How Will CMS’s Inpatient Payment Regulations in 2015 Impact your Facility?

Your facility must make realistic projections for possible losses. Remember:  Hospitals are just trying to hold on to their full pay as opposed to receiving any extra pay.

On April 30, 2014, CMS issued a proposed rule to update Medicare payment policies in 2015 for inpatient stays at general acute care and long term care hospitals, with an aim to promote quality and reduce healthcare costs. Here’s what your hospital needs to know: 

Gear up for bottom-line adjustments

• There are several areas that hospitals need to know – and everything is not good news. Some highlights include:
•  Raise in the relevant percent reduction to 1.5 percent of the base DRG pay under the Hospital value based purchasing program (HBVP).
• Boost in maximum reduction in payment from 2 to 3 percent under the Hospital readmission reduction program
• Assessing hospital readmissions using National Quality Forum’s (NQF) five readmission measures
  CMS proposes to decrease the Medicare inpatient payment by one percent for hospitals with the lowest performance
• The agency also proposes to bring into line the 2015 quality reporting timelines for clinical quality measures for the Medicare electronic Health record with that of the hospital Inpatient Quality Reporting program (IQR).

 What hospitals need to do? Hospitals must make realistic projections for possible losses under these increased percentages. Although a hospital does everything it can for these initiatives, losses may still be suffered. Moreover, it also needs to be remembered that hospitals are just trying to hold on to their full pay, as opposed to receiving any extra pay.

Moreover, the agency also invites input on alternative payment methodologies for short stay inpatients and the established definition of short stays. CMS is proposing to use the most recent labor market area delineations issued by the Office of Management and Budget (OMB) using 2010 Census data in order to maintain a more precise and up-to-date payment system that reflects the reality of population shifts and labor market conditions.

The proposed rule for 2015 also sketches time frames. To reduce potential negative payment impacts because of the proposed adoption of the new OMB delineations, the agency has laid down a one-year transition for all hospitals that would experience a decrease in their actual payment wage index wholly due to the proposed implementation of the new OMB delineations and a 3-year transition for hospitals presently located in an urban country that would become rural under the new OMB delineation.

The agency is accepting comments on the proposed rule until June 30, 2014. The final rule will be out by August 1, 2014. You can find it at http://ofr.gov/inspection.aspx.

To further understand how the provisions of the 2015 IPPS affects your hospital and how to brace your facility to stay unaffected, stay tuned to Inpatient Facility Coding & Compliance Alert.

Ensure ED Providers Document All Their Critical Care Time

The appropriate critical care codes are determined by the physician’s total time.

On-target provider documentation is critical to reimbursement – more specifically for time-based codes for services such as critical care. Auditors are increasingly cynical of generic documentation that’s not specific to the patient or encounter. Using 30-74 minutes language that’s included in some templates and EMRs seem to fit the CPT^® code descriptors. However, don’t rely solely on attestation.

Make sure that your Emergency Department (ED) providers are well-equipped with what documentation is needed to substantiate the time reported.

Where to get time-based documentation guidelines? 

·         CPT Book: CPT^® mentions that “Time spent with the individual patient should be recorded in the patient’s record”.

·         CMS Manual: “The physician’s progress note(s) shall document the total time that critical care services were provided”. CMS transmittals also tell us that the use of “shall” denotes a mandatory requirement.

Physicians and coders watch out: ““The physician’s progress note(s) in the medical record should demonstrate that time involved in the performance of separately billable procedures was not counted toward critical care time.”

Ensure the highest standard of documentation

CPT^® code 99291 doesn’t use numerical documentation requirements for history, physical exam and medical decision making for code selection the way E/M codes do. As an alternative, the proper critical codes are determined by the physician’s total attention time.

Warning: But that does not mean that those E/M elements can be omitted from a critical care chart. These elements are required to show that the patient has a critical illness or injury that deeply impairs one or more vital organ systems such that there’s a high likelihood of looming or life threatening weakening in the patient’s condition.

Heed this: For on-target critical care reporting, document should point to the total amount of time the physician devoted their full attention to the patient providing critical care services. It would be ideal to see a short explanation of the critical nature of the patient, the critical interventions and other activities that added up to XX minutes to make a bullet proof chart.

According to many policy resources, the physician should document their total attention time, and ED physicians should document to that standard. The time range indicated in the code descriptor is for the coder to use to choose the appropriate CPT^® code based on the total time documented by the physician.

Your documentation should comply with coding guidelines and CMS policy to ensure that there’s no room for the auditor to argue that the ED chart doesn’t correctly reflect the service that was provided and/or the code that was reported.  If you need more help to ensure this and increase your compliance confidence, use Inpatient Facility Coding & Compliance Alert - a monthly newsletter that boosts your bottom-line and ensures compliance by focusing on topics specifics to hospitals – from time-based coding guidance, documentation advice and ICD-10-PCS implementation tips to DRG selection, modifier usage advice, and more.

