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UnitedHealth Group, Inc. vs. the United States of America: The case for CDI

Brian-Murphy

ACDIS Director Brian Murphy

Part 4 (click here to view part 1, click here to view part 2, and click here to view part 3)

By Brian D. Murphy

In Part 1 of this series I introduced the developing story of UnitedHealth Group, Inc. vs. the United States of America. In Part 2, I detailed the facts of the case. Part 3 looked at the regulations and commentary regarding claims submission to Medicare Advantage and the ramifications for CDI. Part 4, discusses recent developments of the case.

Since I wrote my initial three parts of the developing case of UnitedHealth Group, Inc. vs. the United States of America there has been a huge development on the legal front. Round 1 of the case of UnitedHealth Group, Inc. vs. the Unites States of America is over, and the decisive winner (at least in the matter of one complaint filed by the DOJ) is United. [more]

Note from the ACDIS Editor: CDI Journal focuses on reimbursement concerns

LA-new headshot

ACDIS Editor Linnea Archibald

By Linnea Archibald

Though any CDI specialist will tell you this profession isn’t about money, a facility’s reimbursement can certainly be affected by CDI professionals’ work. Because of this undeniable fact, we’ve dedicated the November/December edition of the CDI Journal to the multi-faceted world of reimbursement.

Within the newest edition’s pages, you’ll find valuable information covering reimbursement topics such as using PEPPER data for denial defense and tracking CMI metrics. You’ll also get a glimpse into the non-reimbursement fueled world of PPS-exempt cancer centers. [more]

Guest post: Time to learn about HCCs

James S. Kennedy, MD, CCS, CDIP

James S. Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Now that you’ve finally mastered coding compliance with DRGs and quality measures, now it is time to learn the new risk-adjustment method, Hierarchical Condition Categories (HCC).

HCCs are to physicians what DRGs are to hospitals and, as such, are subject to government and Recovery Auditor scrutiny. In fact, a whistleblower accused United Healthcare of “upcoding” ICD-10-CM diagnosis codes affecting HCC-derived risk-adjustment factor scores, mentioning that CMS overpaid insurers by $14.1 billion in 2013 alone, according to an article in the New York Times in May. [more]

Guest Post: Using coding, CDI to transform hospitals’ revenue integrity, part 1

Want to write for ACDIS? Send us your ideas!

Want to write for ACDIS? Send us your ideas!

by Amber Sterling, RN, BSN, CCDS, and Jana Armstrong, RHIA, CPC

Most healthcare systems already have a proven process in place to monitor revenue integrity and ensure correct reimbursement. More than 60% of hospital executives believe revenue integrity is essential to their organization’s financial stability and sustainability, according to a survey by Craneware, Inc.

But does revenue integrity extend beyond charge masters and billing? Kalispell Regional Medical Center (KRMC), one of the “100 Great Community Hospital” according to Becker’s Hospital review, says yes.

For KRMC, revenue integrity focuses on three operational pillars: clinical coding, CDI, and physician education. At KRMC and many other health systems, revenue integrity is a three-legged stool: [more]

UnitedHealth Group, Inc. versus the United States of America: The case for CDI

Brian-Murphy

ACDIS Director Brian Murphy

By Brian Murphy

The work of a CDI professional can at times seem isolating and unimportant. Does it matter if a query gets answered? When we educate physicians and tell them what they document matters, are they listening?

Then a case comes along and demonstrates not just that the CDI profession does matter—but that it matters a lot.

That point was driven home to me while reading a May 16, 2017 court document, United States of America ex rel. Benjamin Poehling v. UnitedHealth Group, Inc., in which the Department of Justice (DOJ), alleges that UnitedHealth artificially increased Medicare Advantage (MA) reimbursement/Hierarchical Condition Category assignment by mining for non-supported diagnoses that were not documented/reported by the physician or through chart documentation.

The case is a qui tam—a lawsuit brought forward by a private individual. The plaintiff is Benjamin Poehling, the former Director of Finance for UnitedHealthcare Medicare & Retirement (and its predecessor Ovations), which was the group at United that managed its MA plans and its Medicare Part D prescription drug programs.

The lawsuit seeks to recover more than $1 billion under the False Claims Act. The total damages sought are unspecified but it’s a large case with a lot at stake.

This case has received quite a bit of coverage, too, from big newspapers like the New York Times and popular healthcare websites like Beckers Hospital Review and HealthLeaders Media.

There is a lot more to this case than this 103-page court document, though. In addition to Poehling’s case (filed in February 2017), another whistleblower, James Swoben, a former employee of Senior Care Action Network Health Plan and a consultant to the risk-adjustment industry, came forward with similar allegations in March.

In a very recent development, UnitedHealth Group’s lawyers are seeking to get the case dismissed, claiming that they are not required to validate the accuracy of diagnostic data submitted by healthcare providers.

I need to reiterate that, at this point, the claims asserted against UnitedHealth Group are only allegations and there have been no determinations of liability. It remains to be seen whether the case will even reach court.

However, the case ultimately resolves, it’s a very interesting, real-world, big-dollar example of the business of healthcare, raising the question of who is ultimately responsible for the accuracy of submitted diagnoses to Medicare (coders, CDI, administrative contractors, physicians?). It calls into question the oft-repeated adage that coders must code what the physician documents. It brings into even greater prominence the process of clinical validation, for which ACDIS recently released a new white paper.

