Top at Risk Issues

1
Top at Risk Issues Charge Capture Audits AT
RISK Patient status DOCUMENTATION

• Finding your lost revenue and keeping it

2
Think Big.. Critical Access

• CAHs have similar services same as OPPS
  hospitals
• CAHs have different claim submission rules for
  outpt to inpt but documentation of billable
  services are the same.
• CAHs are paid differently than the OPPS hospital,
  but the rule for billable services are the same.
• EXCEPTION J codes/pharmacy are only required
  for LCD/NCD drugs G codes for OBS. CAHS are paid
  by billed charges/outpt.

3
Hot spots for audit- Payer and internal CHARGE
CAPTURE

• Does the order match the service that matches the
  billed item/UB- the 3 step! (charge/chart audit)
• Hot spots for audit
• Wastage SDV vs MDV SDV wastage must be
  documented to bill. No ability to bill wastage
  with MDV. JW modifier is not required /MAC
  specific.(CMS pub 100-04 Chpt 17, section 40)
  Nursing, pharmacy, RT, imaging, anesthesia hot!
• Original order changed after receipt.. Did
  referring physicians order change in the
  record? Protocol must be ordered pt specific
• (OB, LAB, Imaging, RT, pharmacy, others?

4
And then there was Charge Capture-- Identify the
Hot Spots- VALUE ADDED

• Lost Charges/Revenue
• Daily Charge Reconciliation
• Cost of Late Charges
• And easy chart/charge audit ideas to identify
  documentation challenges and charge alignment

5
Hot Spots for Lost Revenue

• Recovery house wide up to 4-6 hrs
• Nursing services in ancillary areas
• Drug Administration Observation
• OB HBC scheduled visits, delivery rates/levels,
  labor levels, unplanned
• Hospital based clinics EM visits
• Blood transfusion house wide
• Scheduled procedures done in the ER
• OR Implantables invoice reconciliation
• OR unscheduled, interrupted/7x modifer
• Ancillary reduced/52 modifier

6
Now begin the auditing process to determine what
might be broken

• Department Benchmark UB04 audits
• Compare 10 UB-04/billing documents against the
  itemized statement Outpt areas 1st (Obs, ER,
  Surgery, Hospital based clinics/IV therapy/Chemo)
• Look for potential lost charges (ER sutures but
  no procedure)
• Look for billing combinations that were missed
  250/pharmacy how was it given? IV Infusion,
  injection
• Look for non-billable items present Medicare
  outpt self administered medications/pt pays
  routine supplies
• Look for descriptions that wont pass the Mom
  test
• Look for charges that are not uniform across the
  facility

7
Brainstorm Lost Charges

• Not new revenue but lost revenue
• Question What services are we currently not
  billing for or costs that we are not covering?
• Brainstorm with department heads, compile a
  master list and start looking primarily
  outpatient but limited inpt.

8
Look for Charge Ownership

• Nursing is not good at charge capture..so
• Aggressively look for ways to move ownership with
  nursing still responsible for charting, not
  charging
• Lab Blood Transfusions/36430. Auto have Blood
  products/P 36430 bill together. (Safety net
  billing edit to reject any claims without both
  390 and 391 present.)
• Charge Capture Analyst identifies charges,
  completes charge ticket and logs all lost charges
  due to missing documentation. Nursings
  partnership is to ensure the start and stop times
  of each bag are present. CCA s partnership is
  charge capture. WORKS!

9
Create Daily Reconciliation Process

• Daily Dept-Specific Audits
• Compare scheduled/resulted/completed patients
  against charges generated. (2 day lag)
• Manual schedules or automated
• Registrations with no charges. Why?
• Ensure each patient activity is accounted for.

