Archive for May, 2009

RACs and medical necessity criteria

Q: If my hospital is not using the latest InterQual criteria, could that chart be pulled by the RAC for fraud?

A: InterQual is merely a screening criteria—CMS doesn’t actually require hospitals to use it. Therefore, use of an older version or a different set of criteria such as Milliman is not inherently a problem. However, because outside entities such as RACs, MACs or QIOs will be reviewing cases, most hospitals choose to use the same version used by their contractors (presumably the version for the year applicable to the case). Additionally, outdated versions may not reflect advances in care and may cause inappropriate screening decisions.

Note that a patient may not meet InterQual inpatient criteria, but still be considered an inpatient upon physician review. InterQual is a screening criteria—it screens for the most likely inpatient and outpatient admissions, but can not take into account every medical circumstance. There are a percentage of patients, who will fail inpatient criteria due to factors not considered in the InterQual criteria that upon physician’s review will nevertheless be appropriate for inpatient admission.

For this reason, each permanent RAC will now have at least one physician medical director who will be involved in developing evidence for individual claims determinations and act as a resource for all reviewers making such individual claim determinations. Additionally, the provider has the opportunity to request that the medical director participate in discussions regarding individual claims denials.

In addition, RACs do not audit for fraud. Their only task is to look for overpayments and underpayments, either due to errors by the hospital or by CMS’ processing systems. RACs are simply looking for incorrect payments, no matter whose fault, and getting that money back to the Medicare Trust Fund after taking their cut. Of course, if a RAC believes it uncovers a fraudulent scheme or set of practices, it may make an appropriate referral to one of the contractors monitoring for fraud, but it is not a part of their scope of work.

Editor’s note: This question was answered by Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc. It was originally published in The RAC Report, a bi-weekly HCPro e-newsletter.

It is also important to note that not all RACs will be using InterQual for claims investigations. HealthDataInsights, the RAC for 17 Western states, has declared it will be using Milliman Care Guidelines content and software to review Medicare claims. You can read more about that in a March 3 article published in Reuters.

Does your facility use InterQual, Milliman, or something different? Feel free to share your thoughts and experiences.

Free physician advisor tools

Take advantage of two free tools—courtesy of the Association of Clinical Documentation Improvement Specialists (ACDIS)—to help you ensure that your physician advisors are at the top of their game.

Click here to download a sample physician advisor job description.

Click here to download a sample physician advisor documentation review program.

For further training on the roles and responsibilities of physician advisors, consider purchasing a recording of the audio conference “Clinical Documentation Improvement for Physician Advisors,” sponsored by the ACDIS. The audio conference, recorded on April 14, explains how physician advisors can help you significantly improve initial documentation and physician response rates to queries; however the position must be structured correctly in order for it to work well. For more information about this audio conference, visit HCMarketplace.

Do you have a tip or tool you’d like to share, or perhaps a question for our experts? Contact editor Julie McGinley at jmcginley@hcpro.com. Your tip or question might be appear in the next issue of Case Management Weekly.

Update on case management protocol

In our last post on case management protocol, we said we were trying to reach CMS for a definitive answer as to whether case management protocol is an acceptable practice.

Since then, National Government Services (NGS), one of the largest Medicare contractors in the country, has released a statement in response to several providers asking it to sign off on a specific case management protocol.

The statement, dated April 22, 2009, states that CMS does not require NGS to approve of individual providers’ specific protocols, as approval by Contractors of individual policies might imply a predetermination of payment. NGS also says that RACs do not require a signed statement of approval or allowance of case management protocol, and this has been verified by CMS.

In regard to the compliance of a case management protocol, the statement cites CMS Publication 100-2, Chapter 6, Section 20.6, which states:

“Observation services are covered only when provided by the order of a physician or another individual authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests.”

CMS Publication 100-2 Chapter 1, Section 10 states:

“An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight. The physician or other practitioner responsible for a patient’s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient.”

NGS points out that a patient cannot be considered an inpatient until a physician has signed off on the admission order. Even if a standing order is written “admit to case management protocol”, patients will not receive inpatient status until the physician signs off on it. An example given by NGS is a patient admitted on a Sunday via case management protocol, but the physician doesn’t sign off on the order until Monday morning. In the example, the patient is not considered admitted as an inpatient until Monday morning.

