Increasing Federal Regulations Impact on Care or Documentation of Care Emily A' Boohaker, MD Decembe

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Increasing Federal RegulationsImpact on
CareorDocumentation of Care?Emily A.
Boohaker, MDDecember 9, 2008
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Objectives

• Review recent Medicare regulations
• Medicare Severity DRG (MS-DRG)
• Present on Admission (POA)
• Hospital Acquired Conditions (HACs)
• Recovery Audit Contractors (RACs)
• Medicare Administrative Contractors (MACs)
• Describe the impact on hospital reimbursement and
  hospital/physician profiling
• Illustrate the role of compliant documentation

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Disclaimer

• CLINICAL PERSPECTIVE
• Not a Coder
• Not a Financial Guru
• What works at UAB may not work at other
  institutions
• Clinical Documentation Specialists
• Query Process

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MAC
HAC
RAC
DOCUMENTATION
MSDRG
POA
ACCURATE
CONSISTENT
TIMELY
SPECIFIC
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Momentum for Changes

• Institute of Medicine Report
• Healthcare errors
• Medicare Prescription Drug, Improvement and
  Modernization Act of 2003
• Reducing costs/improving pt care
• Deficit Reduction Act of 2005
• Hospital Acquired Conditions
• Value Based Purchasing
• Active purchaser of higher value healthcare
  services

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Diagnostic Related GroupsDRGs

• Groupings of diagnoses similar clinically and in
  resource utilization
• DRG assigned a Relative Weight (RW)
• Hospital Reimbursement
• Severity of Illness (SOI)
• Resource Utilization

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The Blended Rate

• Rate for reimbursement for individual hospitals
  based on
• Region of country
• Teaching vs non-teaching (phasing out)
• Proportion of uncompensated care
• Bed size
• Medicare Blended Rate
• Ranges from 3,000 to 10,000
• UAB blended rate 6887

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Medicare Hospital Reimbursement Made Simple

• Physician documents all relevant diagnoses and
  procedures
• Coder selects appropriate DRG
• UTI DRG 690
• DRG defines RW
• DRG 690 has RW .7581
• RW drives reimbursement
• RW x blended rate Payment
• .7581 x 6887 5221

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Medicare-Severity DRGs(MS-DRGs)
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Final CMS Rule 2008

• Based on CMS updated analysis of a severity DRG
  system from the mid-1990s, CMS adopted MS-DRGs
• Better recognize severity of illness
• Better demonstrate ability to explain differences
  in patient cost
• CC Co-morbid condition or complication
• MCC Major co-morbid condition or complication
• Often treat but do not document diagnoses

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Medicare-Severity DRGs (DRG Example Table)
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Medicare-Severity DRGs MCC and CC
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From the Federal Register

• We highly encourage physicians and hospitals
  to work together to use the most specific codes
  that describe their patients conditions. Such an
  effort will not only result in more accurate
  payment by Medicare but will provide better
  information on the incidence of this disease in
  the Medicare patient population.

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From the Federal Register

• We do not believe there is anything
  inappropriate, unethical or otherwise wrong with
  hospitals taking full advantage of coding
  opportunities to maximize Medicare payment that
  is supported by documentation in the medical
  record. We encourage hospitals to engage in
  complete and accurate coding.

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Example 1

• 68 yo with h/o DM, COPD presents with altered
  mental status. Family states over the past
  several days he has become more sleepy and is
  having chills.
• PE Ill appearing, diaphoretic. T 102, BP
  127/80, HR 102, RR 24, tachycardic,
  supra-pubic tenderness
• Labs WBC 13k, 90 segs, CBS 200, UA positive

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Example 1(continued)

• Admitting Diagnoses
• UTI
• Urosepsis
• Altered Mental Status
• Diabetes Mellitus
• Hospital Course
• IV antibiotics started
• Urine Culture E. Coli Blood cultures negative
• Mental status returned to baseline
• Discharged home after 5 days

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Example 1(continued)

• What is the principal diagnosis warranting this
  admission?
• Is there another diagnosis that more accurately
  describes the severity of illness and the
  additional resources used to manage this patient?
  
