All Entries Tagged With: "CMS"
OIG gets proactive in 2010 Work Plan
Hospital readmissions, adverse events, and issues related to the American Recovery and Reinvestment Act of 2009 are some of the highlights of the 2010 OIG Work Plan.
“These are relatively new issues so this is pretty proactive on the OIG’s part,” says Steve Miller, JD, chief compliance and privacy officer at Capital Health in Trenton, NJ.
In previous years, many of the OIG’s planned reviews were on topics that have been around for awhile.
“They’re getting a jump on these newer issues right away,” Miller says. This is a good move, he adds, because newer issues tend to present a higher opportunity for errors.
While CDI specialists need not drill down into the nuances of the OIG investigations they do need to be aware of the implications of those governmental efforts on their day-to-day documentation improvement efforts.
For example, the OIG says it’s going to look into coding and documentation changes under the Medicare Severity Diagnosis Related Group (MS-DRG) system, as recommended in a March 2005 MedPAC report. Essentially, the OIG says its going to examine coding trends and patterns to determine whether specific MS-DRGs are vulnerable to potential upcoding.
According to ACDIS’ sister publications’ analysis of the Plan, in 2004, CMS implemented an edit to reject subsequent claims for beneficiaries whom the hospital readmitted on the same day. According to the Medicare Claims Processing Manual, if a same-day readmission occurs for symptoms related to or for evaluation or management of the prior stay’s medical condition, the hospital is entitled to only one DRG group payment and should combine the original and subsequent stays in a single claim. In 2010 the OIG plans to test the effectiveness of this edit and determine the extent of oversight of readmission cases.
“It’s interesting because this is an issue that is getting more attention from CMS this year,” Miller says. In fact, in April, CMS announced a pilot program “Care Transitions” to focus on eliminating unnecessary hospital readmissions.
Sure, some people think the pile of paperwork that constitutes the Plan makes for good bedtime reading (zzzzzzzzzzzzzzzz) a brief examination of its Table of Contents under CMS on page v can give a snap shot of any potential hot topics your facility compliance officer may be thinking about.
Few IPPS changes final rule could cause CDIs trouble
There are a few changes in the IPPS final rule that may prove problematic for clinical documentation improvement specialists, according to Robert S. Gold, MD, CEO of DCBA, Inc., Atlanta.
Hypoxic ischemic encephalopathy (HIE), for example, has its roots in the pediatric population. So it will be important to recognize that the code for an adult with HIE is 348.1— anoxic brain damage. “And we need to be specific about the causes of encephalopathy in the neonate,” says Gold, “they’re not all HIE.”
The 285.3 code for anemia due to anti neoplastic treatment is different from anemia due to neoplastic disease and different from aplastic anemia from chemotherapy. The CDI specialists has to know what cell lines are missing and determine the true cause of the anemia in order to frame the question to the physician properly.
Gold also suggested that CDIs require better specificity of location of blood clots currently under treatment with Coumadin in order to assign the right code for deep vein thrombosis. He also suggested that physicians need to document whether the condition is new during the patient’s current hospital stay or whether it had been under treatment from a previous hospitalization.
Finally, Gold urged healthcare professionals to “work to preserve” the terms acute renal failure and acute kidney injury and to totally downplay the new definition of acute kidney failure. “This is a misunderstanding currently under discussion. You don’t want to promote the use of a term that might not last long. You don’t want to have to re-teach,” he says.
CMS abandons IPPS payment reduction for now
Though many hospitals feared a 1.9% reduction in payment for 2010, they will actually see a 2.1% increase, according to the fiscal year (FY) 2010 IPPS final rule that CMS released July 31. CMS had originally proposed a documentation and coding adjustment to account for the effect of increases in aggregate payments due to changes in hospital coding practices that it says do not reflect increases in patients’ severity of illness.
The proposed adjustment would have resulted in historically low payments for hospitals and especially penalize hospitals that have yet to develop a clinical documentation improvement (CDI) program, says DeAnne Bloomquist, RHIT, CCS, president and chief consultant for Mid-Continent Coding, Inc. in Overland Park, KS. “I think that means that hospitals can breathe a sigh of relief.”
