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.

Billing Initial & Subsequent Hospital Care on Same Day Will Invite RAC Scrutiny

Percutaneos transluminal angioplasty (PTA) procedures too under RAC spotlight!

Make sure your physician does not bill an initial hospital care code for seeing someone in the morning and then follows it up with subsequent care code for seeing her in the afternoon. If he does that, you could invite scrutiny from one Recovery Audit Contractor (RAC).  Here are some audit areas that impact Part B services.

RAC Contractor – CGI Technologies – is focusing its efforts on physicians who collected money for both initial and subsequent hospital care on the same day.

Hospital billing: Initial hospital care and subsequent hospital care 

Your physician is not allowed to bill both initial hospital care and subsequent care codes when he sees a patient more than once – even if he deems his second visit to be “subsequent” care. Seasoned coders know this well but this is an issue that CGI Technologies would be reviewing.

According to CGI, both initial hospital care and subsequent hospital care codes can be reported only once per day by the same physicians of the same specialty from the same group practice. In such scenarios, the physician can report the initial hospital care code if he is the first person to check the patient upon arrival. He should bill the subsequent care codes the next day only. The RAC contractor will collect from physicians who billed both initial and subsequent care codes on the same day. During its audit, it will also be checking claims with Date of Service (DOS) as far back as October 1, 2010.

In CMS’ Section 30.6.9 of the Medicare Claims Processing Manual, the inpatient hospital visit descriptors contain the phrase “per day”. This means that the code and the pay for the code stand for all services provided on that date. Your physician should go for a code that covers all services during the DOS.

Places where this audit will be applicable: Minnesota, Wisconsin, Indiana, Ohio and Kentucky.

RAC Contractor - Connolly Consulting is eyeing Percutaneous transluminal angioplasty (PTA)

Connolly Consulting would be checking medical documentation to determine if the PTA was reasonable and necessary. This audit will apply to all claims with DOS within the last three years. So if your cardiologist schedules too much PTA procedures, make sure he has documentation supporting the medical necessity of the surgeries or be ready to face heavy casualties.

This audit is applicable for all of Region C. Your local MAC might have different coverage criteria; so make sure you check your local services prior to billing Percutaneous transluminal angioplasty services.

2015 IPPS Proposed Rule – Major Highlights

On April 30, 2014, the Centers for Medicare & Medicaid Services (CMS) released the proposed hospital inpatient payment rule that would update fiscal year 2015 Medicare payment policies and rates for inpatient stays at general acute care and long term-care hospitals. The rule will be officially published in the Federal Register on May 15, and comments are due June 30 this year. Here are some of the major highlights of the 1,688-page proposed rule, scheduled to go into effect in October this year.

Payments 
The payment rate update to general acute care hospitals will be up 1.3 percent in FY 2015; however, hospitals that don’t submit quality data would lose a quarter of the market basket update .i.e 2.7 percent - and hospitals that are not meaningful users of Electronic Health Records (EHR) would lose another quarter of the market basket update. According to the agency, if these proposals are effective, the total Medicare payments to acute care hospitals would go down by $241 million!

Medicare DSH Payments 
Medicare disproportionate share hospitals (DSH) payments will be decreased 75 percent by 2019 (or $49.9 billion), as part of the Patient Protection and Affordable Care Act (PPACA).  The just-released proposed rule would cut overall Medicare DSH payments by 1.1 in FY 2015, as compared to the
previous FY 2014.

Alternative to Two-Midnight Rule

The much-criticized Two Midnight Rule has not been functional since it became effective; the agency had introduced the policy to better observe Medicare pay for short inpatient pays and ensure inpatient admissions are medically necessary. Several healthcare systems however considered it as arbitrary. The agency has called for public comments to find another payment system for Medicare short inpatient stays and has requested providers to define short inpatient stays and suitable payments for them.

$ 1.4 Billion in Value-Based Incentives

In financial year 2014, CMS took back 1.25 percent of Medicare pay at hospitals paid under IPPS. The ensuing $1.1 billion was dispersed to hospitals based on how well they performed on healthcare quality measures such congestive heart failure. For the coming year, the agency will keep 1.5 percent of Medicare payments, resulting in about $1.4 billion in value-based incentives.

HRR Program & Better Quality Healthcare

The Hospital Readmissions Reduction Program aims to bring into line Medicare pay with better healthcare quality. The program punishes hospitals for heart attack, heart failure and pneumonia 30-day readmission rates for Medicare patients that are more than estimated, after adjusting for patients’ illness severity. In the coming year, the agency will increase the maximum penalty from 2 to 3 percent. New measures will include total hip/total knee arthroplasty and chronic obstructive pulmonary disease.

HAC Reduction                               

CMS has also proposed to start the HAC Reduction program. Effective October 2014, hospitals with the worst performance in reducing HACs would lose 1 percent of their Medicare pay.