10
What Does a Lost Charge Look Like

• Focus on high stress/severity of illness areas
• Focus on labor intensive processes
• Ask all depts to look for potential lost revenue
• Code Blue how is nursing assuring charges made
  it to the bill? Drugs? Supplies? 92950/Cardiac
  Arrest? Procedures done?
• Sticky for supplies nursing has them on their
  clothing. Who do they belong to? How many go
  down on the sheets?
• Patient complaints once research, corrected
  claim but is research done to determine who the
  charge really does belong to?

11
Nursing Revenue Opportunities-but must be
documented too. Tough with EMR

• Drug adm nursing floating outside the care
  area. Who is completing the charge ticket?
• OB look at the aspects of outpt ER to OB
  scheduled visits post inpt discharge/lactation
  HBC visit, delivery rates
• Scheduled visits in the ER bill as a HBC visit
• Drop in pts for after care as an outpt bill as
  a HBC visit (suture removal, follow up care)
• All Drug Adm and Blood outpt housewide
• Physician orders, medically necessary services,
  EM leveling for all HBC visits, incident to the
  physician

12
The Cost of a Late Charge

• Rework to the individual dept, to PFS and the
  pt as they get corrected bills/EOBs
• Reprocessing the claim, lost productivity
• Lost Revenue with limited accountability

• Decreased patient satisfaction
• Track and trend repeat late activity, dept
  specific
• Do dept heads know what a late charge is?

13
ROUTINE VS NON-ROUTINE SUPPLIESHELP!
The Medicare Reimbursement Manual defines Routine
Services in 2202.6 on page 22-7 Inpatient
routine services in a hospital or skilled nursing
facility generally are those services included by
the provider in a daily service chargesometimes
referred to as the room and board charge.
Routine services are composed of two broad
components (1) general routine services, and (2)
special care units (SCUs), including coronary
care units (CCUs) and intensive care units
(ICUs). Included in routine services are the
regular room, dietary and nursing services, minor
medical and surgical supplies, medical social
services, psychiatric social services, and the
use of certain equipment and facilities for which
a separate charge is not customarily made.   In
recognition of the extraordinary care furnished
to intensive care, coronary care, and other
special care hospital inpatients, the costs of
routine services furnished in these units are
separately determined. If the unit does not meet
the definition of a special care unit (see
2202.7), then the cost of such service cannot be
included in a separate cost center, but must be
included in the general routine service cost
center. (See 2203.1 for further discussion of
routine services in an SNF.)
     
14
Telling a complete Pt story think OF IT as a
bookall payers are auditing

• Top At Risk Issues for Pt Status Audits

15
OPPS 2016 FINAL change to definition of an inpt
(Budget neutral?)

• Effective 10-1-15 changes in auditing short stay
  PE 0 and 1 MN stays
• QIO (level 2 appeal) review 10-25 charts denies
  or approves
• Calls hospital to set up review
• QIO tells MAC to recoup denied claim
• of denials determines referral to RAC (but not
  before 1-16 DOS)
• MAC sends overpayment letter with appeal rights.
• Then Appeal levels begin
• MAC/level 1 QIO/level 2 ALJ/level 3
• Preferred as some physician involvement at the
  QIO
• RACs are not involved until a referral occurs
  patterns of denials

• 2 MN rule is alive and well
• AND we are looking back to the future with an
  enhanced definition of rare and unusual.
• Still use the physicians documentation of why
  an inpt but if the provider cannot estimate 2 MN
  /Presumption then declare an inpt with rationale
  for severity of the condition/intensity of the
  care that will require in hospital care. HUGE
  AUDIT RISK!
• No change to SNF no Short stay DRG
• Effective 1-1-16/back to the future of rare and
  unusual documentation to support inpt without 2
  MN/presumption.

16
All Payers are auditing

• Each payer has their own set of criteria for
  coverage. (United, Blues, Part C Medicare,
  PEPPER/Traditional Medicare is targeting 1 day
  surgical, 2 day Surgical, same day medical, and
  same day surgery, etc.)
• Each payer has their own standards for appeals
• Each payer determines if the documentation
  supports the service that was billed.
• Documentation to tell a strong pt story but be
  aware of the enhanced payer battles..

