copy of the original multiple IV infusion order with each patient encounter documentation.

Name Stamps Ordered  We discovered that in our inpatient/observation charts, the physician who writes/signs an order may not be the provider name printed on the chart sticker. Therefore, no valid order due to illegible provider name.  We ordered provider name stamps with first and last name and credentials printed.

CMP Huddles  Our CFO, PFS Manager, HIM Manager, Lab Manager, Compliance Officer (me), RN Auditor, and others meet every morning M-F for 15 minutes to discuss issues and progress.

OP Requisition Forms Revised All OP diagnostic departments revised their requisition forms that highlight in yellow the requirements of a valid order.

Other stuff  We are currently appealing the denied CMP’s (that have valid orders) to help lower our error rate.  We asked for a different auditor and this was granted.  Our CFO updates our Board of Trustees every Friday per regarding our CMP audit.  Our one-day acute care stays are starting to be audited.  We were informed that we cannot charge for a separate room level for chemotherapy.

Medicare Regulations  Hospital CoP Tag A-0450, §482.24(c)(1) – “All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided.”  Hospital CoP Tag A-0454, §482.24(c)(1)(ii): Currently states “all orders, including verbal orders, must be dated, timed, and authenticated by the ordering practitioner or another practitioner.” This sunsets on January 26, 2012.

Medicare Regulations  Hospital CoP Tag A-0454, §482.24(c)(1)(i): “All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner.” This goes into effect on January 26,  Hospital CoP Tag A-0457, §482.24(c)(1)(iii): “If there is no State law that designates a specific time frame for the authentication of verbal orders, verbal orders must be authenticated within 48 hours.” Montana does not have a state law regarding this.

New CMS Regulation as of January 1, 2011  Federal Register/ Vol. 75, No. 228  All lab requisitions must be signed by the ordering provider.

Challenges  Helping providers and staff understand CMS regulations and adhering to established policies. (One of the biggest deficiencies is no date and time with the provider signature.)  Obtaining complete and clear instructions from our auditor.  Pulling staff away from other duties to spend time on this audit. Paying additional wages for our internal RN auditor.

What is one thing we can do to help in the future?  As of January 26, 2012, if we do not have all verbal/telephone orders authenticated by the ordering provider within 48 hours we cannot bill for them.  We must contact MHA to lobby Montana legislature this year to extend the time beyond 48 hours (Colorado has adopted 30 days).  St. John’s Hospital has contacted Dick Brown at MHA regarding this. Stay tuned!

Questions? Thank you!