regulation update 2019...this often occurs because it is difficult to determine pre-operatively...

Regulation Update 2019

Ronald Hirsch, MD, FACP, CHCQM-PHYADV, FABQAURPR1 RCM Inc.Chicago, IL

Twitter – @signaturedocwww.ronaldhirsch.com

• The opinions I am about to present are not universally accepted

• Some in this room will disagree with my interpretations

• Ambiguity is inherent to CMS regulations and transmittals

• Use this information along with different opinions from your networking and your compliance/legal/finance/utilization review department to develop your own policy

• These opinions do not represent official CMS, MAC, RAC, QIO, or R1 policies (but I am right)

Disclaimer

• CMS removed Total Knee Arthroplasty from inpatient only list

• Does not mean must be performed as outpatient

• Must meet 2 Midnight Rule requirements to be Inpatient

• Two midnight expectation – hemiplegia, Parkinson’s, ataxia

• One midnight expectation but case-by-case determination of increased risk

• Surgical complexity

• Medical comorbidities

• Requires SNF care post-hospital

2018 – The Year of the Knee

• Real

• Not all diabetics at increased risk

• Age alone is not adequate

• Delineated

• Each factor should be documented to highest specificity

• Type II DM with HbA1c=8, COPD on daily inhaled steroids, BMI=38, OSA on CPAP

• Attributed

• “This patient is at higher risk due to X, Y, and Z; therefore inpatient admission is warranted”

“Increased Risk” Assessment Must Be

• Poorly controlled diabetes HbA1c > ?

• HTN – on multiple meds or over ?

• Pulmonary Disease – COPD or Asthma on chronic meds, documented OSA, or abnormal screening

• Cardiovascular Disease – CAD, CVA, PVD

• ASA Score of 3 or higher with factors indicated in anesthesia documentation.

• Anemia Hb < ?

• Age ? years or older

• Morbid obesity, BMI equal or greater than ?

• Chronic Kidney Disease stage ? or greater

• Presence of drug related risks due to underlying polypharmacy

• History of opioid dependency

• RAPT score, Charlson score values

What Factors Can you Consider?

• Document why SNF is expected to be needed• Patient lives alone with no family or friends to care for him;

expected he will need rehab in SNF for safety

• On post-op day 1 and 2, evaluate patient and document “continue in-hospital intense PT to determine if patient able to be discharged home” unless patient able to go home then discharge home

• Post-op day 3, document “patient not safe to discharge home without supervision, transfer to SNF” and transfer

What about SNF?

Create a Policy

• Include references to CFR

• Get surgery department to approve

• Use it

• Include it with any charts audited

• BPCI, BPCI Advanced, CJR all use inpatient admissions only• DRG 469 and 470

• 90-day spending compared to target amount, savings shared with participants

• If outpatient stay or admission for non-surgery-related reason, not in bundle

• If you self-deny and rebill admission, will not be in bundle• Doctor will not be happy

• But you cannot submit false claims

What about Bundled Payment Programs?

• Calculate Δ inpatient v. outpatient• Emory – $16,170 v. $10,296• Johns Creek – $11,684 v. $10,296

• Get your yearly volume of TKA• Emory – 100• Johns Creek – 20

• Calculate dollars at risk• Emory – $868,600• Johns Creek – $27,760

• Decide if it is worth the effort

If You are Not In a Bundle

• MLN Matters SE19002 released 1-9-19, rescinded 1-11-19

• MLN Matters SE19002 v2 released 1-24-19

• Used Observation immediately post-op

• Allowed inpatient admission for malfunctioning pacemaker

• Allowed inpatient admission for “history of CAD, atrial fibrillation, pacemaker” then changed their minds

• Allowed observation after routine post-operative care for no documented reason

CMS Brings “Clarity” in 2019

• After physician-defined routine recovery has ended and patient requires additional hospital care for delayed recovery or complication not expected to pass second midnight• Nausea, pain, fever, abnormal lab, bleeding, urinary retention, etc.

• During routine recovery if complication occurs that requires care beyond that provided during routine recovery• Arrythmia and transfer to tele, hypoglycemia and frequent BS

checks, Hb drop and CT ordered to r/o bleed

• Generally no payment change from C-APC but cost outlier and cost reporting implications so do it

So When Can Post-Op Observation Be Ordered?

• Valid admission order established as condition of payment as of 10-1-2013

• Denials for lack of authentication of admit order prior to discharge started by MACs and QIOs

• 4 years, 7 months later, CMS says, “It was not our intent when we finalized the admission order documentation requirements that they should by themselves lead to the denial of payment for otherwise medically reasonable necessary inpatient stay, even if such denials occur infrequently.”

Inpatient Admission Order

“We are finalizing our proposal to revise the inpatient admission order policy to no longer require a written inpatient admission order to be present in the medical record as a specific condition of Medicare Part A payment. Specifically, we are finalizing our proposal to revise the regulation at 42 CFR 412.3(a) to remove the language stating that a physician order must be present in the medical record and be supported by the physician admission and progress notes, in order for the hospital to be paid for hospital inpatient services under Medicare Part A.”


