All Entries Tagged With: "CMS"
ACDIS advises members to ‘stay the course’ despite potential ICD-10 delay
ACDIS Advisory Board recommend facilities continue with ICD-10 preparations.
As I’m sure most of you are aware, The Department of Health and Human Services (HHS) has proposed a one-year delay of ICD-10-CM and ICD-10-PCS. You can read the complete release here http://www.gpo.gov/fdsys/pkg/FR-2012-04-17/pdf/2012-8718.pdf. The go-live date for which most of us were preparing—October 1, 2013—is now extended to October 1, 2014, barring any last-moment changes.
According to CMS, many provider groups had expressed serious concerns about their ability to meet the initial Oct. 1, 2013 compliance date. The proposed change in the compliance date for ICD-10 will give providers and other covered entities more time to prepare and fully test their systems to ensure a smooth and coordinated transition to these new code sets.
ACDIS would like to offer the following guidance for our members:
Stay the course with ICD-9 and ICD-10 documentation education. Hospitals continue to struggle with documentation and coding requirements under ICD-9; the best way to prepare for ICD-10 is to perform ICD-9 correctly and negotiate the differences between it and the new coding system. Regarding the best time to begin ICD-10 training: We’ve heard anecdotal evidence of hospitals moving out their ICD-10 training dates for their coding staff, which is understandable. However, an industry-wide recommended first step is ensuring that additional required physician documentation is in place for HIM/coding staff. Getting the additional specificity necessary under ICD-10 now is a good way to ensure a seamless transition to October 1, 2014. CDI specialists should use this time to improve their core competencies and knowledge base of ICD-10.
Provide commentary to CMS. Commentary on the proposed rule is open for 30 days starting on Tuesday, April 17. If you feel strongly that the one-year delay should not be implemented, or if you believe that the one-year delay will benefit your hospital, let CMS know by providing your comments at regulations.gov. CMS reviews all provider comments, and who better to hear from than CDI specialists, for whom the change to ICD-10 will be of the greatest impact. To comment on the proposed delay to ICD-10, click the following link to the Federal Register http://www.regulations.gov/#!documentDetail;D=CMS-2012-0043-0001 and click the “Submit a Comment” button. Comments are due on May 17, 2012 by 11:59 p.m. ET.
The clash of clinical vs. coverage/payment concerns
by Trey La Charité, MD
Auditors are increasingly looking at medical necessity denials but shouldn't the physician make the decision about whether the patient needs to be admitted?
In the aggressive post-discharge auditing environment where I now find myself practicing medicine, I and my colleagues are subject to heavy scrutiny by CMS and private insurers. Observation versus inpatient status review is the new focus of these non-clinician auditors and has become the reason for the vast majority of my facility’s denials. This new auditing pressure we all face stems from the completely noble idea that reductions in fraud, abuse, and improper payments will preserve resources for those who truly need medical care. Sadly, as with many commendable aspirations, the execution is poor and often produces a dismal result.
As the physician advisor for CDI, I have been diligently educating every physician at my institution about ensuring the medical necessity of our inpatient admissions. But while CMS asserts that the admitting physician is solely responsible for status selection (i.e., inpatient, outpatient, or observation status), admission status for the physician has no clinical relevance. Physicians do not recognize “conditional” or “partial” admissions, which observation status implies. As far as physicians are concerned, their patients either medically need something or they don’t.
The rules concerning inpatient versus observation status selection are not newly created; CMS’ vague guidelines for
appropriate status selection have been around for years. The difference is that CMS and other payers suddenly discovered that they can extend their existing financial resources by “enforcing” those rules. Payers and their related auditing agents have traditionally avoided the question of whether a patient actually needed the medical care that was provided. Instead, they simply point to inappropriate status selection and deny the associated claim. The issue is whether physicians should be contemplating a patient’s admission status at all.
Editor’s Note: This article is an excerpt from the quarterly publication for ACDIS members the CDI Journal. La Charité is a hospitalist and physician advisor for CDI and coding at the University of Tennessee at Knoxville, and an ACDIS Advisory Board member. Contact him at Clachari@UTMCK.EDU.
Maybe, possibly, definitely: Stay informed regarding ICD-10 delay
Which countdown to ICD-10 calendar will you use?
On February 14, CMS acting administrator Marilyn Tavenner told American Medical Association (AMA) meeting attendees that CMS would “reexamine” the timeline for ICD-10-CM/PCS implementation. Tavenner offered no details, just the vague possibility of potential reconsideration.
The healthcare industry jumped with the news.
