RSSAll Entries in the "Payment matters" Category

Q&A: Finding focus for CC/MCC reviews

haik

William Haik, MD, FCCP, CDIP

Editor’s note: William Haik, MD, FCCP, CDIP, director of DRG Review, Inc. answered the following questions in conjunction with his webinar, “FY 2017 ICD-10-CM CC/MCC List with Revisions: Clinical Indicators and Query Opportunities.” To purchase the on-demand version of the webinar, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Q: I’m having trouble with querying physicians for complication codes. Could you please provide guidance?

A: This is difficult. Unless there is an (coding) index directive, query the attending physician to determine if a condition occurring after surgery is due to, or caused by, the surgical procedure (such as atelectasis following surgery). From a medical perspective, the conditions which occur after surgery are not typically due to the surgery, but are due to other factors such as in atelectasis, operative pain, sedation, supine position, etc. Therefore, when I ask, it is when there is a high probability of being related to the surgical procedure (hematoma, excess hemorrhage which is addressed intraoperatively or immediately post-operatively). 

Q: Does systemic inflammatory response syndrome (SIRS) with pneumonia qualify for sepsis or should this be queried?

A: Unfortunately, in ICD-10-CM, there is no coding index entry for SIRS, and the previous index entry in ICD-9-CM for SIRS with infection no longer leads to sepsis. Therefore, the physician must be queried to clarify the documentation and assign an appropriate code.

Q: Should we query when the physicians use accelerated or malignant hypertension (HTN) in regards to hypertensive emergency/urgency?

A: Yes, as the former terms now are considered unspecified, a more specific condition should be sought.

Q: Would a physician query be necessary if the physician documentation indicates malnutrition (CC) and the dietician’s assessment documents mild to moderate malnutrition (CC)?

A: It is unnecessary to query a physician regarding the non-specific documentation of malnutrition. If the physician documents mild or moderate malnutrition, one would assign malnutrition, not otherwise specified, unless the physician specifies further.

Q: Do you have any suggestions for what CDI professionals should do if the physician documents a diagnosis but it is not supported by documentation in the chart or by clinical indicators?

A: I would ask the physician to review the record along with enclosed medical criteria regarding the condition in question. I have developed a handbook which provides evidence-based clinical indicators for common medical conditions. (For a copy, email Behaik@aol.com.)

Q: Should we query for electrolyte abnormalities on gastric bypass patients. We are told imbalances are normal due to diet restrictions.

A: Although electrolyte disturbances are common in gastric bypass patients, they are not normal and not integral to the procedure. The physician would typically would treated the patient if the levels were significantly clinically deranged. In this setting, I would query the attending physician to determine if the levels are merely lab abnormalities or if they should be clinically significant and reportable.

Q: When acute respiratory failure is reported in the postop period and is integral to the procedure (for example, the patient remains on mechanical ventilation for less than two days following post op), do we have to query to see if it is significant or should we code without a query?

A: From a clinical perspective, I assume major surgery (cardiopulmonary, esophageal, gastrointestinal resection surgery) often require prolonged ventilation. In minor surgeries, such as prostate biopsies, extremity surgeries, etc., if the patient is on mechanical ventilation longer than 24-hours and assuming the patient is awake, then I would tend to query regarding post-operative respiratory failure, particularly if there is a medical complication such as aspiration pneumonia, pulmonary edema, etc.

Q: What’s the difference between acute respiratory failure and acute pulmonary insufficiency? Would oxygen dependent Chronic Obstructive Pulmonary Disease (COPD) be insufficiency instead of failure?

A: Acute respiratory failure is a life-threatening condition which is typified by a pO2 of less than 60 on room air (in patients with previously normal lungs) in the clinical situation of a patient with rapid respirations and increased work of breathing in the acute setting. Acute pulmonary/respiratory insufficiency is a poorly defined term merely meaning non-life-threatening impairment of gas exchange. Therefore, it does not represent a pO2 of less than 60 (in patients with previously normal lungs), but not a completely normal pO2. Oxygen-dependent COPD is consistent with chronic respiratory failure as to obtain oxygen (via Medicare) one must have a pO2 of less than 60.

Q: Post-operative pulmonary insufficiency is an MCC, but post-operative respiratory insufficiency is neither a CC/MCC. Is there a way to differentiate these two diagnoses?

A: There is no medical differentiation between pulmonary and respiratory insufficiency. This is merely an idiosyncrasy of ICD-10-CM.

