cms ipps 2014 final rule - sc hfma€¦ · cms ipps 2014 final rule: best practice ... a dentist in...

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CMS IPPS 2014

Final Rule: Best Practice

Recommendations

Joseph E. Crea, DO, MHA, FACOEP Senior Medical Director: Audit,

Compliance and Education (ACE)

1

Agenda

• Review key points of IPPS Final Rule

• Updates since IPPS release

• Best practice UM recommendations – Medical Necessity

– Physician Certification

• Rebilling issues

• Physician education talking points

2

• “Benchmark of 2 midnights”

– “the decision to admit the beneficiary should be based on the cumulative time

spent at the hospital beginning with the initial outpatient service. In other

words, if the physician makes the decision to admit after the beneficiary arrived

at the hospital and began receiving services, he or she should consider the

time already spent receiving those services in estimating the beneficiary’s

total expected length of stay.”

Page 50946, IPPS

• “Presumption of 2 midnights”

– “Under the 2-midnight presumption, inpatient hospital claims with lengths of

stay greater than 2 midnights after formal admission following the order

will be presumed generally appropriate for Part A payment and will not be

the focus of medical review efforts absent evidence of systematic gaming,

abuse or delays in the provision of care…”

Page 50949, IPPS

Benchmark vs. Presumption

3

• For payment of hospital inpatient services under

Medicare Part A, the order must specify the

admitting practitioner’s recommendation to admit

“to inpatient,” “as an inpatient,” “for inpatient

services,” or similar language specifying his or

her recommendation for inpatient care

Page 50942, IPPS

Physician Order

4

Order and Certification

• “(c) The physician order also constitutes a required component of physician certification of the medical necessity of hospital inpatient services under subpart B of Part 424 of this chapter.

• (d) The physician order must be furnished at or before the time of the inpatient admission.”

0965, IPPS

5

Order and Certification (con’t)

• “…while the physician order and the physician certification are required for all inpatient hospital admissions in order for payment to be made under Part A, the physician order and the physician certification are not considered by CMS to be conclusive evidence that an inpatient hospital admission or service was medically necessary. Rather, the physician order and physician certification are considered along with other documentation in the medical record.”

Page 50940, IPPS

6

• “We did not propose and are not finalizing a policy that would allow hospitals to bill Part B following an inpatient reasonable and necessary self-audit determination that does not conform to the requirements for utilization review under the CoPs.”

Page 50913, IPPS

• 482.30 (1) The UR plan must provide for review for Medicare and Medicaid patients with respect to the medical necessity of:

(i) Admissions to the institution;

(ii) The duration of stays

Medical Necessity Still Matters

7

• it was not our intent to suggest that a 2-midnight stay was presumptive evidence that the stay at the hospital was necessary; rather, only that if the stay was necessary, it was appropriately provided as an inpatient stay. We have discussed in response to other comments that, in accordance with our statutory obligations, some medical review is always necessary to ensure that services provided are reasonable and necessary, and that we will continue to review these longer stays for the purposes of monitoring, determining correct coding, and evaluating the medical necessity for the beneficiary to remain at the hospital, irrespective of the inpatient or outpatient ‘‘status’’ to which the beneficiary was assigned. In addition, claims that evidence that a hospital is effectuating systematic abuse of the 2-midnight presumption, such as unexplained delays in the provision of care or aberrancies in billing, may be subject to medical review despite surpassing 2 midnights after admission.”

IPPS pg. 50951

Must Have Time

AND Medical Necessity

8

• “Use of Condition Code 44 or Part B inpatient

billing pursuant to hospital self-audit is not

intended to serve as a substitute for adequate

staffing of utilization management personnel or

for continued education of physicians and

hospital staff about each hospital’s existing

policies and admission protocols.”

Page 50914, IPPS

Concurrent UM Still Matters

9

Sept. 5 CMS Update:

Physician Certification Physician Certification of inpatient services:

– Authentication of the practitioner order

– Reason for inpatient services

– The estimated time the beneficiary requires or required in the hospital

– The plans for post-hospital care

Timing: The certification must be completed, signed, dated and documented in the medical record

prior to discharge

Authorization to sign the certification: The certification or recertification may be signed only by one

of the following:

– (1) A physician who is a doctor of medicine or osteopathy.

– (2) A dentist in the circumstances specified in 42 CFR 424.13(d).

