observation and the 2 midnight rule - lihima your cfo look like this? roaming the halls while...
TRANSCRIPT
OBSERVATION AND THE 2
MIDNIGHT RULE Maureen Ruga NP
AVP Quality Management
Peconic Bay Medical Center
DOES YOUR CFO LOOK LIKE THIS?
Roaming the halls while muttering about 1 Day Stays, Observation
Status, LOS, Medical Necessity Denials and the 2 Midnight
Rule???????
AND YOUR DOCTORS LIKE THIS?
While driving CDI and HIM crazy asking WHY can’t they just take care
of patients? And if you are making up these rules?
MOST LIKELY CAUSES……….
Observation Status
Code 44
2 Midnight Rule
Electronic Medical Record
ICD-10
RACS AND PREPAID DENIALS
The Recovery Audit Program’s mission is to
identify and correct Medicare improper payments
through the efficient detection and collection of
overpayments made on claims of health care
services provided to Medicare beneficiaries, and
the identification of underpayments to providers
so that the CMS can implement actions that will
prevent future improper payments in all 50
states.
Medicare Administrative Contractors prepaid
denials.
1 Day Stays
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RECOVERY AUDIT CONTRACTOR PROGRAM
What Does A Recovery Auditor Do?
Reviewed paid claims from 2009-2011
The Recovery Audit Review Process:
Recovery Auditors review claims on a post-payment basis
Three types of review:
Automated (no medical record needed)
Semi-Automated (claims review using data and potential human review of a medical record or other documentation)
Complex (medical record required)
Recovery Audits look back three years from the date the claim was paid
Recovery Auditors are required to employ a staff consisting of nurses, therapists, certified coders and a physician.
WHAT IS OBSERVATION STATUS?
Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.
Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.
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OBSERVATION STATUS
Specific criteria include: There must be a physician order to place the patient
in observation!!!!!
For Medicare payment, a HCPCS 99284, 99285, or G0384 ED visit code, critical care, or a 99205 or 99215 clinic visit is required to be billed on the day before or the day that the patient is placed in observation.
If the patient is a direct referral to observation the G0379 may be reported in lieu of an ED or clinic code.
In addition, the E/M code associated with these other services must be billed on the same claim form as the observation service and the E/M must be billed with a modifier -25 if it has the same date of service as the observation code G0378.
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REQUIREMENTS
The observation stay must span a minimum 8 hours and these hours must be documented in the "units" field on the claim form.
For facilities, the "clock" starts at the time that observation services are initiated in accordance with a practitioner's order for placement of the patient into observation status.
Patients must be notified that they are being put on Observation Status (notified in writing prior to discharge)
Observation status can not be used towards a 3 day qualifying stay for SNF!
Part B billing more out of pocket expense
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OBSERVATION CONTINUED
You must carve out time for tests i.e. Radiology
Patient’s home meds are not billable
Policy regarding taking medications from home
CONDITION CODE 44
Policy:
1. In cases where a hospital utilization review committee determines that an inpatient admission does not meet the hospital’s inpatient criteria, the hospital may change the beneficiary’s status from inpatient to outpatient and submit an outpatient claim (TOBs 13x, 85x) for medically necessary Medicare Part B services that were furnished to the beneficiary, provided all of the following conditions are met:
a. The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital;
b. The hospital has not submitted a claim to Medicare for the inpatient admission;
c. A physician concurs with the utilization review committee’s decision; and
d. The physician’s concurrence with the utilization review committee’s decision is documented in the patient’s medical record.
2. When the hospital has determined that it may submit an outpatient claim according to the conditions described above, the entire episode of care should be treated as though the inpatient admission never occurred and should be billed as an outpatient episode of care.
3. Refer to Pub. 100-04, Medicare Claims Processing Manual; Chapter 30, Financial Liability Protections; Section 20, Limitation On Liability (LOL) Under §1879 Where Medicare Claims Are Disallowed; for information regarding financial liability protections.
4. When the hospital submits a 13x or 85x bill for services furnished to a beneficiary whose status was changed from inpatient to outpatient, the hospital is required to report Condition Code 44 in one of Form Locators 24-30, or in the ANSI X12N 837 I in Loop 2300, HI segment, with qualifier BG, on the outpatient claim.
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CASE MANAGEMENT
Assess for Medical Necessity
Provide Level 1 Screen
Milliman Care guidelines (MCG)
InterQual Criteria
Case Managers can not determine but can assist
practitioners in determining if the patient meets
inpatient criteria.
Many hospitals have case managers in the Emergency
Department to evaluate patients prior to admission
orders being written
MCG CONGESTIVE HEART FAILURE
Care Planning - Inpatient Admission and Alternatives
Return to top of Heart Failure - ISC Clinical Indications for Admission to Inpatient Care
Return to top of Heart Failure - ISC Admission is indicated by 1 or more of the following(1)(2)(3)(4):
Hemodynamic instability
Anasarca
Severe electrolyte abnormalities requiring inpatient care(9)
Cardiac arrhythmias of immediate concern
Precipitating cause for acute decompensation (eg, pneumonia, pulmonary embolism) requires inpatient care.
