Archive for October, 2010
Bill will allow observation time to count towards three-day SNF requirement
Joe Courtney (D-CT) has introduced a bill (HR 5950) in the House of Representatives that will allow observation stays that exceed 24 hours count towards the three-day inpatient hospital stay required for Medicare coverage in a SNF. A similar bill will be introduced in the Senate
In support of the new legislation, Rick Pollack, American Hospital Association (AHA) executive vice president sent a letter to CMS which highlights changes to the Medicare inpatient only list, Medicare billing policy, and Medicare audits, that have led to the increase in extended observation stays.
Improvements in medical technology have allowed more procedures to be performed in the outpatient setting, and as a result CMS has removed many medical services from the inpatient only list. This means that more patients require observation services to ensure that they are stable and safe to discharge, the letter states.
The AHA also cited a change in CMS’ billing edits as a reason for more extended observation cases. In 2006 CMS eliminated a claims-processing edit that rejected outpatient claims containing more than 48 hours of observation services. According to the AHA, many hospitals eliminated their internal edits which allowed the claims to be submitted.
Hospital leaders also use observation services to avoid jumping through Medicare policy hoops. The AHA noted that the process required to change an inpatient admission to observation services using condition code 44, is too elaborate and many physicians will err on the side of assigning observation services to avoid it. “The administrative burdens and financial consequences associated with [recovery audit contractor] audits, and subsequent appeals, have caused hospitals and physicians to exercise greater caution when admitting patients for inpatient stays.”
Download the Patient Discharge Plan form
Diana Cripe, MSW, director of case management at Morton Plant Hospital in Clearwater FL was kind enough to share her facility’s Patient Discharge Plan form in the November issue of Case Management Monthly.
Each inpatient has a Patient Discharge Plan form that the multidisciplinary team marks throughout his or her stay. Looking at the form, patients can easily see the problem they presented with, the care they received while in the hospital, and the specific healthcare goals they need to monitor after they leave.
Patients can present the form to care providers at follow-up appointments to give the provider an idea of what went on during the patient’s hospital stay.
Hospital leaders consider case management a top priority
Community hospital CEOs and C-suite executives consider case management the second most important strategic initiative, according to a survey conducted by Curaspan Health Group.
On a 1-to-10 scale, the respondents ranked clinical care highest with a score of 9.3, while case management scored 8.4. Functions often included in case management, such as utilization management and denials management, scored 8.1 and 7.5, respectively.
The results suggest that while the more narrow case management functions matter, what matters more to hospital leadership is how they all work together, writes Jackie Birmingham, RN, MS, is vice president of regulatory monitoring and clinical leadership at Curaspan Health Group said in a column published in Curaspan Connections.
Improving postacute relationships
Although Birmingham was pleased to see that hospital leaders value case management, she was disappointed that they ranked networks with postacute providers last, scoring 6.9. The ranking was particularly odd because respondents ranked transition management fourth, scoring 7.7.
“You can’t have effective transition management—or case management, for that matter—without postacute providers,” Birmingham writes.
Birmingham encourages case managers to make sure their facilities have strong relationships with postacute providers and that hospital leadership appreciates the value of that network.
If every patient seems like a hard-to-place patient, you need to expand your network, she adds. Consider technology if turnaround on referrals takes a long time and information is falling through the cracks. Hospitals can significantly decrease delay days if they invest in building efficiencies with their postacute providers.
With a tuned-up network in place, case managers can highlight its value to hospital leadership. Collect and distribute data that shows how reduced placement time has helped cut LOS by cutting down delay days and how more targeted placements have trimmed preventable readmissions.
Offer physicians insight not just ‘education’
Editor’s Note: The following blog post originally appeared on the Association of Clinical Documentation Improvement Specialists (ACDIS) blog site.
I recently received a fortune cookie from a colleague. After reading the fortune several times, I realized the hidden message certainly has direct relevance to clinical documentation improvement (CDI) efforts toward affecting overall change in patterns of physician documentation. It read:
“Anyone can memorize things, but the important thing is to understand it.”
Most people remember reading college textbooks, listening to professorial lectures, taking notes, and regurgitating the information we supposedly “learned” on tests and final exams, as part of our endeavors of higher learning. We always seemed to ask ourselves why we were “learning” the majority of that rote information anyway. It was difficult to appreciate and understand its practicality and usefulness.