Q: According to resources, a lactate less than 1.0mmol/L, which is normal, is considered a sepsis indicator. Why is this an appropriate indicator if it is within normal limits rather than greater than 2 which is abnormal?

A: Despite the “normal” limits of lactate up to 2.2 in most hospitals, it has been determined, retroactively, a lactic acid level of greater than 1 is a finding seen in sepsis. It is not specific as there are other hypoperfusion states and/or chronic liver disease which may result in an elevated lactic acid level. Therefore, it must only be interpreted in the appropriate clinical circumstances.

Q: Is healthcare associated pneumonia (HCAP) synonymous with hospital acquired pneumonia?

A: They are similar, but not synonymous. HCAP includes nursing homes, long-term acute care facilities, chemotherapy, and dialysis centers. Hospital-acquired pneumonia requires a hospitalization of at least a three-day stay. The pathogenic organisms are similar as is the treatment.

Conference Conversations: Brant offers insight into recovery auditor programs

barbara brant

Barbara Brant, MPA, RN, CCDS, CDIP, CCS

Editor’s Note: Over the coming weeks leading up to the conference, we’ll take some time to introduce members to a few of this year’s speakers. The conference takes place May 9-12, at the MGM Grand in Las Vegas, Nevada. Today, we spoke with Barbara Brant, MPA, RN, CCDS, CDIP, CCS, a senior consultant with Cotiviti Health Care, presenting “CDI Specialists: Impact Potential in the Audit Process.” Since 2005, she has been involved in the development, implementation, and auditing of CDI programs. Brant has assisted health systems with ICD-10 Gap Analyses and created ICD-10-CM educational materials for specialty physician groups. Currently, she provides training and clinical support for DRG auditors. She lives in Camp Hill, Pennsylvania with her husband Marty.

 

Q: What do you think CDI specialists’ biggest misconceptions about the Recovery Auditor program are?

A: There are really three main misconceptions:

  1. Denials are determined without complete review of the documentation
  2. Recovery Auditor’s only look for “gotcha” errors
  3. CMS Recovery Audit programs are performed to only take back

Q: Recovery Auditors are not at the top of anyone’s best friend list in healthcare, but what important purpose do they serve?

A: The goal of any audit is to identify problematic issues. The purpose of CMS’ Recovery Auditors is to identify and prevent improper payments. Therefore, Recovery Auditors serve a purpose by encouraging healthcare providers to work for solutions to correct identified problems, stabilize provider revenue cycles, and ensure accurate payments for payers.

 

Q: What are three things attendees can expect from your session?

A: The three things that attendees can expect are

  1. To understand that Recovery Auditors perform very comprehensive reviews of all documentation provided.
  2. To obtain knowledge that the guidance for recommended reimbursement changes (higher or lower) is based on extensive peer-reviewed research of best-practices, clinical consensus data and Official Coding Guidelines.
  3. To use information from this session for improved denial data due to CDI performance improvements.

 

Q: In what ways does your session challenge CDI professionals to think outside the box?

A: To encourage use of retrospective audit data to concurrently improve problematic documentation

 

Q: What are you most looking forward to about this year’s conference?

A: Interaction with colleagues and to stay updated on CDI’s expanding roles within the revenue cycle

 

Q: Fun question: what’s your favorite movie?

A: A Christmas Story – a perfectly imperfect loving family!

 

Guest Post: The CDI buzz about CMI: What your facility metrics mean

What's your case-mix index?

What’s your case-mix index?

Jocelyn Murray

Jocelyn Murray

By Jocelyn E. Murray, RN, CCDS

There’s no question of the financial sustenance facility case mix index (CMI) provides. An elevated CMI level indicates an increased severity (or acuity weight) in surgical and life sustaining levels of medical care. Facility budgets are formed around the CMI, it is the acuity weight representing the average facility case and therefore reflects upon reimbursement. It makes perfect sense that this marker is a strong point of reference in the financial revenue department and a CFO focus. CMS.gov gives the following description of the CMI:  the average DRG weight relative weight calculated by summing the DRG weights for all Medicare discharges and dividing by the number of discharges.

We know our financial leaders focus on the CMI on an ongoing basis, but is it a true indicator of our CDI operational assessment and program productivity?

In my opinion, the CMI is a good tool to compare area hospital performance at a similar acuity level for medical and surgical care. We know a comparable facility with a much lower CMI can be a direct reflection on missed documentation and lower acuity weighted diagnostic codes. CDI intervention then consists of a provider education plan to improve documentation and capture the severity. Pre-billed audits ensure the acuity is also captured in final coding. Both are standard elements of the CDI process and program interventions.