In the proposed IPPS rule, CMS intended to reduce future payment rates “based on the observed increase in spending due to documentation and coding that occurred in fiscal 2008,” according to CMS’ press release. However, because it does not have a full year of data that would show the extent of documentation and coding effects on 2009, CMS decided not to implement the adjustment until it has a full year of FY 2009 data.
In the next year, hospitals with CDI programs should continue their initiatives, while those who have not implemented one yet should work toward that goal, says Gloryanne Bryant, RHIA, CCS, CCDS, Regional Managing HIM Director at Kaiser Foundation Health Plan Inc & Hospitals.
CMS cheat sheet on IPPS basics available
Page three and four of CMS’ revised Acute Inpatient Prospective Payment System Fact Sheet (January 2009) contains a number of pastel looking charts outlining what seems to be mathematical equations. These graphical details show how IPPS payments are derived through a series of adjustments applied to separate operating and capital base payment rates.
Although I don’t recommend it for bedtime reading, the Medicare Learning Network Payment System Fact Sheet should be on your CDI required reading list.
Maybe you’ve read it before, maybe you’re already well-versed in the IPPS process and know all about how DRGs became MS-DRGs and how the wage-index fits into the final cost analysis, but maybe all this sounds like you need an accounting degree or a master’s in business healthcare administration. Either way, it’s always good to keep an eye on what CMS says about its own systems.
Maybe make it your lunch-time reading instead.
POA: Episode II
Preface to the following: You won’t find a more staunch advocate for ethical behavior in the documentation compliance profession than me. I firmly believe that documentation compliance is all about quality, specificity, and the behaviors and processes that support those aims.
However, we all also know that when it comes to implementing new initiatives it’s the bottom line that makes the decisions. That being said…
Once upon a time in a galaxy far, far away there existed an entity known as CMS, sometimes called the Empire. The Empire controlled everything in its purvue, including hospital reimbursement.
Last year the Empire passed a new law called “Present on Admission (POA)”. All the citizens who reported to the Empire lived in fear of this new law but the first year passed without any significant battles.
Episode 2:
I suspected (as I’m sure you all did) that once the Empire announced that it would exclude payment for hospital-acquired conditions, it was only a matter of time before the commercial carriers followed suit. Guess what? It happened.
After the consultants leave…what now?
Hey, you CDS with new programs out there! How’s it going? Are you sailing along on the smooth seas of phenomenal MCC capture rates or are you stalled in the doldrums? Are you asking yourself the following question: “What do I do now that the consultants are gone?
Been there. Done that …twice, in fact! Are you finding that the people at your hospital who decided that a CDI program was a good idea are now saying things like “the CMI doesn’t seem much different” or “where’s the money they promised us”?
Don’t feel bad. You didn’t do anything wrong. You’re just feeling the pangs of aftermath: the training and support is over and now you’re alone and administration doesn’t even know what you do, exactly.
First, who do you report to? Someone who actually knows from a hole in the ground, or someone who wouldn’t know an MCC if it bit them? This isn’t a silly question. If the person making the decisions doesn’t know what you’re REALLY there for, it’s going to be hard to succeed and grow your program. So, invite this person to come to your team meetings and be sure to share your successes and tell him/her how much more you can do with their active support. [more]
RAC – Who and What are They and Why Should I Care?
While we’ve been busy working our fingers to the bone performing our chart reviews CMS has been diligently working to come up with ONE MORE THING that will ultimately involve CDI Specialists: the RAC program.
The RAC (Recovery Audit Contractor) program is an outcome of section 306 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA). As part of this Act Congress directed the Department of Health and Human Services (DHHS) to conduct a 3-year demonstration program using Recovery Audit Contractors (RACs) to detect and correct improper payments in the Medicare FFS program.
In addition, in section 302 of the Tax Relief and Health Care Act of 2006 (TRHCA), Congress required DHHS to make the RAC program permanent and nationwide by no later than January 1, 2010. [more]