• Sepsis from a urinary source

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Sepsis

• SIRS 2 or more of the following
• T gt 100.4 or lt 96.8
• HR gt 90
• RR gt 20 or PaCO2 lt 32
• WBC gt 12k or lt 4k or gt 10 bands
• Sepsis SIRS due to suspected or confirmed
  infection (do not need positive blood cultures)
• Severe sepsis Sepsis associated with organ
  dysfunction, hypoperfusion or hypotension
• Septic shock Sepsis induced hypotension
  despite adequate fluid resuscitation along with
  presence of perfusion abnormalities
• American Journal of Medicine (2007) 120, 1012-1022

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MS-DRGs Example 1
RW Payment LOS
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Example 2

• 30 yo s/p renal transplant, h/o leukopenia with
  disseminated Zoster, presents with fever and sore
  on tongue.
• PE No acute distress, T 100.8, BP 135/82, HR
  120, tongue with pustular lesion
• Labs WBC 1, Hct 41, BUN/Cr 28/2.7
  (baseline 10/1.2), CXR neg, culture neg

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Example 2(continued)

• Admitting Diagnoses
• Neutropenic fever
• Renal insufficiency
• Hospital Course
• Treated with acyclovir
• Aggressive IVFs
• Frequent monitoring of renal function
• Creatinine returned to baseline
• Discharged home after 6 days

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Example 2(continued)

• Is there a more accurate diagnosis to better
  describe what is going on with his renal
  function?
• Acute Renal Failure

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MS-DRGs Example 2
RW Payment LOS
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Severity Matters

• Public reporting of mortality/morbidity
• Contract negotiations for the organization
• Ex treating UTIs when truly septic
• Pay for performance for physicians

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Present on Admission(POA)
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POA Indicators

• Initiated in January 08 for Medicare and October
  08 for BCBS
• Identify potentially preventable
  hospital-acquired conditions vs conditions
  already present on admission
• All diagnosis codes must have an indicator

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General POA Reporting Requirements

• Indicator is required for all claims involving
  Medicare and BCBS inpatient admissions to general
  acute care hospitals
• Defined as present at the time the order for
  inpatient admission occurs
• Includes conditions that develop during an
  outpatient encounter in
• Emergency department
• Observation
• Outpatient Surgery
• Issues related to inconsistent, missing,
  conflicting, or unclear documentation must be
  resolved by the provider

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CMS POA Indicator Reporting Options and
Definitions
CODES REASON FOR CODE

• Y
• N
• U
• W
• 1

• Diagnosis was present at time of inpatient
  admission
• Diagnosis was not present at time of inpatient
  admission
• Documentation insufficient to determine if
  condition was present
• Clinically undetermined by provider
• Unreported/not used. Exempt from POA reporting

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POA Example

• 78 yo with CHF presents from Spain Rehab with
  acute dyspnea/hypoxemia.
• MET activated
• Afebrile, BP 90/50, RR 20, HR 70
• O2 sat 80
• Using accessory muscles, chest crackles, lower
  extremity edema

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POAExample (continued)

• Admitting Diagnoses
• CHF
• PTE
• HAP
• On day 3 attending documents hypoxemic
  respiratory failure
• Coder after discharge assigns respiratory failure
  with an N indicator

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POA Example (continued)

• Was respiratory failure present on admission?
• YES clarify as late entry in chart

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Hospital-Acquired Conditions(HACs)
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HACs Scope of the Problem

• IOM Report
• To Err Is Human Building a Safer Health System
• HACs are leading cause of MM in US
• 98,000 Americans die annually due to medical
  errors
• National costs of these errors estimated at
  17-29 billion
• CDC Report
• Estimated that HACs add nearly 5 billion to US
  health care costs annually
• IOM To Err is Human Building a Safer Health
  System, November 1999 (http//www. iom.edu)
• Centers for Disease Control and Prevention Press
  Release, March 2000 (http//www.cdc.gov)

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HACs

• Section 5001(c) of the DRA required the Secretary
  to identify those conditions that
• Are high cost or high volume or both,
• Result in the assignment of a case to a DRG that
  has a higher payment when present as a secondary
  diagnosis,
• Could reasonably have been prevented through the
  application of evidence-based guidelines

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HACs

• Conditions not payable after 10/01/08
• Air embolism
• Blood incompatibility
• Object left in during surgery
• Catheter-associated UTIs
• Vascular catheter-associated infections
• Pressure ulcers (stage 3 and 4)
• Mediastinitis after CABG
• Hospital-acquired injuries fractures,
  dislocations, burns, crushing or intracranial
  injuries

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Additional HACs

• Surgical site infections following certain
  elective procedures including certain orthopedic
  surgeries, and bariatric surgery for obesity
• Certain manifestations of poor blood glucose
  control
• DVT or PE following total knee and hip
  replacement procedures

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BCBS HACs

• Conditions not payable after 01/01/09
• All Medicare HACs PLUS
• 11 more from the National Quality Forum
• Surgical events
• Product or device events
• Care Management events
• Environmental events

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Documentation of HACs

• HACs that are usually well documented
• Blood incompatibility
• Air embolism
• Object left in during surgery
• Mediastinitis after CABG
• Hospital-acquired injuries
• DVTs or PEs after certain orthopedic surgeries

