Archive for October, 2009

Listen to expert interpretation of Condition Code 44 regulations

Condition code 44 is one of those topics that never goes away.

• Can we use condition code 44 if the physician has already written the discharge order?
• Can we use condition code 44 if the attending physician doesn’t concur with the utilization review committee?
• Can we use condition code 44 to change inpatient time to observation services?

For whatever reason questions like these continue to come up. Perhaps it’s the vaguely-worded regulation or the conflicting advice found on the internet. Whatever it is, people are confused.

We at HCPro were thinking that because condition code 44 is such a contentious and confusing topic perhaps a written article is not the best way to explain it. That’s why we decided to call in the experts (Kimberly Anderwood Hoy, JD, CPC, the director of Medicare and compliance for HCPro, Inc and Sandra McCune BSN, RN utilization management specialist) for a 90-minute audioconference that will hopefully put all your condition code 44 concerns to bed.

How and McCune will share their interpretation of the rule using the official guidance provided by CMS. The program includes a 30-minute question and answer portion that will give you the chance to get your burning condition code 44 question addressed by our experts.

Take a listen to the following audio clip I recorded with Kimberly Hoy. In it, she explains why it is important for folks to listen to the program and highlights some of the important information the audience will take away.

If you like what you hear head over to the HCMarketplace and sign up for the program, Condition Code 44 and the Utilization Review Committee: Ensure Process and Documentation Compliance.

Is H1N1 hype clogging your ED?

Is it a cold or something worse?

The nightly news is teaming with stories about seemingly healthy young people becoming critically ill from the H1N1 virus, and people are worried.

I am no exception. When I hear a coworker cough of sniffle, I get a little uneasy. I have been able to stay healthy during this young flu season. However, should I find myself running a fever and coughing, my unease might turn to worry. And where do most folks go when they are worried about their health? The doctor, or if they can’t wait for an appointment, the ED.

EDs are crowded as is. The last thing ED staff members need is people presenting to the ED that are afraid their head cold could kill them. That is why Emory University and Microsoft have teamed up to create a the H1N1 (Swine Flu) Response Center.

The H1N1 (Swine Flu) Response Center is a Web-based assessment tool that asks site visitors a series of questions, including:

• Age
• Gender
• Geographic location
• Severity of symptoms
• Length of symptoms

After answering these questions, users receive symptom management advice. In severe cases, the tool instructs users to consult a physician immediately. In less severe scenarios, the tool may instruct users to visit a walk-in clinic or stay in bed and drink fluids.

Site sponsors hope people with less severe symptoms will use this tool’s advice instead of visiting the ED, but is it enough? Some folks might be satisfied by this tool opinion, but others might not trust the advice, after all, there is no better cure for worry than the clinical judgment of a real, live healthcare professional, right.

Tell us about what is going on at your facility. Is your ED crowed with people with flu symptoms, looking for a little reassurance that they are not facing peril? Has your facility developed a system to handle the expected surge in visitors?

Are you paying attention to your case mix index?

What is Case Mix Index (CMI) and why, as a case manager, do I care what that is?  According to the Financial management for nurse managers and executives (3rd ed.), CMI is the measurement of the average severity of illness of patients treated by a healthcare institution.  Basically, CMI helps determine the dollar amount assigned to a diagnosis related group (DRG) for the Medicare population. Medicare assigns a dollar amount for every facility, which is partially determined by the CMI.

Hospitals use the CMI to determine the budget, and if the actual CMI is lower than the budgeted CMI, the incoming money for those DRGs will be less. This causes an imbalance in the hospital revenue. If the money isn’t coming in as planned, a financial fiasco can occur. Think of CMI as the yellow light that warns the hospital of any impending decrease in hospital income. The financial wizards and senior management monitor the CMI on a monthly basis.

Appropriate DRG assignment for each inpatient case impacts the CMI. This is another reason why complete and accurate documentation is important. Coders need thorough documentation to assign the appropriate DRG. Appropriate coding determines the DRG, and the average DRG weight determines the CMI. Case management and clinical documentation improvement specialists can help the coding team by ensuring documentation supports the appropriate diagnoses, which will lead to appropriate assignment of a DRG.

CMI is complex, but essential to the revenue survival of hospitals. CMI is used to adjust the hospital’s average cost per patient. CMS uses the annual CMI to determine the DRG amounts for the next year. CMI is a very complicated concept to grasp, but it is important to remember that CMI is a tool that is used to predict income, outlines patient types, and helps explain the cost of treating a hospital’s population. In the end it goes back to complete, accurate and timely documentation and appropriate coding practices.

Do you know what your institution’s budgeted CMI is and what your actual CMI is?