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Key elements for Payers- as ordered by providers

• ALL PAYERS
• Admit to inpatient
• Diagnosis
• Reason for Admit/Plan for why an inpt (dx or
  multiple dx) need 2 MNs/Presumption or an
  additional MN/Benchmark to resolve the condition.
• (Hint Pre-created ques in the CPOE order set
  excellent)

• MEDICARE ONLY
• Clarify that the LOS is an estimated 2
  MN/Presumption
• Clarify that after the 1st outpt MN, a 2nd in
  hospital MN is required/Benchmark
• After 1-1-15, provider still outlines why the 2
  MN, what is the plan that will take 2 MN. No
  longer certify but still needs to clarify the
  order/signed prior to discharge and rationale for
  the 2 MN. (Do certify 20 day mark/outlier)
• Critical Access Hospital must still certify
  initial 96 hrs and again, at the 96 hr mark.

19
Hot Spots for Documentation audits inpt and obs

• Does the physician clearly state Why an inpt?
  What is the plan that will take 2 MN/Medicare?
  For non- Medicare why cant the pt be treated
  safely as an outpt. (Same issues as
  Medicare-just no 2 MN declaration)
• Medicare/only-If the pt needs a 2nd MN after 1 MN
  as an outpt what is occurring with the pts
  condition that will push the pt to stay a 2nd
  MN? Convert to inpt and include Why?
• Mgd Care Medicare/PartC/Medicare Advantage HIGH
  AT RISK. What criteria are they using? Get it in
  the contract! NOT SUBJECT TO TRADITIONAL
  Medicare rules
• Commercial Mgd Care or Commercial- who knows?
  Makes their own rules for disallowed charges.

20
And more updates- Part C

• Managed Medicare Plans/Part C HUGE
• They do not have to adapt Traditional coverage
  rules.
• Treat them like a Commercial Payers get
  pre-certs, determine if they are using 2 MN
  rule methodology and/or clinical guidelines.
• Update contracts to CLEARLY outline the tools
  used to determine what is an inpt.
• Always use Physician order with rationale for
  why? (Sound familiar??)
• Big increase in denials
• WHAT IS THE PAYERS DEFINITON OF AN INPT!

21
Huge Managed Care /Part C/Advantage Issues

• USA July 27th reported 2 huge potential
  purchases
• Anthem BX purchase of Cigna
• Aetna purchase of Humana
• Making United the last of the 3 powerhouse
  companies.
• WATCH Denial for the catch phrase not
  medically necessary! MEANS?
• Negotiating will be more difficult.
• Ensure there is arbitration in all contracts.
• Define an inpt-with no ability to do retro
  denials after discharge.
• Timelines to certify inpt status.

• Hot issues with denials or lack of inpt
  certifications
• Long LOS in obs with no rules for conversion to
  inpt
• Each payer gets to define their own coverage
  rules
• Following the 2 MN Medicare Traditional rule AND
  clinical guidelines. (EITHER Interqual or
  Milliman.)
• Levels of appeal clearly included clarify why
  not following the 5 levels within CMSs process.
  Timelines for each and who does what.
• Denials of coverage after discharge as the pt
  ended up getting better faster/not as sick as
  presented on 1st contact/ other
• HAVE AN ATTORNEY READY !!

22
Key elements of new Medicare inpt regulations 2
methods

• 2midnight presumption
• Under the 2 midnight presumption, inpt 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.
• Pg

• Benchmark of 2 midnights
• The new Medicare Inpt
• the decision to admit the beneficiary should be
  based on the cumulative time spent at the
  hospital beginning with the initial outpt
  service. In other words, if the physician makes
  the decision to admit after the pt arrived at the
  hospital and began receiving services, he or she
  should consider the time already spent receiving
  those services in estimating the pts total
  expected LOS.
• Pg 50956

• CLEARLY At the point of conversion WHY AN INPT
  for a 2nd MN? Then if d/c early what
  unexpected?