– (3) A doctor of podiatric medicine

Format:

– As specified in 42 CFR 424.11, no specific procedures or forms are required for certification

and recertification statements. The provider may adopt any method that permits verification.

The certification and recertification statements may be entered on forms, notes, or records

that the appropriate individual signs, or on a special separate form.

10

Sept. 5 CMS Update:

Physician Order

• Qualifications of the ordering/admitting practitioner: – At some hospitals, practitioners who lack the authority to admit inpatients under

either State laws or hospital by‐laws may nonetheless frequently write the sets of admitting orders that define the initial inpatient care of the patient. In these cases, the ordering practitioner need not separately record the order to admit ….. the order must identify the qualified “ordering practitioner”, and must be authenticated by the ordering practitioner (or by another practitioner with the required admitting qualifications) prior to discharge.

• Verbal orders: – A verbal or telephone inpatient admission order must be authenticated

(signed, dated and timed) by the ordering practitioner (or by another practitioner with the required admitting qualifications in his or her own right) in the medical record prior to discharge, unless the hospital or the State requires an earlier timeframe

• Timing: – The order must be furnished at or before the time of the inpatient admission.

11

CMS Open Door Forum: Key Points September 26, 2013

• MAC “Probe and Educate” Program

o Not a delay in implementation, but rather a transition period

o Three (3) month transition runs from 10/1/13 until 12/31/13 for this program. Possibility of an

extension of the transition period

─ CMS will study the results, determine the level of hospital compliance, what additional

guidance CMS can provide

o MACs will focus on 1 midnight inpatient cases.

─ They may not review cases greater than 2 midnights

─ 10 claims for a small hospital, up to 25 for a larger hospital

─ Post review, the MAC will provide feedback to each provider. How well the provider is

doing, what to focus on

o All claims continue to be subject to ZPIC, CERT, OIG and DOJ audit and review

• RAC Reviews

o No prepayment RACs reviews except therapy reviews in the pre-payment demonstration

states

o No post-payment RAC review of cases greater than 2 midnights

o RACs will not be able to review cases for one midnight or less with admission dates of

October 1, 2013 through December 31, 2013

12

CMS Open Door Forum: Key Points September 26, 2013

• Key Takeaways from Q&A

o If patient is staying for convenience or for services better rendered at nursing home level care, non-hospital level care all – DOES NOT count toward the 2 MN benchmark or presumption

─ 2MN rule is an overlay to existing medical necessity decision making

─ No changes to the hospital conditions of participation

o A patient receiving observation services (did not meet inpt med necessity) ─ CMS did NOT say that the patient should become inpatient just because the

stay is to extend beyond 2MN -- suggesting that some thought process is required with regard to medical necessity.

─ Also, did not say that the patient was appropriate for observation services beyond 2 MN

o Receiving services in ER does count as first midnight ─ Time spent in the waiting room does not count towards benchmark

─ The measure for the start of services is when the patient begins receiving hospital services

13












Best Practice

Recommendations to

Comply with 2014 IPPS

Requirements

14

Effective October 1, 2013

• Maintain UR processes at the time of admission as these

remain critically important

• Address the additional importance of physician order,

certification and documentation to support Medical

Necessity

• Expect sub-regulatory guidance in key areas as noted

• Review UM plan and update to define process

adjustments

15

Best Practice

Review Recommendations

• Review cases as close to time of admission as possible

• Review all cases – single process for medical and

surgical/procedure cases

• UM process should ensure that all of the following are

present for an inpatient admission:

– Expectation of a two-midnight stay

– Medical necessity (documented and validated)

– Elements of physician certification (documented)

16

Review Considerations

• Expectation of two-midnight stay AND medical necessity

must be established for an inpatient claim

– Both are required

– Neither alone is sufficient

• New process must screen for physician expectation of

two-midnight stay

• Medical necessity must be established and validated for

inpatient cases using evidence-based admission review

17

Recommended

Screening Process

• Best Practice

– Screen all cases for expectation of two midnights or Inpatient-Only List

Procedures

– Validate medical necessity for any potential inpatient admission

– Perform reviews in accordance with UR plan and Conditions of Participation

• Order - Impacts UR Process

– Order has to be present

– Order cannot be corrected to IP after discharge

– Delays in getting appropriate IP order will result in increased short stays,

potentially resulting in more charts being requested by auditors for review

– Delays in getting appropriate IP order can also impact SNF qualifying stays

18

Recommended

Screening Process (con’t)

• Expected LOS - impacts UR process

– Is there a clear documented expectation of

discharge earlier than two midnights?