Now, let’s look at CDI training and education. The majority of training, education, and execution of CDI programs center around:
- understanding the MS-DRG system
- learning what a MCC/CC is
- gaining a practical sense and understanding of coding rules and policies governing principal and secondary condition selection/assignment
- learning how to review the record
- learning how to identify opportunities to improve clinical documentation and financial reimbursement
Finally we learn how to enter the data into the tracking software for reporting purposes. If we’re lucky we learn to track
- how many queries were left
- how many were responded to
- how many contained a positive response
- how often records were reviewed
- how much of a financial impact CDI has on hospital’s bottom line
The entire process is similar to the college experience in the sense we “memorize” the steps of CDI, apply its principles consistently, and ensure we review the standard number of records each day in the name of that learning. While I am not fundamentally against established “quotas” for record review, I do advocate for quality of chart reviews which work in tandem with CDI efforts to educate of physicians, particularly to the extent that we are not repeatedly leaving the same queries day in and day out for the likes of acute blood loss anemia or the type of congestive heart failure. [more]
Happy Case Management Week
Case managers, this week is your time to shine.
National Case Management Week is your opportunity to tell everyone else what you and you fellow case managers already know; case managers are an essential part of hospital operations. Whether it’s helping physicians determine level of care, reviewing orders for medical necessity, ensuring proper use of resources, setting discharge plans for patients, or helping prepare RAC appeals, case managers are involved in patient care from door to door.
If you are looking for National Case Management Week posters, banners, and pins to help spread the word check out the American Case Management Association’s National Case Management Week catalog.
The Case Management Society of America (CMSA) also put out a 20-page packet that is full of ways you can raise case management awareness:
- 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 National Case Management Week.
- Write a guest editorial to newspapers, journals or magazines regarding the positive impact of case management.
- Distribute a press release announcing National Case Management Week.
This is not an exhaustive list. See the full list of suggestions at the CMSA Web site
What are your plans for National Case Management Week?
Medicaid RACs coming soon
Editor’s Note: The following blog post was adapted from the Revenue Cycle Institute.
CMS has begun laying the groundwork for expanding the RAC program to Medicaid. The agency released an information collection form and supporting documents for contractors for Medicaid plans September 10. The release of formalized information comes as no surprise, according to Elizabeth Lamkin, MHA, president of Dalzell Consulting Group, Inc., in Hilton Head, SC.
“As we learned from the Medicare RAC demonstration project, the RACs collected $1.3 billion at a cost of 20 cents on the dollar,” she says. “There is a huge incentive to expand the RAC program to Medicaid.”
The forms list several criteria for the RAC expansion, including provisions related to:
- Payment of the Medicaid RACs
- Appeal of adverse Medicaid RAC determinations
- Coordination of Medicaid RAC activity with other reviewers and entities (e.g., the Medicaid integrity program)
According to the Federal Register, CMS created the forms to prepare for the RAC expansion into Medicaid, as required by the Patient Protection and Affordable Care Act:
Under section 1902(a)(42)(B)(i) of the Social Security Act, States are required to establish programs to contract with one or more Medicaid RACs for the purpose of identifying underpayments and recouping overpayments under the State plan and any waiver of the State plan with respect to all services for which payment is made to any entity under such plan or waiver. Further, the statute requires States to establish programs to contract with Medicaid RACs in a manner consistent with State law, and generally in the same manner as the Secretary contracts with Medicare RACs.
State programs contracted with Medicaid RACs are not required to be fully operational until after December 31, 2010. States may submit, to CMS, a State Plan Amendment (SPA) attesting that they will establish a Medicaid RAC program. States have broad discretion regarding the Medicaid RAC program design and the number of entities with which they elect to contract.
Because the administration of Medicaid is up to individual states, the expansion of RACs into Medicaid may in fact prove difficult, according to Lamkin.
“We do not know how the RAC contractors will interpret state rules or work with providers,” she says. “We may see the problems much as we did in the Medicare demonstration project based on a learning curve for providers and RAC auditors.”
CMS followed the information collection with letter to state Medicaid directors on RAC expansion. The letter instructs each state and territory to either attest that it will establish a Medicaid RAC program by December 31, 2010, or indicate that it is seeking an exemption from this provision.