It can also be a useful tool to help identify how outpatient CDI focus programs in the ED, short-stay surgery, and observation practice levels help ensure CMI accuracy. The DRG for a patient admission that does not meet medical necessity, indicates the patient’s care could have been provided on an outpatient basis. It could also have a critical impact on the CMI.

The lower weight CMI, as reflected by the DRG in this case, is tossed into the bucket as part of the calculated averaged acuity level for the site. One or two occurrences of low CMI weighted inpatient cases may not be a concern, but a handful of cases would certainly have a detrimental overall effect.

In my first years of CDI program implementation, the facility had a significant drop in the CMI over a couple of months during the summer. I dug into the metric further and discovered the top two acuity case surgeons in both neuro and orthopedic were away on vacation. A significant drop in surgeries occurred, and a small number of high-acuity procedure cases were performed and made available in the in that period’s calculation. Of course, the surgeon’s absence had nothing to do with our CDI program productivity efforts. And yet, the CMI drop was brought to my attention by the chief financial officer (CFO) who questioned the cause as CDI productivity. Together, we reviewed my identified findings and took the opportunity to bring forward critical information to the leadership team. The CMI changes had no reflection on the CDI program impact in the absence of surgical caseloads available during that time period.

CDI programs (CDI) are working at more advanced levels in 2017 and need to focus on understanding how their CMI metrics are effected and how the program responds. One key performance of the CDIP is identification of the root cause with any metric change.  Only then can you can establish a responsive goal and develop an individualized action plan for intervention.

In my case, a report identified the absence of two key surgeons and the effects of their absence on revenue for the facility. It was then up to the executive leadership and chief medical staff to strategize on how to prepare, plan, and focus actions for this type of revenue impact in the future.

Editor’s Note: Murray is a senior CDI consultant, HIM services, at ComforceHealth. Her subject matter expertise includes consultative CDI services, training and education, and implementation of new programs. She has expertise both in program assessment and enhancement to improve the quality, productivity, and effectiveness of CDI programs within an organization. The opinions expressed do not necessarily reflect those of ACDIS or its Advisory Board.  Contact her at jocelyn.murray@comforcehealth.com.

 

 

Guest Post: Protecting documentation from clinical validity denials

by Erica E. Remer, MD, FACEP, CCDS

Clinical validation denials (CVD) result from a review by a clinician, such as a registered nurse, contractor medical director, or therapist, who concludes, retrospectively, that a patient was not really afflicted by a condition documented in the medical record and coded by the coder.

If a coder assigns a code for a condition not really present, and removing that code assignment results in a lower-weighted DRG, then it is reasonable for a payer to expect the overpayment back.

However, if the condition was indeed present, medical personnel invested time, energy, supplies, and other resources, the hospital is entitled to reimbursement. Therefore, it is not appropriate to remove a diagnosis which was genuinely present. It is also unfair to remove legitimate diagnoses, because this results in the downgrade of severity of illness and complexity of management, and falsely deflates the quality measures assigned for that patient’s care.

Thorough documentation

It has never been reasonable or compliant for a coder to infer medical conditions from clinical indicators, and it is not reasonable to expect a coder to decide that a condition doesn’t exist if the provider documented it.

The ICD-10-CM Official Guidelines for Coding and Reporting for 2017 states:

The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient.

Although the provider’s statement may be sufficient to code a particular condition, it does not mean the condition indisputably exists.

The adage is, “if you didn’t document it, you didn’t do it.” But we all know that is not true. No physician documents every thought or action, and it would be absurd to expect them to do so. The dilemma arises when a physician documents a condition without giving adequate evidence as to what led him or her to make the diagnosis.

Concurrently, a documented diagnosis which is not really present could lead other healthcare providers down an erroneous path. Conversely, not providing clinical support for a valid diagnosis sets the stage for future denials.

The legal definition of the standard of care is managing a patient at the level at which the average, prudent, similarly qualified practitioner in a given geographic medical community, would be providing medical care under the same or similar circumstances. There are clinical guidelines and scores which may assist a clinician in making diagnoses, but prudent practitioners also bring their past experience, knowledge, and judgment into play.

Medicine is an art, not a science, and not every patient “reads the textbook.” Many patients’ lives have been saved by a clinician who followed his or her gut. Just because a patient doesn’t strictly meet clinical criteria, doesn’t preclude him or her from having the medical condition that an astute provider diagnosed.