23
Understanding 2 MN benchmarkMM 8586 1-24-14

• EX) Pt is an outpt and is receiving observation
  services at 10pm on 12-1-13 and is still
  receiving obs services at 1 min past midnight on
  12-2-13 and continues as an outpt until
  admission. Pt is admitted as an inpt on 12-2-13
  at 3 am under the expectation the pt will require
  medically necessary hospital services for an
  additional midnight. Pt is discharged on 12-3 at
  8am. Total time in the hospital meets the 2 MN
  benchmark..regardless of Interqual or Milliman
  criteria.
• ER, Observation, outpt surgery all included in
  the 2 MN Benchmark.

• Ex) Pt is an outpt surgical encounter at 6 pm on
  12-21-13 is still in the outpt encounter at 1 min
  past midnight on 12-22-13 and continues as a
  outpt until admission. Pt is admitted as an inpt
  on 12-22 at 1am under the expectation that the pt
  will required medically necessary hospital
  services for an additional midnight. Pt is
  discharged on 12-23-13 at 8am. Total time in the
  hospital meets the 2 MN benchmark..regardless of
  Interqual or Milliman criteria.

24
Rare 2 MN Dont make it so hard

• NSETMI According to the 2 MN, the admission
  status is determined by the expectation of care
  crossing 2 MNs and the need to be in hospital.
  In our facility, if the pt comes in under the
  wire such that he can have the cath that same
  day, he will only cross one MN before discharge,
  therefore, is discharged (as an outpt.)
  However, if he comes in and crosses a MN before
  the cath (stabelizing), the cath is done the next
  day and the pt is discharged the following day
  (thus care crossing 2 MNs in hospital ) then
  the pt is an inpt.
• This is why I have taught the staff to pay close
  attention to when a pt started receiving medical
  care to determine if the NSTEMI should be placed
  as inpt or outpt obs.
• In our facility, therefore some NSTEMI are inpts
  (because the care crossed 2 MNs based upon their
  time of presentation) and some are observation
  (unplanned event needing beyond routine recovery
  /de) because they had their cath on the same
  day of presentation..did not cross 2 MN.
• RAC RELIEF Debbie Jones, MD 2-19-16

• RARE AND UNUSUAL I think the exception to the
  2 MN rule for rare and unusual circumstances is
  a land mine waiting for a hospital to step on.
  As I have pointed out before, how can a hospital
  make a case that inpt care is required based on
  clinical presentation when CMS/Medicare says inpt
  and outpt care is distinguished only by LOS? The
  only exception CMS has acknowledged so far is
  unplanned mechanical ventilation and they said
  its because these cases usually required more
  than 2 MNs.
• Complete this sentence without implying that
  theres a difference between inpt and outpt care
  This pt required inpt care regardless of the
  anticipated LOS because. I say it cant be
  done. That is why CMS wont give an example.
  There isnt one and they wont admit their
  mistake either.
• If the pt needs inpt care, its going to be a
  patient who needs more than 2 MNs. If less than
  2 MNs, why didnt you order obs?
• RAC RELIEF Dr Steven Myerson 2-20-16

25
2 MN with a plan and then an early discharge..

• 2 MN presumption ALWAYS ensure there is a
  clinical plan for why the pt needs 2 MN at the
  first point of contact. The plan is key!
• Ensure the ER provider and the Hospitalists or
  attending AGREE on the plan.. Handoffs need
  evaluated to ensure consistency. UR and PA
  involved.
• The care is then documented with nursing and
  the provider documenting the course of
  treatment/progression of care as it relates to
  the plan.
• SURPRISE Clearly document the patients
  unexpected recovery unexpected transfer out
  unexpected response to treatment. Then, a
  beautiful inpt.
• 2 MN benchmark ALWAYS ensure there is a
  clinical plan for why a 2nd MN was medically
  appropriate/in hospital care after an outpt 1st
  MN. The plan is the key !
• The hospitalists/attending and UR need to
  communicate closely as the 2nd MN approaches DO
  NOT WAIT UNTIL the am of the 3rd day.
• CAREFUL not to convert early on the 2nd day and
  then discharge same dayno 2nd MN. What was the
  plan? Was it met early?
• Note Order takes effect when written. EX) Day
  3 am, doctor converted to inpt. 10 mins later,
  discharged. How was the plan met in 10 mins?