“This proposal does not change the requirement that an individual is considered an inpatient if formally admitted as an inpatient under an order for inpatient admission.”

Interpretation – An admission order is not needed but it is needed.


• Unsigned Admission Order

• Get admission order signed prior to discharge

• If you miss one, get it signed ASAP and bill admission

• But if inpatient admission was not appropriate, don’t get it signed and bill outpatient part B

What does this Mean?

• Absent Admission Order

• Is it a compliant admission per 2 MN Rule?

• If not, bill as outpatient part B

• If so, investigate and document investigation

• Talk to Compliance and decide

What does this Mean?

Admission order note absent – Patient presented to ED with septic shock, was resuscitated in ED, transferred to ICU under care of Dr. Smith. Dr. Smith H&P states “admit to ICU.” Patient registered as inpatient and IMM delivered to daughter. Patient illness severe and inpatient admission warranted. Patient discharged after 5 day stay. No inpatient order found. Per documentation and course, it is clear that intent was inpatient admission. Contacted Dr. Smith who agrees. Will bill part A.

Show Your Work

©2018 MedLearn Media, Inc.

Dear Dr.____

Your patient, _____________, underwent _____________ surgery. After discharge it was determined that the surgery was on the CMS Inpatient Only list. Patient was not admitted as inpatient preoperatively or during hospital stay. This often occurs because it is difficult to determine pre-operatively exactly which procedures will be needed and what CPT code(s) would apply and the complete operative report was not available to accurately code the claim prior to discharge. If the surgery was determined to be on the CMS inpatient only list prior to or during the hospital stay, would your intent have been to formally admit the patient as inpatient either preoperatively or prior to discharge?

___Yes, my intent would be to admit the patient as inpatient

___ No, I was aware the surgery was inpatient only and intended to perform it as outpatient

Show Your Work

• CMS moving some auditors from random audits to targeted audits

• Targeted Probe and Educate – TPE• Data analytics used to pick targets – volumes, pattern shifts,

PEPPER-like data, CERT reviews, dollars at risk

• Applies to MACs and BFCC-QIOs, not CERT, SMRC, UPIC, etc.

• Adds educational period to review cases and change minds

• Recovery Audit Contractors• Must have targets approved by CMS – posted online

• Must spread amongst types – physicians watch out!

• Lots of medical necessity for elective procedures

• No short stay audits approved yet. TKA starting 1-1-20

Audit Updates


If you receive a documentation request from a Medicare review contractor, submit:

1. The order from the ordering practitioner –

If you forgot to keep a copy of the order, contact the ordering practitioner and request that they send you a copy of the order.

If the ordering practitioner can’t find a copy of the order in the patient’s medical record, ask them to send you the progress notes, plan of care, or any other medical record entry from PRIOR to the day of the CT scan that documents the intent to order the CT scan.

2. The ordering practitioner’s progress notes or other medical record entries (e.g. medical history, physical exam) documenting why the CT scan is needed

Medicare Learning Network ICN907793 April 2014

Don’t Believe Me? Outpatient CT Scan Audits


• Who ordered the service?• Provide the signed order or progress note

• Why was the service performed?• Provide the documentation to support the service

• Was the service done?• Provide the administration record

• What was the result?• Provide the test results/operative note

The 4 W’s of Medical Necessity Audits


• Long Term Acute Care Hospital discharges on day of maximal financial benefit

Are We All Innocent?


American Economic Review 2018, 108(11): 3232–3265

• November 3, 2015 – CMS proposed changes to the discharge planning conditions of participation

• Law allows 3 years for CMS to modify and adopt rules

• October 30, 2018 – CMS grants itself a one-year extension based on “exceptional circumstances.” Need coordination with Office of National Coordinator for Health Information Technology

• Proposal added formal discharge plan for all Obs, outpts with sedation, more choice, more patient involvement, more data sent on transfer, provide quality and resource use data on post-acute providers

• Final Rule by November 2, 2019 – start preparing now

• Is it time for the patient’s RN to do discharge planning on simple patients?

Discharge Planning in 2019


• California new law

• Jan 1 – Homeless patient discharge policy required

• Must help identify a sheltered destination, provide a meal, clothing, and transportation within 30 miles

• July 1 – must coordinate services with local agencies, keep a log of discharge destination for every homeless patient

• What happens on the coast eventually becomes national

• Look at your policies and procedures for homeless

Discharge Planning in 2019


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Medications that are not taken cannot treat the disease

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Have Your Doctors Done a Medication Debridement Today?

www.acpadvisors.org

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[email protected]

RonaldHirsch.com

Don’t trust the so-called experts; read the regulation yourself

regulation update 2019...this often occurs because it is difficult to determine pre-operatively...

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