American Health Information Management Association (AHIMA) immediately published a release urging healthcare professionals to move forward with their ICD-10 implementation and training plans, and downplayed the announcement, pointing its vague language.
“This is a promise from CMS to examine the timeline, not to change it,” said Dan Rode, MBA, CHPS, FHFMA, vice president for advocacy and policy at AHIMA, in the release. “But government officials are sending mixed signals that many in the healthcare community will interpret as a reason for delay.”
The AMA celebrated.
“The timing of the ICD-10 transition could not be worse for physicians as they are spending significant financial and administrative resources implementing electronic health records in their practices and trying to comply with multiple quality and health information technology programs that include penalties for noncompliance,” wrote Peter W. Carmel, MD, AMA president in a February 16 release. “Burdens on physician practices need to be reduced—not created—as the nation’s health care system undertakes significant payment and delivery reforms.”
The very next day, February 15, HHS Secretary Kathleen Sebelius said “the federal government will delay for an unspecified time the implementation date for the ICD-10 diagnostic and procedural coding system,” HealthLeaders Media reported.
Specifically, the HHS release stated that the agency “will initiate a process” to delay the ICD-10 implementation date for “certain health care entities.”
And that was pretty much it.
The rest of the release reiterates that the provider community feels burdened by the ICD-10 implementation, but also reiterates the importance of the move to ICD-10 because it will “provide more robust and specific data that will help improve patient care.”
Meanwhile, CMS confirmed to ACDIS’ parent company HCPro Inc., that the agency will use the rulemaking process when revisiting the ICD-10 implementation timeline; a process known to be lengthy, a process that does not always furnishes an expected result (meaning after the rulemaking CMS may just decide to keep the implementation date firm).
So multiple experts from ACDIS Advisory Board members to AHIMA directors repeated the refrain,; “Stay the course with ICD-10 implementation.”
I’m on their side.
In a phone conversation earlier this week, an ACDIS member told me that she was glad to hear CMS delayed ICD-10 by two years. Two years, she said.
Of course, I asked where she got her information and she cited some reputable sources which, on closer examination, actually said nothing of the sort.
All this commotion—all this maybe, possibly, definitely thinking about it—may ultimately cause serious difficulties for those in the midst of ICD-10 implementation plans. The possible delay could cause facility administrators to pull back the purse strings on training funds. Programs could decide to delay important technology purchases to save money since the implementation date isn’t imminent.
Meanwhile, we hear how far behind facilities actually are in their ICD-10 planning. CDI staff (according to a recent survey) say they do not even know if a ICD-10 implementation committee is meeting at their facility or what will be expected of them as the coming change draws near. Possibly postponing the actual “go-live” date only adds to facility procrastination on these issues.
The more advanced facilities have already evaluated their staffing needs in terms of CDI specialists’ concurrent record reviews and coding needs. These facilities have already budgeted for additional employees and charted a course for staff member training beginning with anatomy and physiology. Even more advance programs have already begun reviewing their top MS-DRGs for documentation improvement opportunities related to ICD-10.
History may prove me wrong (especially as rumors also abound about HHS opting to skip ICD-10 and jump directly to ICD-11!) but I remain convinced that ICD-10 implementation is inevitable and that the sooner facilities prepare themselves the better.
Guidance on documentation requests, queries, and late entries in the record
Lynne Spryszak, HCPro’s CDI Education Director, was one of several speakers offering great information during yesterday’s ACDIS members’ Quarterly Conference Call. She mentioned a November 2011 CMS publication about documentation requests that can have a direct impact on provider requests. Here is the link:
http://www.cms.gov/manuals/downloads/pim83c03.pdf
Lynne also provided more information from the Medicare Benefit Manual:
3.3.2.5 – Late Entries in Medical Documentation
(Rev. 377, Issued: 05-27-11, Effective: 06-28-11, Implementation: 06-28-11) This section applies MACs, CERT, Recovery Auditors, and ZPICs, as indicated.
“A provider may discover that certain documents were misfiled or needed to be filed in the medical documentation during the process of responding to an ADR. Providers are encouraged to add to the medical record or notes file all relevant documents that were created at the time of service or within a few days of the date of service.
“The MACs, CERT, Recovery Auditors, and ZPICs shall give less weight when making review determinations to documentation, including a provider’s internal query responses, created more than 30 calendar days following the date of service. If the MACs, CERT, or Recovery Auditors identify providers with patterns of making late (more than 30 calendar days past the date of service) entries in the medical documentation, including the query responses, the reviewers shall refer the cases to ZPIC and may consider referring to the RO and State Agency.”
Thank you, Lynne!