26
STILL largest lost revenue 2 MN benchmark
converting after 1st MN

• After the 1st MN as an outpt anywhere or the
  first MN in another facility and transferred in
• The decision to admit becomes easier as the time
  approaches the 2nd MN, and the beneficaries in
  necessary hospitalization should NOT pass a 2nd
  MN prior to the admission order being written.
  (IPPS Final rule, pg 50946)
• Never, ever, ever, ever have a 2nd medically
  appropriate MN in outpt..convert, discharge or
  free

27
More on decision making-Inpt

• If the beneficiary has already passed the 1
  midnight as an outpt, the physician should
  consider the 2nd midnight benchmark met if he or
  she expects the beneficiary to require an
  additional midnight in the hospital. (MN must be
  documented and done)
• Note presumption 2 midnights AFTER obs. 1
  midnight after 1 midnight OBS at risk for inpt
  audit but still an inpt.
• Pg 50946

• ..the judgment of the physician and the
  physician s order for inpt admission should be
  based on the expectation of care surpassing the 2
  midnights with BOTH the expectation of time and
  the underlying need for medical care supported by
  complex medical factors such as history and
  comorbidities, the severity of signs and symptoms
  , current medical needs and the risk of an
  adverse event. Pg 50944

28
Meeting Criteria means?

• It never has and never will mean meeting
  clinical guidelines (Interqual or Milliman)
• It has always meant the physicians
  documentation to support inpt level of care in
  the admit order or admit note.
• SO if UR says Pt does not meet Criteria this
  means Doctor cannot certify/attest to a
  medically appropriate 2 midnight stay right?
• 11/1/2013  Section 3, E. Note It is not
  necessary for a beneficiary to meet an inpatient
  "level of care" by screening tool, in order for
  Part A payment to be appropriate
• Hint 1st test Can attest/certify estimated LOS
  of 2 midnights? THEN check clinical guidelines
  to help clarify any medical qualifiers but the
  physicians order with ROA trumps criteria.

29
And more update - Transfers

• Transfer update During MedLearn call (2-26-14)
  CMS updated receiving hospital CAN count time at
  a sending hospital toward their own 2 MN
  benchmark.
• Q2.2 How should providers calculate the
  2-midnight benchmark when the beneficiary has
  been transferred from another hospital?A2.2 The
  receiving hospital is allowed to take into
  account the pre-transfer time and care provided
  to the beneficiary at the initial hospital. That
  is, the start clock for transfers begins when the
  care begins in the initial hospital. Any
  excessive wait times or times spent in the
  hospital for non-medically necessary services
  shall be excluded from the physician's admission
  decision."

• Sending hospital if there is knowledge that the
  pt is being transferred/next day, the pt is obs
  as only 1 MN is appropriate in the sending
  hospital
• Use Occurrence Code Span 72/field to identify the
  date of the 1st MN/sending hospital.
• Place the date on the Inpt UB that may only have
  1 additional MN for the receiving hospital.
• 2 MN Benchmark is now present on the 1 MN UB from
  the receiving hospital.
• Reference SE1117revised MLNMatters
• Correct provider billing of admission date and
  statement covers period.