This is something to keep in mind for facilities that have these types of written standing orders. If the patient admission is delayed until the physician signs off, it could have unplanned effects, such as the patient not qualifying for skilled nursing facility care due to the three-day qualifying stay rule.

However, there are some facilities that have made this protocol work for them. Keep an eye out for future stories in our monthly publication, Case Management Monthly.

Let us know how your facility successfully handles admissions and level of care status, whether with a case management protocol or other process.

More Condition code 44 advice

This week’s tip, an “Ask the Expert”, was submitted by a Case Management Weekly reader, and answered by Kimberly Hoy, Esq, regulatory specialist for HCPro.

Q: The tip of the week in the April 15 issue of Case Management Weekly addressed use of condition code 44, which has specific guidelines. If the CM or utilization review (UR) nurse and the attending physician agree that the patient’s status should have been observation and the attending physician is ready to discharge that patient, there is insufficient time to process it through the UR committee to obtain another approval if we are trying to comply with code 44 guidelines by writing the order prior to discharge. How should we handle this?

A: Condition code 44 requires a UR committee determination that a patient’s status should be changed from inpatient to outpatient, even if the attending physician is in concurrence. A representative of the committee may make this determination. However, the CM and UR nursing staff are not considered members of the UR committee for purposes of the Conditions of Participation (CoPs) so they may not be considered representatives of the UR committee. That leaves you in a very difficult position in the scenario you describe in which CM/UR nursing staff determines very close to the time of discharge that the patient’s status should have been observation.

Even though the attending physician agrees, condition code 44 and the CoPs require that two physicians make this determination. One may be the attending physician, but at least one must be a representative of the UR committee. In this situation, you may not be able to meet requirements for condition code 44 to bill the case as an outpatient, but all is not lost. CMS states in MLN Matters Article SE0622 that the appropriate billing method when you don’t meet condition code 44 criteria but the UR committee finds lack of medical necessity upon review of the case using CoPs guidelines is submission of the claim on a 12X type of bill. This type of bill allows payment for certain limited services (i.e., diagnostics, implants, dressings) under Part B when the stay was not medically necessary under Part A. Refer to the Benefit Policy Manual, Chapter 6, Section 10 for more information, including the complete list of services paid under the 12X billing methodology. This will require good communication with your billing department to distinguish these cases from condition code 44 cases, but affords hospitals the opportunity to receive some payment instead of writing the entire stay off as not medically necessary.

Going forward, the hospital may wish to consider asking physicians such as hospitalists, who are more readily available in these time sensitive situations, to serve on the UR committee. Alternatively, some hospitals find that a paid physician advisor, who serves on the UR committee and is on-call for consultation, is helpful when time is an issue. Physician advisors can be internal physicians on your medical staff with an interest in the UR committee. Alternatively, some companies provide contracted physician advisor services.

Do you have a tip or tool you’d like to share, or perhaps a question for our experts? Contact editor Julie McGinley at jmcginley@hcpro.com. Your tip or question might be featured in the next issue of Case Management Weekly!

HIPAA clarifications of importance to case managers

CMS Medicare Learning Network has posted a revision of a special edition (SE) posting that clarifies several privacy points of HIPAA that are important to case managers, particularly those who are working with patients, families and post-acute providers during the discharge planning process.

The title of the article is:

Clarification about the Medical Privacy of Protected Health Information

Note: This article was first published in 2007 and was revised on May 11, 2009, to reflect updated Web addresses for several products (resources) referenced in the article and to clarify those ‘sticky’ points of whether what case managers do is or is not HIPAA compliant.

You can access the article here.

The purpose of the article is to review:

• The Privacy Rule’s protections for personal health information held by providers and the rights given to patients, who may be assisted by their caregivers and others, and
• That providers are permitted to disclose personal health information needed for patient care and other important purposes.