Is there a standard of documentation similar to that legal definition of a standard of care? The purpose of patient record documentation is to foster quality and ensure continuity of care. It is clinical communication. The fallacy is that documentation needs to be expansive and long; it just needs to convey to the subsequent healthcare provider (as well as the coder, utilization/case manager, auditor, lawyer, etc.) what the provider was thinking and why.

What coders can do

Sensible, qualified, and experienced coders or CDI specialists may read documentation and have concerns that a diagnosis is not supported by the clinical indicators.

Do they just unfailingly code a documented condition because the Official Guidelines for Coding and Reporting say that the provider’s statement is sufficient, or do they query the physician? Which conditions are prone to this? What clinical indicators should they be considering? How does one broach this subject with the physician?

The ACDIS/AHIMA’s Guidelines for Achieving a Compliant Query Practice recommend generating a query when the health record documentation “provides a diagnosis without underlying clinical validation.” It notes that “the focus of external audits has expanded in recent years to include clinical validation review,” and instructs coders to follow CMS and Coding Clinic guidelines, and to “query the physician when clinical validation is required.”

The CMS Statement of Work for the Medicare Fee-For-Service Recovery Audit Program 2013 notes that “clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder.”

I concur that a certified coder who has identified a diagnosis which needs more clinical support does not have the ability to validate it, but has the skills to recognize the necessity for validation.

If your institution has CDI specialists, then you have someone with the appropriate credentials in place to generate a query. The physician is the one who performs the validation by responding to the query in the affirmative, and by providing their clinical evidence for the diagnosis in question.

Editor’s note: This article, written by Erica E. Remer, MD, FACEP, CCDS, founder and president of Erica Remer, MD, Inc., Consulting Services, first appeared in its entirety, in JustCoding. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Contact her at icd10md@outlook.com. For the second part of this article, return to the blog next week!

Guest Post: Physician practice CDI could start with help from medical assistants

Rose Dunn

Rose Dunn

by Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS

The coding function would not exist if there were no physician documentation from which to code. The challenge for coders is not so much that there is no physician documentation; it’s that the documentation they have does not provide them with what they need to assign an accurate and specific code.

The reason for this is that the physician is capturing the clinical nuggets he or she needs. “The physician mind is focused on the associated process of evaluating, treating, and managing the health conditions presented by each patient. The chart documentation provided by the physician is all framed in the language of diagnostic phrasing and language, and [that language] certainly is not about codes,” (Insights from the HCC, n.d.).

Many hospitals have implemented clinical documentation programs to coach physicians on the documentation elements required for the hospital to optimize its coding efforts. However, if physicians don’t feel they or their patients benefit from efforts to alter documentation practices, they quickly disengage. Physicians are accustomed to being paid by their evaluation and management level, not their diagnoses.

Thus, the lack of precision of documented conditions, such as pancreatitis without specifying whether acute, idiopathic, alcohol-induced, sclerotic, or not indicating length of laceration or use of anesthetic or even providing details without a diagnosis (e.g., glomerular filtration range provided to indicate stage of kidney disease) is not unexpected, according to Lucyk et. al. from the University of Calgary (Lucyk, Tang, & Quan, 2016). No, it’s not just a United States problem.

At the office

For the physician practice, the superbill, or encounter form, often contributes to incomplete, unspecified, and inaccurate coding. The superbill often lists the most common diagnoses seen in the practice.

Conditions treated may be forced into those listed on the form or not captured at all. If the physician documents the condition, it may be generic (e.g., asthma, without indication of whether it’s intermittent, persistent, mild, moderate, or severe). In preparation for ICD-10, many practices took the convenient route and selected the unspecified code for each of their most common diagnoses.  Therefore, the more specific ones are not on the form to be selected.

Even if the physician uses the electronic health record (EHR) for diagnosis selection, when a long list of choices appears for the condition, it is unlikely that the physician will take the 30–60 seconds to glance down the list to find the specific one; worse yet, the condition that previously had a code may no longer have one (e.g., accelerated hypertension). The physician may believe that for the current state, diagnoses may not be needed for reimbursement purposes, but that’s short term thinking.

Helping the physician help us

For the physician practice, if we desire details, we need to push some of the responsibility out to others in the practice. It should start at the front desk when the appointment is made and the health questionnaire is returned from the patient. That is when, at minimum, duration or date of onset can be obtained.

