Archive for July, 2009

“Voluntary refunds” to MACs/FIs

Many providers are taking a proactive approach to the arrival of the Medicare Recovery Audit Contractors (RAC) and performing their own audits. Using the RAC “hot topics,” providers are using those audit outcomes to understand their risks, to change internal processes regarding areas of concern and to return reimbursements for claims that were found to be paid in error.

Once a self audit has been performed and if an improper payment has been identified, what should be the provider’s next steps? CMS Frequently Asked Question (FAQ) #9503 was updated last week to clarify the process of notifying the RAC on self audit outcomes.  If an improper payment related to a specific claim is identified, the provider should report their findings to their Medicare Administrative Contractor (MAC) or their Fiscal Intermediary (FI) if their transition to a MAC has not been completed.

A “voluntary refund” based on the specific claim can be made and the MAC/FI will make the appropriate adjustment. For details regarding the required claim information that is necessary to complete a voluntary refund, contact your local MAC/FI.  According to CMS, the “RAC will be aware of the adjustment, but the refund does not preclude future review.” Providers should create an internal process to identify any claims that have been processed as a voluntary refund.

Editor’s note: This article was originally written for the MedicareMentor blog. Click here to read the original post.

Medicaid Integrity Contractors: Coming to a hospital near you

Nearly 500 Medicaid audits are under way in 17 states, and the program will roll out to the entire country through the end of the year, according CMS representatives who spoke on the Medicaid Integrity Program Special Open Door Forum on July 15.

CMS hopes to identify additional contractors within the next few days. These contractors, known as Medicaid Integrity Contractors, are firms CMS has chosen to carry out the following Medicaid Integrity Program goals:

• Review provider actions to determine whether fraud, waste, or abuse may have occurred
• Audit provider claims
• Identify overpayments
• Educate those involved in Medicaid administration, providers, managed care entities, beneficiaries and others with respect to payment integrity and quality of care

There are three types of contractors: Review, audit, and education MICs. The review MICs analyze data and identify issues to pass on to audit MICs to pursue, according to CMS. Education MICs will provide education to providers and others on Medicaid payment integrity and quality of care.

CMS acknowledged on the call that it could do a better job of provider outreach, and it is taking measures to increase educational efforts, now that it has finished building the Medicaid Integrity Program organization and developing the audit process.

Fortunately, additional resources will soon become available for providers. CMS plans to soon release FAQs, a procurement timeline, background on the program and its goals, as well as other information on the Medicaid Integrity Program Web site. CMS also plans to release Web-based training currently in development for pharmacies.

Hospitals aren’t the only providers that need to prepare: 44% of the current audits focus on hospitals, but 29% are on long-term care facilities, 21% of audits are on pharmacies, and the remaining 6% are on physicians, labs, transportation, and other types of providers, according to CMS.

RACs vs. MICs

MICs have been termed “RACs for Medicaid,” but there are certainly differences between the programs. For example, the RAC lookback period is three years, but MICs base the length of time on individual state lookback guidelines. Similarly, the number of days a provider has to produce medical record copies for MICs is dependant on state rules, unlike with RACs, where providers have 45 days regardless of their location. In addition, MICs have no set medical request limits, while RACs max out at 200. Also, CMS will not reimburse providers for the cost of copying records, which is also different from the RAC program.

And unlike RACs, MICs are not paid by contingency fee, but rather through a sort of fee-for-service model. The dollars MICs recover aren’t tied to their compensation, according to CMS, although they will be eligible for bonuses based on how “effective and efficient” they are. Finally, in some cases MICs will do desk audits, and in other instances, auditors will come on-site to do the reviews.

MICs will also attempt to coordinate with RACs so as not to audit the same facilities simultaneously, CMS Medicaid Integrity Program field director Rob Miller said on the call.

Tip: Query for Noncompliance with medical treatment (V15.81)

Editor’s note: This blog was written by Brian Murphy, CPC, the director of the Association for Clinical Documentation Improvement Specialists, for the ACDIS Blog. Read the original post here.

CDI specialists should be on the lookout for indications of patient noncompliance with medical treatment when reviewing patients’ charts, says Garri Garrison, RN, CPUR, CPC, CMC, director of consulting services with 3M Health Information Systems (HIS) and a member of the ACDIS advisory board.

According to Garrison, payers are increasingly denying hospital readmissions and the problem is likely to worsen with the nationwide rollout of the Recovery Audit Contractor (RAC) program and CMS’ increasing scrutiny of the cost of readmissions. “Readmissions can be the result of, or influenced by, patients who leave the hospital and refuse or elect not to follow recommended treatment plans (by choice, by misunderstanding of discharge instructions, or due to costs), which may cause their condition to worsen, resulting in a readmission,” Garrison says.

However, CDI specialists can assist facilities by identifying when noncompliance plays a role in the readmission. By securing the necessary documentation to allow coders to report V15.81, hospitals can use this documentation and coded data to help prevent or appeal denials, Garrison says. “If the V code is reported in the top nine diagnosis codes when it is transmitted on the UB-04, (it allows) the payer to have the knowledge that patient noncompliance may have contributed to the readmission,” she says.

“I have always recommend the use of the V15.81 code for noncompliance to both coders and physicians when supported by the clinical documentation,” adds Gloryanne Bryant, RHIA, CCS, CCDS, regional managing HIM director, NCAL Revenue Cycle of Kaiser Foundation Health Plan Inc. and Hospitals in Oakland, CA, and a member of the ACDIS advisory board. “I agree this is helpful, but mostly for understanding which patients really are not following medical instructions. Is it the diabetic patient or the dialysis patient, etc?