Lists of topics included.  Numbers 1 and 2 of particular importance for case managers:

1. HIPAA does not require patients to sign consent forms before doctors, hospitals, or ambulances can share information for treatment purposes;
2. HIPAA does not require providers to eliminate all incidental disclosures;
3. HIPAA does not cut off all communications between providers and the families and friends of patients;
4. HIPAA does not stop calls or visits to hospitals by family, friends, clergy or anyone else;
5. HIPAA does not prevent child abuse reporting;

For each of the above listed topics, there are links that will take you deeper into the topic and allow you to fully understand that HIPAA was not, and is not, intended to interrupt the work you do with patients.  Case managers need to communicate across the continuum and thus are in a unique position when it comes to protecting information while promoting continuity of care.

As a case manager, this is essential reading. Share this with your compliance officer pointing out what efforts you are taking to comply and yet provide a safe transition of care.

Let us know how you apply this info to your policies and procedures in your organization.

What do hospital case managers do, anyway?

This is a question frequently asked by patients, family members, physicians, and other members of the medical staff.

Many people think that case managers are discharge planners, and that the only time a patient needs a case manager is when he or she has discharge needs. Case management is much more than that. It is important that we make sure that, not only do patients and families know what case management is, but that the nursing staff members know also.

Case managers work in forces behind the scenes, much like the crowd of people in the Verizon commercials. Case management is a hidden resource for patients. Often, the case managers work in the trenches, with their heads in charts, communicating with an interdisciplinary team of healthcare professionals to make sure that the patient is moving smoothly through the continuum of care, and there are no delays or detours in their care. This is usually an unknown aspect of case management.

Hospital personnel and the public need to be aware that case managers are advocates for all patients; they ensure that their healthcare facility and professionals are doing what is truly right for the patient, in the right setting, receiving the most appropriate care, and in the most cost-effective manner. Case management follows the patient’s plan of care to make sure that it is appropriate and timely, that their hospital admission status is appropriate, that their discharge planning is initiated, and that goals are set to meet the discharge plan. It is imperative that the case manager build a relationship with the patient and their families in order to reach a mutual goal of discharge.

It is also important for the bedside nurses to know that case managers are an excellent resource for them in planning the patients’ care and goals. One thing I did at our institution while we were redesigning our case management model was to do a mandatory in-service to nursing staff on how case management affects not only patient outcomes, but the financial outcomes for hospitals.

At our institution this year, we included a station on case management and interdisciplinary rounds at the nursing annual competency testing. Case management had a display booth with information about what case management is and the importance of interdisciplinary rounds. We also had a test for the nurses to complete. The comments we received from staff were very interesting.

Does your institution do anything like this? Are you confident that nursing staff members truly understand what case management is?

And one more important question: Do your physicians really know what case management is?

Determine your facility’s goals for ED case management

The most frequent question I get asked about ED case management is: “Do I need an ED case manager in my institution?” There is no right or wrong answer and what I usually reply is,  “what are the issues you are facing and want to address?”

Some potential goals of an ED case management program would be:

1. Fewer discrepancies between payers and the institution regarding whether an admission should be inpatient or observation status. Clean claims will decrease the amount of time for claims to be paid which can improve revenue flow.
2. Increased referrals to alternative levels of care, resulting in better utilization of inpatient beds, which can also result in avoiding some non-acute admissions.
3. Better communication between the ED, outpatient providers, community providers ,social agencies, families, and payers.
4. Decreased recidivism based on the implementation of certain programs
5. Identification of barriers to adherence to a plan of care such as inability to afford medications, lack of insurance, lack of transportation, etc., and working to address these barriers.
6. Earlier identification of at risk individuals and earlier interventions (i.e., refer to disease management programs, etc.)
7. Assist with arranging expedited follow-up appointments.
8. Early identification and assessment of admitted patients for discharge planning starting in the ED (i.e., identification and early referral to post acute providers, etc.)
9. Improved patient/family satisfaction with the discharge planning process from the ED.
There are many possible goals, but each goal must address the needs of the organization. It is important to define what the goals are and to have a means of measuring the impact of the program.

It would be helpful if people would post information about case management programs at their institutions and include the size of the institution, what the goals of their programs are, the hours of operation, and how it is staffed. There are programs in small hospitals and large organizations and people on this blog come from a variety of settings, so it would be helpful for people to begin to understand how they might be able to operationalize a program. Thanks to all who have contributed to this blog as we can all learn from one another.