VBP discussion offers new initiatives for CDI programs
Join us next week for a discussion of the implications of Value Based Purchasing.
Most facilities are already familiar with the Value-Based Purchasing (VBP) measures since CMS has collected data on them for some time. The Hospital Inpatient Quality Reporting Program is now known as QualityNet, but some know it better as the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU). Many CDI programs incorporate RHQDAPU items on physician documentation improvement tip sheets. (See the Physician Documentation Improvement Pocket Guide, by Pamela P. Bensen, MD, MS, FACEP.)
Until now CMS hadn’t tied payment to a facility’s performance. Instead, hospitals were paid to participate in the program and simply reported the requested conditions. Since 2005, CMS has published each RHQDAPU participating hospital’s measure rates on the Hospital Compare website. Starting October 2012, Medicare will begin paying hospitals for quality measures, according to a CMS fact sheet released April 29.
Editor’s Note: This article is an excerpt from the July edition of the CDI Journal. Join Deborah K. Hale, CCS, CCDS, and Susan Wallace, MEd, RHIA, CCS, CCDS, of Administrative Consultant Service, LLC, in Shawnee, OK, on Tuesday, November 8, for an audio conference discussion regarding the implications of VBP for documentation and coding accuracy.
CMS posts podcasts of 2011 ICD-10 meetings
CMS created the following four podcasts based on the January 12 national provider call, “Preparing for ICD-10 Implementation in 2011:”
- Welcome and ICD-10 Overview
This post was originally published on the ICD-10 Trainer Blog
- Implementation Strategies for 2011
- Question and Answer Session, Part 1
- Question and Answer Session, Part 2
You may also access the following four podcasts based on the May 18 national provider call, “CMS ICD-10 Conversion Activities National Provider Teleconference – Including a Lab Case Study:”
- Welcome and ICD-10 Overview
- Case Study on Translating the Lab NCDs
- ICD-10 Updates from CMS Subject Matter Experts
- Question and Answer Session
CMS releases FY 2012 IPPS final rule
CMS released its final rule for the FY 2012 Inpatient Prospective Payment System integral to inpatient Medicare reimbursement at short-term and long-term acute care hospitals as announced in an August 1 press release.
In a major surprise, CMS finalized a documentation and coding adjustment (DCA) of -2.0% instead of the proposed -3.15% for fiscal year (FY) 2012, according to the 2012 inpatient prospective payment system (IPPS) final rule released August 1.
CMS originally proposed a year-over-year reduction of 0.5% in payments to acute care hospitals under the FY 2012 IPPS, including a DCA of -3.15%. However, CMS finalized a cut of 2.0%, a decrease from 2.9% in FY 2011, which translates to $1.13 billion more in hospital payments in FY 2012 than they had received in the previous year. “We’re very pleased to see that CMS has scaled back their proposed coding cuts,” says Joanna Kim, senior associate director for policy for the American Hospital Association (AHA) in Washington, DC. “We are quite disappointed that CMS did not change their methodology of analyzing documentation and coding, but are glad they recognized that the proposed 3.15% cut would be very difficult for hospitals to absorb all in one year.”
Kim suggests that hospitals look closely at the new payment rates and make sure they can budget appropriately.
James S. Kennedy, MD, CCS, managing director for FTI Healthcare in Atlanta, agrees that the temporary reprieve is a positive for hospitals. “The DCA is what it is. At least for next year, it’s good that we got a break,” he says. “But CMS will maintain its current methodology of calculating it and will continue to assess it to hospitals until they have recouped what they believe they have overpaid.”
“We recognize the concerns regarding possible financial disruption that may be caused by the proposed documentation and coding improvement payment adjustment,” CMS states in the rule. “We note, however, that these payment adjustments are necessary to correct past overpayments due solely to documentation and coding improvements. We have already delayed implementation of the required prospective adjustment amount, and we proposed only a portion of the remaining required adjustment to allow hospitals time to adjust to future payment differences and to moderate the effect of this adjustment in any given year.
Editor’s Note: This article was initially send to ACDIS members on Tuesday, Aug. 2. Read the complete analysis online at www.hcpro.com
House and Senate urge CMS to reconsider IPPS coding offset
With all the wrangling over the Federal debt and other items at least there is something the House and Senate do agree on—urging CMS to reconsider its coding offset when it publishes its inpatient prospective payment system final rule for 2012 expected to be released any day.
If CMS does include the coding offset “the policy would cut hospital payments by 6.05%, or $6.3 billion, and would create substantial volatility in inpatient PPS rates for the next two years,” according to an article in AHA News.