Speak up: CMSA urges case managers to contact local legislators

You may have heard, but Congress is attempting to enact some type of healthcare reform in the near future. Although the extent of that reform is still up for debate, the conversation about how to improve the current healthcare model is not going away.

What better way to celebrate National Case Management Week than to contact your local legislator and tell him or her about how case managers can improve the healthcare system?

Healthcare reform will have a huge impact on the way you do your job, which is why The CSMA Public Policy Committee is encouraging case managers to speak up and share their experiences.

“We want case managers to share their stories with their local legislators,” said Carol A. Gleason, MM, RN, CRRN, CCM, LRC, BCPC Chair of the CMSA Public Policy Committee.

Gleason says she and the committee are not asking people to talk politics, but rather share what works with the current model and what needs improvement. The idea is that if case managers and other healthcare professionals share their wealth of knowledge with lawmakers, who have likely never worked in a hospital, than our government will be better equipped to create reform that works.

You can also think of it as another form of patient advocacy. Case mangers know how the system affects certain populations because they deal with difficult case everyday. This is a chance to tell the story about the time it broke your heart to tell someone, “I’m sorry but that’s just how the system works.”

The Case Management Model Act

The public policy committee has also created a Case Management Model Act which defines the case management role and explains how the case management principles can be the building blocks for successful healthcare reform. You can download a copy of the Model Act at the CSMA Web site. While you are there, check out the sample letter you can send to your representative and the list of talking points you can use to call him or her directly.

Case Management Week is almost upon us

Case managers, next week is all about you. October 11-17, is National Case Management Week, which is your opportunity to spread awareness about what case managers do and how they improve healthcare across the continuum of care.

Several case management associations have released information that describes how you and your staff members can celebrate all things case management.

If you are looking for National Case Management Week posters, banners, and pins check out the American Case Management Association’s National Case Management Week catalog.

The Case Management Society of America (CMSA) put out a 20-page packet that is full of ways you can raise case management awareness:

• Individual activities
  • Tell 10 other professionals you are a case manager.
  • Offer to speak at community events on case management.
  • Write letters to your local paper. Contact radio and TV stations to let them know about CM Week.
  • Write a guest editorial to newspapers, journals or magazines regarding the positive impact of case management.
  • Distribute a press release announcing National CM Week.
• Community activities
  • Host a celebration or reception to recognize a case manager in your community.
  • Host professional seminars and workshops for health professionals in your community.
  • Arrange exhibits and displays in public facilities.

This is not an exhaustive list. See the full list of suggestions at the CMSA Web site

Please share your plans for National Case Management Week.

Understanding the insurance company case manager’s goals can help hospital case managers

While discussing a hospital admission with a case manager employed by a well-recognized national third-party payer, I learned of an interesting revelation that case managers may wish to take note of.

Each insurer-employed case manager is charged with meeting a monthly average length of stay goal set by the individual hospital as well as the aggregate hospital. The insurance case manager receives a weekly report of cases that achieved average length of stay compared to individually-assigned average length of stay goals and objectives. To this end, the case manager knows at any given time where he or she stands in regards to meeting the assigned goals for hospital length of stay.

This insurance company case manager informed me that he is reminded on a regular basis of the ramifications of not meeting the established monthly length of stay goals. In extreme situations, insurance companies will terminate case managers that do not meet objectives.

Depending on the time of month and how the insurance company’s case manager is faring, hospital case managers can expect different volumes of cases designated for medical director review and potential medical necessity denial. There exists a certain realism that insurer case managers and medical directors may err on the side of conservatism when using Interqual or Millman care guidelines and clinical judgment to determine denial of inpatient stays. The bottom line is hospital case managers will need to take inventory of their communication skills and core competencies, including drafting of effective, succinct denial appeal letters—if the hospital charges him or her with doing so as one of their duties.

In this context, hospital case managers should track and trend denials communicated by insurer case managers and understand these case managers need to achieve pre-established average monthly length of stay goals. Hospital case managers must prepare for increased inpatient stay denials given the current economic climate of private health insurers, decreased member covered lives, and resulting decrease in health insurance premium income. Increased medical loss ratios and the number of uninsured and underinsured patients seeking care through the emergency room with subsequent need for inpatient admission can also add to the number of denials.

I am certainly not advocating for case managers assuming additional work. At many hospitals, the administration assigns new tasks and assignments to case managers with the rationale being case managers already “review the record” and thus have the time to take on new responsibilities. Unfortunately, the case management function has become so convoluted that case managers find themselves regularly performing duties that questionably contribute to the role of case management. However, I am advocating for their development and reinforcement of core competencies and skill sets in the art of “forceful” communication and negotiation.