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Documentation of HACs

• HACs that may require additional documentation by
  provider
• Catheter-associated urinary tract infections
• Vascular catheter-associated infections
• Pressure ulcers (site and stage)
• Surgical site infections after gastric bypass

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Medicare HAC Payment

• If this is the only complication or co-morbid
  condition driving the MS-DRG to a higher level
• For compliant coding must include the condition
  on the bill
• Medicare will reimburse at the lower MS-DRG
• If this is not the only complication or co-morbid
  condition driving the MS-DRG to a higher level
• For compliant coding must include the condition
  on the bill
• Medicare will reimburse at the higher MS-DRG

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HAC Example 1
Patient presents with an MI. Foley catheter
inserted on admission. Patient later develops a
UTI.

• MS-DRG 281 Acute MI, discharged alive with a CC
  only CC is UTI
• RW 1.2213 (8411)
• Query for catheter-related UTI
• Lose CC
• RW 0.8696 (5989)

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HAC Example 2

• 83 yo transferred from OSH for LLE
  ulcer/cellulitis, CHF, DVT, etc
• After 5 days pt acutely decompensates/febrile/sob
• Possible HAP, cellulitis, possible sepsis from
  line infection-will change
• Cath tip showed 40 CFU Candida parapsilosis
• Blood cultures negative
• Did this pt have a hospital acquired vascular
  cath associated infection?

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HAC Example 2

• Attending queried
• Late entry in to chart patient had negative
  blood cultures from that day, so he did not meet
  the CDC definition of line associated bacteremia
  or fungemia.

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BCBS HAC Payment

• How do you get paid if the condition is HAC?
• For compliant coding must include the condition
  on the bill
• Was it preventable?

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Recovery Audit Contractors(RACs)
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RAC Background

• Medicare Modernization Act of 2003
• CMS to use RACs to identify and recoup over and
  under payments
• Tax Relief and Health Care Act of 2006
• RAC Program permanent
• Expansion to all 50 states no later than 2010

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Overpayments Collected by Provider Type
in millions
Source Self-reported by the Claim RACS
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Overpayments Collected by Error Type
in millions
Source Self-reported by the Claim RACS
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Claim Review Process

• Automated Reviews
• Look for low hanging fruit
• Use data mining techniques
• Mainly outpatient hospital claims
• Multiple units billed
• Missing modifiers that would impact payments
• Payment for discontinued HCPCS/CPT codes

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Claim Review Process

• Medical Record Audits
• Hospitals have 45 days to comply
• Missing records automatic denials
• Request 100 records/45 days for UAB
• RAC has 60 days to review chart and issue either
  a denial or an all clear letter to the provider
• Providers must follow Medicare appeal rules to
  dispute a RAC adjustment

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Issues Identified

• Information on claim did not match the medical
  record
• Excisional debridement
• Respiratory failure
• Claims with single secondary diagnosis designated
  as a complication or co-morbidity
• Discharge status/transfers claim indicates
  discharge to home or other facility but medical
  record indicates beneficiary was discharged to
  another hospital or home with home care

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Issues Identified

• Medical necessity
• Inpatient rehab
• Short stay admissions, including chest pain, back
  pain, congestive heart failure, and
  gastroenteritis
• Admission for scheduled elective procedures
• Wrong number of units billed
• Neulasta
• Speech therapy
• Transfusions

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Medical Necessity(according to Medicare)

• CMS determines whether the item or service is
  reasonable and necessary for the diagnosis or
  treatment of illness or injury or to improve the
  functioning of a malformed body member.
• Two questions
• Is the therapy/treatment/device/procedure
• Is the setting in which it is deployed
• NECESSARY AND APPROPRIATE FOR THE PATIENT IN
  QUESTION?

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Medicare Administrative Contractors(MACs)
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MACs

• Required by section 911 of the Medicare
  Prescription Drug, Improvement and Modernization
  Act of 2003 (MMA of 2003)
• CMS is replacing its current claims payment
  contractors - fiscal intermediaries and carriers
  - with new contract entities called Medicare
  Administrative Contractors (MACs)
• For the first time, MACs will enable the
  government to match, link and compare both Part A
  and Part B claims submitted for a specific
  episode of care.

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MACs

• Improved Beneficiary Services
• Claims processed by one contractor
• Integrated approach to medical coverage
• Single point of contact
• Improved Provider Services
• Single interface for Parts A/B
• More accurate claims payments
• Greater consistency in payment decisions

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Conclusions

• The word game is here to stay
• Engage each other in the game
• Documentation must reflect excellent care