Avoid 4 ‘Discharge Coding Traps’ to Ensure Correct Pay for your Facility

CMS does not expressly mention that the physician must see the patient on the discharge date in order to bill a discharge code. Watch your steps for next day discharge.

Reporting discharged services are not as straightforward as they seem; even skilled coders don’t get it right sometimes. Staying clear of these four common mistakes in your facility claims can save you thousands of dollars.

Who bills when multiple physicians are involved

During a patient care, several physicians might be involved, and each of them might try to bill for the discharge. If you read the Medicare Claims Processing Manual, you’ll find that only the attending physician should bill for the discharge day management service. Physicians or non-qualified practitioners, other than the attending physician, will have to use Subsequent Hospital Care (CPT^® code range 99231- 99233) for a final visit.

Heed this: To help distinguish from other physicians who might become involved in the patient’s care, the admitting physician should add modifier AI (principal physician of record) to the relevant admission code.

When is a patient not eligible for discharge code

There could be many scenarios when a patient may not be eligible for a discharge code. For instance, you should never report a discharge code if the patient never made the exit from the emergency room or was never admitted as an inpatient. Instead, the applicable ED service code (99281-99285, Emergency department visit for the evaluation and management of a patient …) should be used. One more instance could be that a patient has been admitted as an inpatient, however, at the last hour, the patient is changed to an observation case. In some cases, the documentation for such cases may be delayed. 

Next day discharge ensnare

A patient treats a patient on Monday and says that she can go home the following day if she doesn’t have any more vomiting or pain. If the physician does not see the patient on Tuesday, some coders will feel hesitant to bill a discharge on the date that the physician does not see the patient.

But note that CMS does not anywhere mention that the physician must see the patient on the discharge date to bill a discharge code.

Medicare Claims Processing Manual reads: “The E/M discharge day management visit shall be reported for the date of the actual visit by the physician or qualified non-physician practitioner even if the patient is discharged from the facility on a different calendar date.”Although the patient’s actual day of discharge is Tuesday, all the work was completed on Monday.

Remember: In the manual, CMS leaves it open for interpretation so till the time it clarifies it, follow your local MAC’s advice on coding discharges.

Nonphysician practitioners can perform the discharge

Even a non-physician practitioner can perform the discharge, provided all of the rules are met.

Coding discharge inappropriately and not following correct guidelines could mean leaving your facility’s much deserved money on the table. Your facility needs to have a finely honed process involving coding, billing and compliance to ensure that the initial claim goes out correctly and gets paid correctly. You could look at Inpatient Facility Coding and Reimbursement Alert to help you establish the process and guide you on the essentials for successful inpatient coding and pay.

Essentials of On-Target Subsequent Hospital Care Coding

Are you losing money by frequently reporting the lowest code for subsequent hospital care services? Learn 5 quick ways to increase your facility’s bottom-line.

                       

You may be reporting the lowest code for subsequent hospital care services from physicians such as hospitalists; however it doesn’t mean that it’s right to do so. The care level for most hospital stays changes and this could derail your coding if you do not watch your steps.

Here are some pointers on how to know when you are using 99231 more frequently and how to consult the physician’s report to rectify the coding.

Keep a tab on your use of 99231

Many specialists use 99231 more than any other subsequent hospital care code. That code is right in most cases; however, if you use 99231 for all your subsequent hospital care services, you may invite more trouble than anticipated. 

What does reporting 99231 mean?

This means that either most subsequent hospital visits are low-level services or physicians regularly under code for inpatient care. But all hospital visits are not low-level; therefore you should also be reporting higher-level subsequent hospital care – but only if your documentation merits it.

When problem arises: Since most payers normally bundle hospital care into postsurgical visits, many physicians are not well-versed with the documentation guidelines associated with subsequent hospital care for non-surgical situations.  Use 99231-99233 if you take up the patient’s care after another physician admits the patient to the hospital.

Five steps you can take to ensure you are using subsequent hospital care codes correctly are:

·         Learn the coding levels: Teach your clinicians about what CMS and CPT® require for each level of care.

·         Warn physicians of red flags: If your physician reports 99231 for all subsequent hospital care services, this could raise red flags with payers. Using this code will not save you from a government audit, as is normally believed. 

·         Focus on MDM: According to CPT®, of the three E/M components – history, exam and medical decision making – you need to document only two to use one of the subsequent care codes.

·         Include additional observations: While documenting subsequent hospital care, experts advice that providers should include additional observations such as whether the patient’s condition is stable, is the condition improving or worsening, and has any new problem developed.

·         Perform a chart review: Carry out a chart review if your facility reports the same code over and over again. Take a random chart sampling where you used 99231. Determine the history, exam and MDM levels on each file to figure out whether it meets the 99232 or 99233 requirements.

Overusing lowest level codes for subsequent hospital care could raise red flags for payers. Following the above tips will however take the headaches out of your subsequent hospital care coding to a great extent. For additional help, refer to SuperCoder Inpatient Facility Coding & Compliance Alert.