Acute cardiac ischemia causing or associated with failure. See AnginaISC or Myocardial InfarctionISC as appropriate.
Inpatient admission required rather than observation care (see Heart Failure: Observation CareISC guideline as appropriate) because of 1 or more of the following: Significant finding or clinical condition judged too severe (eg, treatment intensity or expected duration requires
inpatient admission) or too persistent (eg, insufficient improvement or worsening despite initial intervention or treatment for up to 24 hours) to be within scope of observation care, including 1 or more of the following:
Pulmonary edema that is severe or worsening
Cognitive impairment that is severe or persistent
Acute renal insufficiency that is severe (reduction of more than 50% in estimated glomerular filtration rate from baseline) or progressive (reduction of more than 25% in estimated glomerular filtration rate from baseline, with creatinine continuing to rise) GFR - Adult Calculator
Acute peripheral ischemia (eg, pulseless, cool, mottled, or cyanotic extremity)
Acute renal failure
Other significant finding or clinical condition judged not to be within scope of observation care
Treatment or monitoring requiring inpatient admission (eg, due to intensity or expected duration) as indicated by need for 1 or more of the following(10):
Supplemental oxygen or respiratory treatments for over 24 hours that are performable only in acute inpatient setting
Pulmonary artery catheter monitoring
Other treatment or monitoring requiring inpatient admission
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2 MIDNIGHT RULE
BACKGROUND
CMS wants to limit the use of observation status
to reduce its financial burden on Medicare
beneficiaries.
Observation stays result in greater out-of-pocket
expenses for beneficiaries and do not count
toward the three-day eligibility requirement for
Medicare skilled nursing facility (SNF) coverage.
CMS is particularly concerned about the growth
in long-stay observation cases (those greater than
48 hours) which have increased from 3% of all
observation cases in 2006 to 8% in 2011.
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2 MIDNIGHT REQUIREMENT
CMS contractors will operate under the presumption that stays of
at least two midnights are medically necessary, with the “clock”
beginning when the patient starts receiving hospital services
(including observation services).
During the September 26 open-door forum, CMS clarified that if a
patient stays one midnight in observation and the physician
expects that the patient will require at least another midnight in
the hospital, the patient can be appropriately admitted despite
the fact that it is a one-day inpatient stay.
If a patient is admitted but ultimately doesn’t stay two
midnights, clear physician documentation supporting the order
and expectation of two midnights will be required.
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WHEN CHANGING STATUS FROM OBS TO
INPATIENT
Observation time will count the towards 2 midnight stay
Observation time does not count toward SNF qualifying stay.
If the patient recovers prior to 2 midnights you can still bill as inpatient with the appropriate documentation
If the patient has a procedure on the inpatient only list you can bill as inpatient
If the patient is placed on a vent you can bill as inpatient
ICU status alone is not sufficient for inpatient billing if patient stays less than 2 midnights
MEDICARE PROBE AND EDUCATE
• Medicare Audit Contractors (MACs) will focus their reviews on claims that are less than "two midnights" after admission. They will continue to conduct coding reviews, or reviews to ensure coverage guidelines are met for a certain surgeries, but for the purpose of verifying inpatient, outpatient, and observation status, only claims marked as one inpatient midnight will be used.
• RACs will not be conducting medical necessity reviews during the three-month "amnesty" period. (restart in Oct)
• Ten claims will be gathered from most hospitals, while a larger sample—about 25 claims—will be taken for larger facilities.
• MACs will review the results of the claims to provide education back to providers, and inform hospitals how well they're doing in terms of compliance.
• At the end of the three-month period, CMS will review the results to gauge the need for more guidance and "go from there," Combs-Dyer said.
HOSPITALS GET A GRACE PERIOD—OF SORTS
The deadline to begin enforcement of certain
aspects of the "two-midnight" rule had already
been delayed from Oct. 1, 2013, to March 31,
2014, after providers voiced their concerns.
Friday's announcement pushes the deadline
another six months, requiring recovery
auditors—who use data-mining techniques to
locate suspicious admissions—to wait until Sept.
30 to begin penalties for incorrect claims under
the rule.
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RISK ASSESSMENT OF OUR RECORDS
No LOS documented in H&P
Uncertainty of coders of status of patient
Consultant letters (Too late to place patient on OBS,
MD doesn’t agree, No UM note etc…..)
Registered as inpatient when physician order
was for observation and vice versa
No admit order what so ever!!!!
No inpatient order!!!!!!
Design of EHR
HYBRID CHARTS
Just complicate everything!!!!
ED still on paper
Coders are abstracting from EHR and paper.
Coders are dual coding preparing for ICD-10
THANK YOU!!!!!!
Questions??????