“It further explains and provides insight into healthcare resource use, length of stay, costs, and readmission rates,” Bryant adds. ”I would recommend that facilities run a data report on their inpatients with this V code assigned and conduct some audits and reviews to gather insight. I would also track/trend this V code over time and share the information with providers.”

NGS statement on billing condition code 44

We have received many questions on the articles we have published on the counting of hours of observation in cases where condition code 44 is used to convert an inpatient to an outpatient after UR review.  A couple weeks ago I wrote about this issue following contact by a National Government Services representative, encouraging providers to contact their local MAC for more information.

I recently received some further clarification from National Government Services and wanted to update you.  As you know, I’ve advised that hospitals should not be counting the time between the inpatient order and the change to outpatient status as observation – rather, I said, the observation time should begin with the change in status to outpatient when the observation order is written (assuming the appropriate level of care). NGS’ recent clarification, confirmed to me in an email exchange, is as follows:

As you are aware, the recent regulation changes resulted in many questions.  We received confirmation from our CMS representative that indeed, a written order for observation status is required and that the inpatient stay can not be converted to observation time when CC 44 is applicable.  If the physician (or UR committee in conjunction with the physician) deems the patient meets observation criteria after conversion to outpatient status, then observation time may be billed if the level of care is met.  But observation time would begin when the order is written; and the previous (although incorrect) inpatient time could not be billed as observation. The services rendered while the patient was placed in inpatient status would be billed as outpatient services, but no observation time could be billed.

NGS is relying on their CMS central office contact for this clarification and not just their individual interpretation.  Therefore, if any of you have received conflicting advice from your MAC, I would encourage you to provide them with this information and continue to use caution in billing any hours of observation without a proper order for observation services.

Editor’s note: This article was written by Kimberly Anderwood Hoy, the director of Medicare and regulatory compliance for HCPro. It was originally published on the MedicareMentor blog. Read the original post here.

Readmissions data now reported by CMS

CMS released a statement on Thursday, July 9, saying that its Hospital Compare Web site will now contain data reporting how frequently patients return to a hospital after being discharged, “a possible indicator of how well the facility did the first time around,” says the statement.

The statement goes on to say that, on average, one in five Medicare beneficiaries discharged from a hospital is readmitted within a month.  President Obama and Congress are focusing on reducing readmissions as a way to improve quality and achieve cost savings, according to the statement.

Hospital Compare data show that 19.9% of patients admitted to a hospital for heart attack treatment will return to the hospital within 30 days, 24.5% of patients admitted for heart failure will return to the hospital within 30 days, and 18.2% of patients admitted for pneumonia will return to the hospital within 30 days.

“Research has shown that hospital readmissions are reducing the quality of healthcare while increasing hospital costs,” the statement reports.

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Critical care tutorials

I came across this excellent reference for critical care that case managers may wish to use in their review of cases as part of the admission to Intensive Care Units. While screening criteria provides guidance from an intensity of service and severity of illness standpoint as to clinical conditions warranted admission and continued stay in the ICU, there are instances where patients do not meet the ICU criteria as published, yet from a clinical perspective the patient appears to be “sick” enough to appropriately be admitted and managed within the confines of the ICU.

In an earlier post, I discussed the merits and importance of physician clinical documentation to support his/her clinical impression and reflection of medical decision-making and clinical judgment. With this in mind, one may find the critical care tutorials helpful in expanding one’s knowledgebase and clinical understanding of critical care from a physician’s perspective. The tutorial includes definitions of critical care including a discussion on the different clinical entities constituting critical care. A quick review of these tutorials will help in gaining a better appreciation for critical care, thereby assisting the case manager in recognizing possible physician clinical documentation deficiencies contributing to inaccurate reflection and reporting of patient acuity, patient acuity required to clinically substantiate admission to the ICU. To this end, the case manager can address the identified  documentation deficiencies with a clinical discussion with the physician.

The critical care tutorials can be found here.

Enjoy

The physician advisor: An invaluable resource

If your facility does not have a physician advisor, my recommendation is to get one. The physician advisor at our facility is great. Dr. Jim Chambers is very knowledgeable, not only in the field of cardiology, but he is quite knowledgeable in the area of coding. Dr. Chambers has spend countless hours educating and assisting our hospital billing department in establishing correct billing codes.

Documentation is key in obtaining the appropriate billing code. Physicians work hard taking great care of their patients, but what they lack is being able to document everything they have done for the patient and the outcomes. Outcomes are essential in the world of coding. For example, when a patient comes in with an abnormal prealbumin level, the physician treats this, but yet sometimes only documents that the patient has malnutrition. In this case, the hospital is reimbursed at the lowest level for malnutrition.

The stages of malnutrition are based on the prealbumin level, so the physician needs to document what level of malnutrition the patient is experiencing as there is dollar difference in the different levels of malnutrition. Our physician advisor has been working with our physicians to correct this. [more]

Call for Complex Cases

Are you proud of the way your case management staff handled a particularly difficult case? Want to share your experiences with other hospital case managers?

In each issue of HCPro’s journal, Case Management Monthly, we feature a true Complex Case submitted by you, our readers. This is a great opportunity for you to get published and share with hospital case managers around the country.

Interested in submitting a case? Have questions about how your case will be used? Email editor Julie McGinley at jmcginley@hcpro.com.