The proposed rule this year contained a proposed payment reduction of nearly a half a billion dollars compared to payments in 2011, according to Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc., in Marblehead, MA. “This reflects a controversial documentation and coding adjustment of -3.15%. This is greater than expected, although CMS indicates they are required to recoup 3.9% and will recoup the remaining .75 in the future to avoid too great an impact on hospitals in 2012,” Hoy wrote on the MedicareMentor Blog when the proposed rule was released earlier this year.
CMS seeks comments on COPD outcomes
Comments Accepted through Friday, July 8
Having just received this notice from CMS, and noticing its comments’ deadline, I thought I’d share this brief with ACDIS members via this post. The Yale New Haven Health Services Corporation/Center for Outcomes Research and Evaluation (YNHHSC/CORE) is developing two hospital-level, quality outcomes measures for patients with chronic obstructive pulmonary disease (COPD). The measures will be designed for public reporting. CMS says it hopes they will be complementary measures intended to assess different domains of hospital quality. The two measures are:
- 30 day, all-cause mortality following hospitalization for acute exacerbation of COPD
- 30 day, all-cause readmission following hospitalization for acute exacerbation of COPD
CMS says it particularly wants feedback about:
- Cohort for inclusion in the measures
- Inclusion/exclusion criteria
- Risk adjustment strategy
All comments on the measures must be received by July 8. Comments received will be posted for approximately four weeks once this public comment period closes. To submit comments access the CMS Public Comment system and COPD measure documents at http://www.cms.gov/MMS/17_CallforPublicComment.asp and submit your comments to COPDmeasures@yale.edu.
CMS releases Medicaid HCACs final rule
CMS announced Medicaid HCACs
States to implement payment reductions for provider-preventable conditions
Provider-preventable conditions (PPC), including health care-acquired conditions (HCAC), are now subject to payment adjustments under the Medicaid program, according to the final rule released by CMS June 1.
The rule, “Medicaid Program; Payment Adjustment for Provider-Preventable Conditions Including Health Care-Acquired Conditions,” implements provisions in the Patient Protection and Affordable Care Act requiring HHS to prohibit federal payment to states for specified HCACs, as well as additional conditions determined on a state-by-state basis.
“We found that 29 states do not have existing HCAC-related nonpayment policies,” according to the final rule. “Most of the 21 states that currently have HCAC-related nonpayment policies identify at least Medicare’s HACs [hospital-acquired conditions] for nonpayment in hospitals.
“However, it is important to note that at least half of the existing policies we reviewed exceeded Medicare’s current HAC requirements and policies, either in the conditions identified, the systems used to indicate the conditions, or the settings to which the nonpayment policies applied.”
CMS introduces the term PPCs in the rule, which consists of two categories: HCACs and other provider preventable conditions (OPPC). OPPCs would be those additional conditions identified and approved by states that are not found on the list of HCACs, which are included on pages 20 and 21 of the final rule. This also allows states to expand beyond the inpatient hospital setting HCACs.
“We believe, and confirmed through public comment, that incorporating Medicare’s HACs in Medicaid’s policy is inherently complex because of population differences across programs,” according to the rule. “We fully understand that the HACs developed for Medicare’s population will not directly apply to various subsets of Medicaid’s population. While we have established Medicare as a baseline, we understand that states will, through their payment policies, appropriately address these differences.”
As with the Medicare HAC program, there will be no payment reductions for those conditions that existed prior to treatment by the provider, according to the rule.
In addition, payment reductions are limited to only those PPCs that would otherwise result in a payment increase and those that the state can “reasonably isolate for nonpayment the portion of the payment directly related to treatment for the PPC.”
In the rule, CMS notes that while the point of the Medicaid PPC payment adjustments is to improve quality of care, it does expect to realize cost savings on a state and federal level.
The federal government expects to save approximately $4–5 million annually between 2012–2015, with states experiencing an additional savings of $3–4 million each fiscal year, leading to a total savings of $35 million through 2015.
“These steps will encourage health professionals and hospitals to reduce preventable infections, and eliminate serious medical errors. As we reduce the frequency of these conditions, we will improve care for patients and bring down costs at the same time,” CMS Administrator Donald M. Berwick, MD, said in a June 1 press release.
Due to the fact that the majority of hospitals already have programs in place to reduce the occurrence of Medicare HACs, CMS does not believe the cost of implementing a similar program for Medicaid HCACs will be significant.
The effective date of the rule is July 1, 2011; however, CMS is delaying compliance action until July 1, 2012.
Editor’s note: Access the display copy of the final rule here. The proposed rule was published in the Federal Register February 17. This article was published as an HCPro Inc., breaking news alert on Thursday, June 2.