• Procedures on the Medicare Inpatient-Only List remain inpatient

and require order pre-procedure

• Other cases will probably not meet threshold for inpatient

consideration

• If patient remains, review again when additional data is

available

– If anticipation of discharge is not documented, or

the stay is expected to be two midnights or

greater, then perform admission screening

19

First level screen

Expected discharge in <2 MN

IP

Re-review as new information is

available

Expected discharge in >=2 MN

or

No documentation of expected discharge

Meets

Doesn't meet

Review elements of Certification

Re-review as new information is

available

Obs/OP

OBS/OP

Review elements of Certification

Recommended Work Flow

Hospitalized for condition other than Inpatient-Only Procedure

Plan for discharge before 2nd midnight?

Yes

No

Physician Advisor review

Clinical Info Needed

• The following information is needed for case review – History & Physical

– Case management notes

– Consult or emergency department notes (when applicable)

– Procedure notes and progress notes (when applicable)

– Physician orders

– Laboratory and diagnostic test results

– Medication Administration Record

21

Special Considerations for

Admission Review

• Slide 19 provided a recommended work flow for

admission review

• However, this process might generate situations

which could benefit from follow-up reviews:

– Inpatient admissions expected to span two midnights

but did not, may require additional review

– Outpatients whose lengths of stay extend beyond two

midnights may require additional review

22

Certification Requirements

• Certification (§424.13)

– Begins with the order for inpatient admission

– Must include the reasons for hospitalization for inpatient medical treatment

– Must include diagnosis

– Must include the estimated time the patient will need to remain in the

hospital

– Plans for post-hospital care, if appropriate

– May be entered on forms, notes, or records that the appropriate individual signs,

or on a special separate form.

– If information is in different places (i.e. progress notes, H+P) [certification]

statement should indicate where it may be found

– Must include services were provided in accordance with §412.3 of this

chapter

– Certification must be signed and documented in the medical record prior to

the hospital discharge (if delayed – reason must be documented)

23

Certification Template

• Validate documentation of:

– Order for inpatient admission and location

– Reason for hospitalization

– Expectation of two-midnight stay and estimated

length of stay

– Evidence of services planned or provided

– Plan for post hospital care

• Requires signature and completion of elements in

medical record by provider prior to discharge

24












2014 IPPS

Rebilling Options

25

Rebilling Evolution

26

Prior to New

Rulings

Interim 1455 CMS Final Rule

Self-

Auditing

Bill Part B Ancillaries only.

Subject to limitations of

CC 44

Allows providers to rebill only

for claims denied by a

Medicare contractor

Allows providers to rebill

inpatient Part A claims denied

as a result of a “self-audit”

Part B

Rebilling

Only allowed if Judge

determined appropriate. No

regulations

Rebilling of covered Part B

charges when the Part A claim

is denied as not medically

reasonable and necessary

Part B rebilling to claims for

services rendered to

beneficiaries enrolled in

Medicare Part B

Timeliness

for Rebilling

Only if within timely filing

(one year) or Judge orders

(no time limit)

Allows for rebilling 180 days

from denial or lost appeal with

date of service before Sept. 30,

2013

Standard timely filing

requirements (1 year from the

date of service) on rebilled

claims

Impact to

Beneficiary

To be held harmless Upon rebilling, requires hospital

to adjust beneficiary billing

Upon rebilling, requires hospital

to adjust beneficiary billing

• “Adjudicators review the contractor’s initial determination(s) on the claim for items and services furnished to a beneficiary, and issue a decision with respect to that initial determination. For example, a QIC reviews initial determinations, and its decision must either reverse or affirm (in whole, or in part) the initial determination, including the redetermination that is before them…neither the Medicare statute nor the Secretary’s implementing regulations grant ALJs or other adjudicators the authority to order equitable remedies.”