30
Denials by Type WPS1st and 2nd Round PE
5PC01 Documentation does not support services medically reasonable/necessary
5PC02 Insufficient documentation
5PC12 Order missing
5PC13 Order unsigned
5PC15 Certification not present
5PC17 No documentation of 2-midnight expectation
31
Top Reasons for Denial Second Round-
Novitas/2nd round of PE
Denial Reason Denials JH Denials JL
Documentation did not support two midnight expectation (did not support physician certification of inpatient order) 56 53
No Records Received 16 17
Documentation did not support unforeseen circumstances interrupting stay 4 3
No inpatient admission order 9 15
Admission order not validated/signed 11 11
Other 4 1
32
PE findings First Coast/MAC 244 hospitals
FL, PueRico, VirIsland

• 1st round
• 35 denial rate
• REASONS
• 55 failed to document need for 2 MN
• 45 failed admission order requirements
• 48 signed after discharge
• 39 order missing from the record
• 13 order not signed

• 2nd round
• 36 denial rate
• REASONS
• 40 failed to document need for 2 MN
• 60 failed admission order requirements
• 35 order missing from record
• 17 order not validated
• 8 order not signed (as of 2-11-15)
• MAC recommendationsProviders document their
  decision making process. Paint a clear, concise
  picture of the pt.

33
Tell a better, more complete patient story

• Begin with the 1st point of contact ER, direct
  or Surgery
• Why is the pt not safe to be discharged/ED?
• Why is the surgery an inpt if the CPT is not on
  the inpt only list? (Medicare only)
• What provider laid out a plan for why 2 MN for a
  direct admit to the floor? Did the hospitalist
  see the pt immediately? Did UR talk to the
  ordering provider?
• Who is validating status for transfers in? Who is
  asking both the sending and the receiving the 2
  MN question? Count 1st in sending.

34
THANKS A TON FOR Allowing ME TO JOIN YOU IN YOUR
CONTINUING COMMITMENT TO EXCELLENCE! Join us for
the 2016 Physician Advisor /UR Boot camp, July
22nd , San Antonio, Texas 

• Day Egusquiza, Pres
• Daylee1_at_mindspring.com
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35
  Routine Supplies always a challenge Medical
supplies are those items that, due to their
therapeutic or diagnostic characteristics, are
essential to the care ordered by the physician to
treat or diagnose the patients illness or
injury. These supply items fit into two
categories Routine (not separately billable)
supplies are customarily used during the usual
course of treatment, are included in the unit
supplies and are not designated for specific
patient. Non-routine (separately billable)
supplies are necessary to treat a specific
patients illness or injury based on a
physicians order and a documented plan of care.
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Conducting a Charge, Chart Audit

• At least quarterly, take a small sample and
  compare orders, against documentation of service,
  against actual billed service against the UB.
• Ensure they all match consider
• Protocol vulnerabilities
• LCD/NDC limitations
• Physician orders present
• Documentation to match the order
• Severity of illness /doctor w/intensity of
  services/nursing - inpt
• Evaluate the impacts of the hybrid medical record
• DEVELOP CORRECTIVE ACTION with compliance

37
Monitor the process

• For charge capture to work, each individual must
  understand their role in the process.
• Explore observing each area, 24 hr shift
• Develop charge capture internal manual
  addressing manual process, order entry, and
  other, more unique processes pods, HIM, etc.
• Develop feedback process for Dept-specific
  auditing

38
Finally, Create Tracking Systems

• Using the ongoing department-specific audits,
  create tracking systems/T-N-T
• Accuracy of claims
• Revenue identified
• Lost charges lost no more!
• New understanding of ownership
• Change of culture
• REPORT progress at Dept head meetings

39
Role of CDM/Revenue Integrity Team
Diagramming the process flow for updating,
changing, etc. the CDM-including assessment the
volume of items for activity level.   Reviews all
new or change items to the CDM with a focus on
standardizing like items, looking throughout the
organization for other areas providing similar
services and educating on same. (Focus on
Routine supplies)   Providing yearly department
head education on CDM issues.   Like-Item Pricing
audits as new items are added to specific
area.   FOCUS ON PATIENT FRIENDLY and
SIMPLIFY!