To read the complete 2015 IPPS Proposed Rule, click here. Alternatively, you can also stay tuned to the monthly Inpatient Facility Coding & Compliance Alert to get a clearer picture on how the provisions of the 2015 Rule would impact your hospital/facility – and at the same time keep up with the latest inpatient coding and billing updates.

 

Coding Institute: Qualified NPPs can treat certain patients

Watch out for these pitfalls – and opportunities – of getting your NPPs to work for you. 

Having a non-physician practitioner (NPP) around can have its advantages as your practice can serve more patients and allow physicians more time to look at more complex cases; thus boosting revenue in the process. However if you don’t follow correct guidelines, you could fall prey to scrutiny from OIG and payers. 

In a Coding Institute sponsored audio conference “2014 Risk Areas for NPPs and Incident-To”, Elin Baklid-Kunz, MBA, CHC, CPC, CCS, said, “Under incident-to rules, qualified NPPs can treat certain patients and still bill the visit under the physician’s National Provider Number (NPI), bringing in 100 percent of the assigned fee.” The reimbursement equals the payment that the payer would have allowed had the physician performed the procedure. To qualify for incident-to, the visit must meet these criteria laid down by CMS:

• The NPP performs the service in a physician’s office and not in hospitals – inpatient, outpatient or emergency services. He must also have a direct financial expense relationship with the physician.
• The NPP performs the service within the scope of her practice and in accordance with State law. In the 2014 Medicare Physician Fee Schedule, CMS changed its incident-to regulations to directly require that personnel performing “incident-to” services meet any appropriate state law requirements to provide the services (and that includes licensure).

Note: There may be more audits for incident-to where the focus may be more on the registered nurse/LPN to see if the work that they are doing incident-to a physician is within the scope of what they are allowed to provide to Medicare patients.

• Thirdly, the physician must have seen the Medicare patient during a previous visit and established a clear plan of care. If the NPP is treating a new problem for the patient, or if the physician has not established a care plan for the patient, then you should refrain from reporting the visit incident to.

Note: However in many cases, even if you find the service doesn’t meet incident-to-billing requirements, you don’t have to miss out on payment totally. If a Medicare credentialed NPP provides the service, you can bill under his own NPI.

• Lastly, the physician must be on site (direct supervision) when the NPP is rendering the service. Direct supervision means a supervising physician must be immediately available in the office during the service. He may not be the physician who started the treatment. Make sure you bill in the name of the physician present and providing the supervision at the time of the NPP visit, irrespective of whether he saw the patient or not.

Note: See to it that the billing reflects this difference. The physician who supervises in the office goes in box 33 while the physician who wrote the plan of care for the visit goes in 17 of CMS Form 1500. Remember: Do not bill for the service if a member of your auxiliary staff such as a medical assistant provides a service when there is no direct supervision.

The Coding Institute Experts Say - Make Best Use of Extended ICD-10 Training Time

Despite the delay in implementation, experts warn that practices must continue their efforts to prepare for ICD-10 use.

According to a study by Aloft Group in March 2014, nearly half of healthcare providers in the US have completed only 25 percent or less of their ICD-10 implementation plans.  The ICD-10 delay – therefore – is welcome news to many providers.

Providers should view the ‘delay time’ as practice time for detailed documentation – an opportunity to boost new skills. “Of note, we should not throw away the chance to improve the physician’s clinical documentation just because the code set implementation has been delayed,” says Barbara Cobuzzi,  MBA, CPC, CENTC, CPCH, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.. “It is always a goal to improve clinical documentation,” Cobuzzi adds.

To make the best use of the extended training time, providers should stay focused and take these steps:

·         Maintain the momentum towards ICD-10 readiness

·         Keep tabs on the most frequently-reported ICD-9 codes

·         Devise a top-25 list that will help guide you to the most relevant chapters in the ICD-10 coding manual

·         Focus only on the codes you are most likely to use – All the codes don’t apply to every specialty.

·         Boost your documentation skills – particularly in your focus areas so that by next year, your records will regularly include the kind of detail coders will need.

·         Become familiar with the new coding concepts.

·         Know all of your “points of contact” for ICD-10

·         Ensure practice management/EHR systems can handle the transition.

Providers should also take advantage of various training resources available from AHIMA, CMS, The Coding Institute and other organizations.

Training should be specifically targeted to the conditions physicians handle on a daily basis. The Coding Institute (TCI) offers various ICD-10 training resources through its website, where providers can access ICD-10 charts, newsletter, crosswalks based on general equivalency mappings, and other tools. Last week, the company launched ICD-10 Multispecialty Guide - a Quick-Reference Guide for 23 specialties - to help medical practices in jumpstarting their conversion to ICD-10.