There’s value in using the medical assistant (MA) to help with securing some of the diagnosis details needed for ICD-10 and augmenting the physician’s efforts. MAs are typically members of the physician office team. If certified, these individuals have completed a structured education program with courses in anatomy, medical terminology, coding, and disease processes. Physicians can benefit from the talents of their MAs and possibly in areas other than ICD-10.

They are one of the first clinical team members to speak with the patient, often collecting the patient’s initial history information, capturing specimens for lab tests, and in some states placing, initiating an IV, and administering IV medications. Since organizations are struggling with capturing start and stop times for IV infusions, perhaps the MA may be another option for capturing start and stop times.

Given their understanding of medical terminology, and with an orientation to ICD-10 code requirements, MAs can quiz the patient and capture some of the details often overlooked by physicians. MAs can save physicians time, supplement the physician’s documentation, and help the physician select a more specific code.

If we look at the ICD-10 injury code elements, most of the elements can be captured in whole or in part by the MA in a short interview with the patient:

  • What was the injury? The MA can query the patient for this information and capture “upper/lower” and laterality, as well.
  • When did it happen? The MA can help the physician establish whether this is an initial encounter for active treatment, whether the patient is in the healing stage, or if the condition is sequela.
  • Where did it happen? Knowing the patient fell at home will not get us to the most specific code. We need to know where in the home, and sometimes even need to ask for the type of home.
  • What was the patient status and what was the patient doing when the injury happened? If the patient has been bitten by a cat, it may be attributed to a patient status of other, but if the person bitten by the cat was a vet tech when she was holding the cat for the vet to give it an injection, the status leads to an activity for income. Assigning the code for the activity of “holding a cat” would lead to the Y code for animal care.

This example shows us that with a little bit of prodding from the MA, we can get the additional information we need for a specified code. [more]

Guest Post (Part 3): Complying with definition changes

James S. Kennedy

James S. Kennedy

Note: This post is part three of four, excerpted from an article originally published in JustCoding. Read the first installment published on November 15. Click here to read the original.

by James S. Kennedy, MD, CCS, CDIP

For those who have been reading along with my columns regarding sepsis documentation and coding challenges, allow me to suggest the following strategies to assure a balance of compliance :

  • Standardize the definition and documentation of severe sepsis first. Recovery Auditors (RAs) will be looking for records with sepsis codes that do not have R65.20 or R65.21 as a secondary diagnosis as to deny these codes and DRGs. So CDI specialists should work with medical staff to establish standardized definitions; this could incorporate any or all of the following three criteria:
    1. Change in SOFA score of 2 or more, which means that a new PaO2 of <60 on room air, or a Glasgow Coma Scale of 13 could, by themselves, generate the two points needed to qualify for an acute organ dysfunction. The physician would have to document what the organ dysfunction is, which may not necessarily be an organ failure, given that ICD-10-CM uses the word “dysfunction” rather than “failure” in justifying R65.20, severe sepsis. I suggest this be part of a standardized emergency department assessment template or admission order involving an infection, which means we must reprogram our electronic health record (Epic, Cerner, Meditech, McKesson) to systematize their capture.
    2. A lactate level of 2 mEq/L or more due to an infection. If the coder requires an organ dysfunction to go with R65.20, the physician would have to document tissue hypoperfusion for which no ICD-10-CM code is in the index to diseases. I suggest coding I99.8, other disorder of circulatory system.
    3. Any of the criteria described in SEP-1 (which can include a lactate level of 4 mEq/L or more to define septic shock). Note that SEP-1 documentation or order templates must be reviewed in light of what is needed for ICD-10-CM, given that these are signed by a provider, they may be used for coding purposes.

No matter what criteria you use, be sure to coordinate it with your quality and CDI/coding staff so if a physician documents “severe sepsis” or “septic shock,” the SEP-1 algorithm can be implemented. Also, be sure that physicians explicitly link organ dysfunctions to sepsis or preferably use the word “severe sepsis” so R65.20 is not inadvertently missed by the coders. As mentioned above, coders and CDI specialists should work closely with quality to ascertain if any of these organ dysfunctions in the setting of sepsis represent severe sepsis prior to claim submission. Here are my suggestions as to how to handle the current situation:

  1. Develop a facility-wide definition for sepsis without organ dysfunction. As you see above, many physicians in the United States do not believe that organ dysfunction is required to diagnose a patient with sepsis. Given that RAs are likely to use Sepsis-3 as a foundation for denying claims, you must have the statements of your internal medicine, critical care, and other physician committees as to what the definition of sepsis is for clinical and coding purposes so that when it is documented by a provider, this statement can be used to disprove the RA’s denials. These will be handy if you are appealing beyond the first level.
  2. Remind the RA that the ICD-10-CM guidelines is part of HIPAA and that coding is based on provider documentation, not the RA’s interpretation. I’m sure that all of our contracts with private-payers state that we will comply with federal law, such as HIPAA. Given that the 2017 ICD-10-CM Official Guidelines state that we are to assign ICD-10-CM codes based on provider documentation and that Coding Clinic, First Quarter 2014, pp. 16-17, states that “the official guidelines are part of the HIPAA code set standards.” We don’t want RAs to violate HIPAA or our contracts with payers, do we? This may require that a hospital attorney or compliance officer weigh in, given that RAs have been known to deny codes based on provider documentation.
  3. Be on the lookout for Coding Clinic advice clarifying this issue.  Coding Clinic for ICD-10-CM/PCS addressed some aspects of this in its fall 2016 publications for the third and fourth quarter. In addition to this advice, you may wish to submit your own cases to Coding Clinic advisors to see how they comment.

Editor’s note: This post is an excerpt from an article originally published in JustCoding. Click here to read the full version.

Guest Post (Part 1): Documentation and coding challenges abound for sepsis-3

James S. Kennedy

James S. Kennedy

Note: This post is part one of four, excerpted from an article originally published in JustCoding. Click here to read the original. The comments and opinions represent those of Kennedy

by James S. Kennedy, MD, CCS, CDIP

There are a number of coding compliance challenges with sepsis-3 and with sepsis or severe sepsis in general. In this article, I’ll review my top four concerns.

First, sepsis-3 states that patients with an infection meeting the new sepsis criteria should be coded as R65.20, severe sepsis. This is impossible in the United States, given that ICD-10-CM code R65.20 can only be assigned if the physician documents “severe sepsis,” not sepsis alone, or if the physician documents that an acute organ dysfunction is associated with sepsis, though many coders fail to assign R65.20 when these links are made. Its apparent that the sepsis-3 authors are not familiar with Coding Clinic for ICD-10-CM/PCS, the Department of Justice, or our friendly neighborhood recovery auditors (RA).

Secondly, ICD-10-CM still has a multitude of codes for sepsis without organ dysfunction (e.g., A40-A41). The 2017 ICD-10-CM Official Guidelines for Coding and Reporting states that “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. It states:

The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.” (Emphasis added.)

Recent advice from Coding Clinic supports the concept that if an individual physician documents sepsis using his or her own criteria (that may differ from sepsis-3 or that of a RA), coders are obligated to code it. Therefore, if a physician documents sepsis, can we still defend the coding of an A40-A41 code if there is no documented organ dysfunction? I believe that the Guidelines and Coding Clinic say that we can, even if the RA doesn’t like it.

Thirdly, the ICD-10-CM table instructions for code R65.20, severe sepsis, tell us to use an “additional code to identify specific acute organ dysfunction.” If a physician documents severe sepsis based on the sepsis-3 criteria of a lactate over 2 milliequivalent per liter (mEq/L), or sepsis-3’s changes in the Glasgow Coma Scale, what is the organ dysfunction that should also be coded or queried for? Without an organ dysfunction documented and coded, a RA may claim that the severe sepsis code is invalid.

Finally, in my own personal review of the CMS 2015 MedPAR, approximately 45-55% of MS-DRGs 871 or 872 (septicemia or severe sepsis) do not have a code for severe sepsis, yet a number of patients have acute organ dysfunctions present on admission which I believe should have been linked to the patient’s sepsis to render the severe sepsis code.

RAs look at sepsis DRGs without R65.20, severe sepsis, or R65.21, septic shock, as opportunities to take money away from facilities who coded sepsis (e.g., A40-A41) as present on admission and sequenced it as a principal diagnosis without an additional R65.20 or R65.21 code. To take these records out of the RA data mining pool, CDI professionals must make every effort to query providers if the clinically valid indicators of organ dysfunction due to sepsis are present but the record does not have the documentation interpreting these indicators as to report R65.20 and R65.21 and their associated organ dysfunctions. This effort, however, must be coordinated with the SEP-1 or quality manager, given that any coding of R65.20 or R65.21 subjects the record to the SEP-1.

Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. The comments and opinions represent those of Kennedy and not necessarily ACDIS or its Advisory Board and advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions.Contact him at 615-479-7021 or at jkennedy@cdimd.com.