Page 50929, IPPS

Prohibits Partial Payment Orders

27

Rebilling – Claims Impacted

Claims after the October 1 start date of IPPS:

• “The claims for Part B inpatient and Part B outpatient services would have to be submitted within the timely filing period [one year from date of service]. ”

Page 50913, IPPS

Claims subject to the Interim Rule 1455:

• “The timely filing requirement in § 414.5(c) will not supersede the Ruling’s treatment of Part A claim denials to which the Ruling originally applied. Hospitals are permitted to follow the provisions in the Ruling regarding appeals and submission of Part B claims after the effective date of this final rule, provided (i) the Part A inpatient claim denial was one to which the Ruling originally applied, or (ii) the Part A inpatient claim has a date of admission before October 1, 2013 (the effective date of this final rule), and is denied after September 30, 2013, on the grounds that through inpatient services were not reasonable and necessary, hospital outpatient services would have been reasonable and necessary.”

Page 50935-50936, IPPS

28

Beneficiary Impact

“Beneficiaries who are treated for extended periods of time as hospital outpatients receiving observation services may incur greater financial liability than they would if they were admitted as hospital inpatients. They may incur financial liability for Medicare Part B copayments, the cost of self-administered drugs that are not covered under Part B, and the cost of post-hospital SNF care because section 1861(i) of the Act requires a prior 3-day hospital inpatient stay for coverage of post-hospital SNF care under Medicare Part A.” Page 50907, IPPS

29

• “The hospital is prohibited from collecting any amounts for the denied Part A services from the beneficiary and must refund any amounts previously collected.”

• “We will issue sub regulatory guidance about how this refund should occur when there is both a Part A refund owed to and a Part B liability owed from the beneficiary.”

Page 50919, IPPS

Beneficiary Impact of Rebilling

30

•“…[T]he issue of whether hospitals are required to

bill the beneficiaries for their Part B liabilities is

governed by the beneficiary inducement and anti-

kickback laws and, therefore, falls under the

jurisdiction of the Office of the Inspector General

(OIG). We refer the commenters to the OIG

regarding whether hospitals are required to bill these

beneficiaries for their Part B liabilities.”

Page 50920, IPPS

Balance Bill the Patient?

31












CMS IPPS 2014

Final Rule Documentation Guidelines

for Physicians

32

IPPS Key

Requirements/Changes

• The Time the patient is expected to stay in the hospital (2 midnights is guide)

• The Order to “admit to inpatient” or “refer for observation/outpatient”

• The Documentation and Certification of medical necessary to support the patient’s inpatient admission

33

Expectation/Certification

• Physician must document if they expect the patient’s

hospital care to span more or less than two midnights

─ Treatment time spent in the ED can be counted towards

two midnights

• Guidelines:

─ If you believe the patient will be discharged same day

or the day following hospitalization, consider

ordering Outpatient or Observation

─ If you believe the patient will NOT be ready for

discharge the day after hospitalization, consider

ordering Inpatient

34

• Inpatient Cases: must include the words “Admit”

and “Inpatient” to be a valid inpatient order

• Observation/Outpatient Cases: Should include the

phrase “refer for Observation Services” or

“outpatient status”

─ Avoid using “admit” and “Observation or Outpatient” in

the same order. CMS considers this to be contradictory

─ “Admit to Tower 7” or “Admit to Dr. Smith” are not

recommended

Physician Order Guidelines

35

Certification Requirements

• CMS requires physician certification of the patient’s inpatient

admission in the medical record. The certification must include:

─ Order for inpatient admission (as discussed)

─ Diagnosis and rationale for hospitalization/ inpatient medical treatment

─ Documentation of the estimated time the patient will need to remain in the

hospital (as discussed)

─ Plans for post-hospital care, if appropriate

─ May be entered on forms, notes, or records that the appropriate individual signs,

or on a special separate form.

─ If information is in different places (i.e. progress notes, H+P) [certification]

statement should indicate where it may be found

─ Certification must be signed and documented in the medical record prior to the

hospital discharge

CFR §424.13

36

Guidelines for

Documentation/Certification

• Excellent patient care should continue to be the top

priority

• Clearly document and sign the diagnosis, medical

rationale, plan of care and anticipated discharge

• Sign the admission order and certification (if

appropriate) prior to discharge

37

Summary

•Maintain processes to ensure correct

status at time of admission

• Establish process to ensure that required

documentation is present on the medical

record early in the hospital stay

• Stay tuned for CMS updates and sub regulatory

guidance

38

Questions?

Joseph E. Crea, DO, MHA, FACOEP

Senior Medical Director

Audit, Compliance and Education (ACE)

[email protected]

39

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