Reading through these articles and the original court document, I thought to myself, if only UnitedHealth Group had a robust, compliant CDI process in place, this suit could have been prevented. More than anything, United States of America vs. UnitedHealth Group Inc. is confirmation that your work as a CDI professional matters, and that the broader CDI profession matters.

I plan to share my thoughts on this case in a series of blog posts here and I welcome your thoughts and commentary.

Editor’s note: To read the summary of the case, visit the DOJ website by clicking here. To read the court document in its entirety, click here. Brian Murphy is Director of the Association of Clinical Documentation Improvement Specialists (ACDIS). He can be reached at bmurphy@acdis.org.

 

 

Q&A: Rejections for claims for removing impacted cerumen

ask ACDIS

Ask ACDIS

Q: We have started receiving rejections for ED claims when the service involves removing impacted cerumen. We are reporting CPT® code 69209 (removal impacted cerumen using irrigation/lavage, unilateral) for each ear, and the documentation supports the irrigation/lavage rather than the physician removing the impaction with instruments. Our claims just started getting rejected in April. 

A: While your question doesn’t specify, it appears that you may be billing this with one line for the left ear with modifier -LT and one line for the right ear with modifier -RT. This code is included in the surgical section of CPT and correct coding requires that this be reported with modifier -50 for a bilateral procedure. In fact, there is a specific parenthetical note that states “For bilateral procedure, report 69209 with modifier -50”. 

[more]

Measuring the effect of HCCs, part 3

Editor’s note: This article originally appeared in the Revenue Cycle Advisor. For more information about Hierarchical Condition Categories (HCCs), read this article from the CDI Journal by Gloryanne Bryant, RHIA, RHIT, CCS, CCDS. To read the first part of this article, click here. To read the second part of the article, click here. The views expressed do not necessarily represent those of ACDIS or its advisory board.

The effect of hierarchical condition categories (HCCs) may double as hospitals buy physician practices and form health systems made up of a spectrum of different types of providers. Physician reimbursement has become increasingly complex and some physicians find it easier to operate with the support of a larger organization. Organizations that were once solely hospital-based now have to grapple with the complexities of a different set of billing and reimbursement regulations, says James P. Fee, MD, CCS, CCDS, vice president of Enjoin, Collierville, Tennessee and a hospitalist at Our Lady of the Lake Regional Medical Center in Baton Rouge, Louisiana.

Fee’s seen a lot of interest in HCCs from large multi-practice groups affiliated with a larger organization and some smaller physician practices have also started to pay attention to HCCs, particularly if they work with a larger organization for EHR assistance to support meaningful use. “I think we’re at a tip of an iceberg in terms of interest in HCCs. I think providers have a lot more to learn about HCCs,” he says.

As provider organizations grow, they should create a program to collect and merge patient data for analysis just as payers do. This will give the provider insight into what reimbursement they can expect for certain patient populations and it can help pinpoint what departments need more help.

[more]

Measuring the effect of HCCs, part 2

Editor’s note: This article originally appeared in the Revenue Cycle Advisor. For more information about Hierarchical Condition Categories (HCCs), read this article from the CDI Journal by Gloryanne Bryant, RHIA, RHIT, CCS, CCDS. To read the third part of this article, come back to the blog next week. The views expressed do not necessarily represent those of ACDIS or its advisory board.

Separate rumors from facts in relation to risk-adjustment

Organizations may mistakenly believe that hierarchical condition categories (HCCs) are currently being applied to all reimbursement models and CDI program staff may not understand the nuances of how risk adjustments get calculated for certain claims-based outcomes such as mortality or readmissions, says James P. Fee, MD, CCS, CCDS, vice president of Enjoin, Collierville, Tennessee.

Organizations need to begin understanding HCCs and what their risk-adjustment factor (RAF) is, but these codes do not currently affect all reimbursement models across the board. For example, HCCs primarily affect the cost category of MIPS. The relative category weighting for cost is 0% for 2017 but will be 30% for 2019 and will not begin to affect payment until 2020. Evaluate what metrics and reimbursement are affected by HCCs and target resources.

“All of these risk-adjustment methodologies and HCCs in particular are being used in compensation in ACOs and in the value-based purchasing models that we’re looking at for future reimbursement,” says Monica Pappas, RHIA, president of MPA Consulting, Inc., in Long Beach, California. “So we really have to learn more about the system and be more informed about the impact of some of these codes that we typically don’t pay attention to.”

Organizations already specify if codes are complications or comorbidities or major complications or comorbidities and make calculations based on Medicare Severity-Diagnosis Related Groups. The same general principles can be applied to HCCs, Pappas says. Although the sheer number of codes can seem overwhelming, hospitals can work with vendors to create systems to track and flag the codes, and many HCCs fall in the same category, she says.

Coders and CDI professionals can use that as a shortcut to help them remember common targets. As demand rises, vendors will likely develop more sophisticated tools to assist in identifying these codes, flagging documentation for physicians and CDI specialists, and analyzing data.

“I don’t think any human being is capable of knowing all this,” she says. “The amount of information is massive and if we don’t look to some technology solutions, we’ll never win.”

 

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!