Guest Post: New Law Puts Providers on NOTICE

Debbie Mackaman

Debbie Mackaman

by Debbie Mackaman, RHIA, CPCO, CCDS, regulatory specialist for HCPro

While many providers are still digesting the IPPS Final Rule, muddling through how the OPPS Proposed Rule might impact their bottom line, and kicking rocks because the 2-midnight rule was not chucked, President Obama signed a bill into law on August 6, 2015—and it’s one providers should note. Unanimously approved by both the House and Senate earlier this year, the Notice of Observation Treatment and Implication for Care Eligibility Act, otherwise called the NOTICE Act, will not take effect until August 2016, but will certainly add one more layer to the administrative burden associated with outpatient observation services when it does.

Public Law 114-42 will amend the Social Security Act and require a hospital or critical access hospital (CAH) to provide the beneficiary with a written notice when they receive outpatient observation services for more than 24 hours. The notice must be provided within 36 hours of the start of observation, which would coincide with the order for such service, or prior to discharge or transfer, whichever occurs first after the initial 24 hours has been reached.

Hospitals and CAHs currently provide many “notices” to the patient, including a financial consent, consent to treatment (procedure, anesthesia, blood transfusion, etc.), release of information, Important Message from Medicare (IM), Detailed Notice of Discharge (DND), Advance Beneficiary Notice (ABN), and the Hospital Issued Notice of Noncoverage (HINN)—just to name a few. The regulation clarifies that this notice will not be in “hit and run” form, as it requires hospital staff to provide an oral explanation of the implications of remaining in outpatient status.

As hospitals begin to draft the notice and develop a process for issuing it, they should also consider who will be responsible to eloquently explain the situation to the patient. Key elements of the notice must include a written and oral explanation stating:

  1. The patient is an outpatient and not an inpatient of the hospital and the reasons why;
  2. The implications of remaining in outpatient status, primarily the related financial issues including deductible, coinsurance, and items or services not covered by Medicare, such as self-administered drugs; and,
  3. All time spent as an outpatient, including observation services provided on the inpatient floor, will not count towards the 3-day acute care qualifying stay required for coverage of a subsequent skilled nursing facility (SNF) stay, if appropriate.

The notice must be written in easy-to-understand language and available in “appropriate languages.” This requirement is not further specified in the law, although the IM, DND and ABN notices can only be provided in English or Spanish versions, so more clarification will be needed. At this point in time, it is unclear if CMS will provide standardized language similar to that used to inform the beneficiary and the provider about the financial liability protections under the Fee-for-Service (FFS) Medicare and, in certain cases, the Medicare Advantage (MA) Programs.

The notice must also be signed by the patient or the person acting on behalf of the patient and the hospital staff member who presented the notice. If the patient or his or her authorized representative refuses to sign the notice acknowledging their outpatient status, the hospital must indicate on the refusal on the form and include the name, title, and signature of the staff member issuing the notice, as well as the date and time of the refusal. This procedure is similar to recommendations CMS has provided when a patient refuses to sign an ABN. However, refusing to sign the new notice does not release the beneficiary from any financial obligation.

As hospitals incorporate the new regulation into their current processes, they should also be acutely aware of the 2-midnight benchmark and the implications of keeping patients in outpatient status receiving observation services for more than 24 hours. CMS has stated that they do not expect a Medicare patient receiving medically necessary hospital care to pass a second midnight without an order for inpatient care. Providing the new notice to the patient should not only serve to inform them of their potential financial liability as an outpatient but also to put the hospital and the attending physician on notice regarding the correct application of the 2-midnight rule.

Editor’s Note: This article originally published in HCPro’s Medicare Insider eNewsletter.

What is All This Fuss about Quality?

Reach out to your physician advisors, case managers, chief medical officers, vice president of medical affairs, president of the medical staff, and any other supportive individuals in your facility.

The typical P4P program provides a bonus to health care providers if they meet or exceed agreed-upon quality or performance measures.

By Karen Newhouser, RN, BSN, CCDS, CCS, CCM

Quality. If we had a dollar every time that word is used, we would be wealthy. But money isn’t everything. Just consider the evolution of the CDI profession.

True, the CDI profession was built on a financial platform – it’s how CDI programs got in the door in the early years. Now, the focus in healthcare is quality. Quality is the common theme in many healthcare initiatives. It may seem that quality just surfaced, but it has been on the scene for decades.

Pay-for-performance (P4P) is the umbrella from which all modern-day quality indicators stem since its emergence in the early 2000s—after deficiencies in quality were highlighted on two major reports by the Institute of Medicine, To Err is Human: Building a Safer Health System, in November, 1999, and Crossing the Quality ChasmA New Health System for the 21st Century, in March, 2001. These reports recommended a sweeping redesign of the health care system to improve quality of care.

In this context, P4P emerged as a way for payers to focus on quality, with the expectation that doing so will also reduce costs. The typical P4P program provides a bonus to health care providers if they meet or exceed agreed-upon quality or performance measures. P4P programs can also impose financial penalties on providers that fail to achieve specified goals or cost savings.

P4P programs can be broken down into both private sector and public sector initiatives. The largest and longest running (2001) is the California’s program. Within the public sector, CMS established a Value-Based Purchasing (VBP) program to provide incentives for physicians and providers to improve the quality and efficiency of care. Most of these programs focused on quality with little, if any, cost consideration.

P4P evolved and grew and the Affordable Care Act further encouraged improvements in quality of care while addressing the subject of cost. Due to CMS’ continuous updates in its IPPS proposed and final rules, a few of the P4P programs worth paying attention to include:

  • Hospital Value Based Purchasing Program
  • Hospital Readmission Reduction Program
  • Hospital Acquired Condition (HAC) Reduction Program

As with most quality measures, establishing present on admission (POA) status is crucial. If one looks at POA with a widely general view, if the patient did not come into the hospital with a particular condition, then they acquired it in the hospital. One element to remember is that POA is not limited to a “Y” (Yes) or “N” (No) determination; a provider may also state that he or she is unsure/unable to determine/doesn’t know if the diagnosis was POA. This POA indicator of “W” is considered to be equivalent to an indicator of “Y” and will exempt the condition from being identified as a HAC.

Similarly, a fourth indicator of “U,” or the documentation is insufficient to determine if the condition was present at the time of inpatient admission, is equivalent to an indicator of “N” in a POA determination where a HAC is identified. It is important to note the words “documentation is insufficient…” in the above indicator explanation. These words should be an indication that a query is warranted in an attempt to obtain sufficient documentation to make a POA determination.

The most important point to understand about these initiatives is that they are risk-adjusted. Reporting agencies have their own risk-adjusted methodologies and most are proprietary; it is not necessary to know the methodology. What is relevant is these methodologies use factors such as chronic and co-morbid conditions to determine the degree of risk. The greater the number of, and/or the more significant, the chronic and co-morbid conditions, the higher the risk.

We all realize that the patient entering the hospital today is much sicker than the patient entering the hospital 20 years ago. That is the role of the CDI specialist—to ensure that the record identifies an appropriate principal diagnosis and reflects all significant reportable secondary conditions to match the care delivered and resources consumed.

We are charged with carrying forward the story of the patients’ encounter. We are, in essence, the editors of a non-fiction story. As we move towards a personal health record in our mobile age, it is imperative that we advocate for the patient and appeal for a complete, accurate account of their health status.

Yes, this is the fuss about quality. Our patients are depending on us. We won’t let them down.

And while it isn’t all about money, I would be remiss in not recognizing the role that money plays in all of the above; however, I leave you with this thought…

Quality doesn’t follow money; money follows quality.

Editor’s note: Newhouser is the director of CDI education for MedPartners CDI in Tampa, Florida, and the 2015 winner of the CDI Professional of the Year award. Contact her at KarenMPU@medpartnershim.com. This article originally appeared in the CDI Horizons newsletter.

 

News: Study reveals overspending on U.S. billing and insurance paperwork

CMS says new date for ICD-10-CM/PCS implementation set for 2015.

Billing paperwork costs billions

Healthcare organizations spent approximately $471 billion on paperwork related to billing and insurance in 2012, with 80% of that potentially wasted, according to the study “Billing and insurance-related administrative costs in United States’ health care: synthesis of micro-costing evidence,” published in BMC Health Services Research.

Using a standard definition of “billing and insurance-related costs” (BIR), researchers found that physician practices spent approximately $70 billion, hospitals spent roughly $74 billion, and other institutions (e.g., nursing homes, home health care agencies, prescription drug, and medical supply companies) spent approximately $94 billion. Private insurers spent approximately $198 billion on BIR compared to $35 billion spent by government-sponsored health insurance programs.

Adopting a simplified, single-payer insurance system similar to Medicare could save the U.S. approximately $375 billion annually or more than $1 trillion in three years.

Editor’s Note: This article originally published in the HIM-HIPAA Insider.