Archive for January, 2011

CMS issues guidance on hospital inpatient admission decisions

Despite the loads of guidance CMS offers about proper inpatient admission decisions, it appears that hospitals still cannot get it right. In order to clear up any confusion CMS issued a special edition MLN Matters article that includes excerpts from several CMS manuals for guidance.

The release is timely. Medical necessity determinations have become a hot button for government auditors such as recovery audit contractors (RAC), Medicare administrative contractors (MAC), fiscal intermediaries (FI), and comprehensive error rate testing (CERT) contractors. Facilities that do not assign appropriate patient status risk losing reimbursement.

Commercial screening criteria

While commercial screening products such as Interqual and Milliman, may assist facilities in making patient status determinations, CMS explains in the release that such products are just one of several tools providers can use to make the call. The release includes an excerpt from the Medicare Benefit Policy Manual, which states, “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.” It further states:

The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient’s medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital’s by-laws and admissions policies, and the relative appropriateness of treatment in each setting. Factors to be considered when making the decision to admit include such things as:

• The severity of the signs and symptoms exhibited by the patient;
• The medical predictability of something adverse happening to the patient;
• The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and
• The availability of diagnostic procedures at the time when and at the location where the patient presents.

Staff education

Providers should use the Special Edition MLN Matters article to help educate physicians, case managers, and any other clinical staff involved in the decision-to-admit process, says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc.

In addition, Mackaman says coders and CDI specialists should use the article to identify potential documentation improvement areas. Auditors and compliance staff should also review the specific manual sections to ensure compliance with the regulations.

The release may also pose a challenge for providers that rely heavily on screening criteria, according to Deborah Hale CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, OK.

“Certainly one can understand the need for physician judgment to determine that an admission is unnecessary but to say that a hospital can’t depend upon screening criteria to determine that an admission is necessary becomes a challenge.”

To read the special edition MLN Matters article, click here: http://www.cms.gov/MLNMattersArticles/Downloads/SE1037.pdf

Editor’s note: HCPro Associate Editor Jimmy Carroll contributed to this article.

Decrease length of stay through communication and collaboration

The case management team’s objective is to come up with a safe, agreed upon discharge plan for the patient and develop goals to reach that discharge plan in a timely manner and cost effective manner. The only way to accomplish that objective is through proactive, ongoing communication within the team.

At the healthcare facility where I am the director of case management, we have a -team of highly-skilled, experienced social workers and case managers with intermingled job responsibilities. The social workers assess the patient’s environmental and social issues, while the case manager’s focus on the medical barriers preventing discharge. The entire team then meets every morning to brainstorm possible solutions to overcome those barriers. The social workers and case managers continue to communicate with each other during the day to develop appropriate discharge plans.

The physician advisor is also in constant communication with our team. We meet weekly with our physician advisor to discuss the patients’ care plan, LOS, and barriers to discharge. This leads to further communication between case managers, social workers, physician advisor, and attending physicians.

If you are not communicating as a team, you will not be successful in decreasing LOS. And in the end, it is the patient that loses out. I am lucky to have such a great team of case managers and social workers. Together we continue to strive to make our great team even better. Get engaged with your case management team today!

CMS issues proposed rule on value-based incentive payments to acute care hospitals under the IPPS

Editor’s note: Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc., wrote the following post for the Medicare Mentor blog.

As part of its continuing efforts to forge a closer link between Medicare’s payment systems and improvement in healthcare quality, CMS recently published a proposed rule to provide value-based incentive payments to those acute care hospitals that meet relevant requirements.  These incentive payments are to be incorporated into the IPPS (which is the principal acute care hospital payment methodology) effective for discharges on and after the beginning of FY 2013 (10/1/12).

As stated in a related fact sheet issued at the same time, “The transition of these [quality] initiatives to value-based purchasing is intended to transform Medicare from a passive payer of claims based on volume of care to an active purchaser of care based on the quality of services its beneficiaries receive.”  The proposed hospital value-based purchasing program (the “Hospital VBP”) would provide value-based incentive payments to hospitals based on their achievement, or improvement, on a set of specific quality measures.   These measures are designed to foster improved clinical outcomes, as well as to improve the overall quality of the inpatient experience from the patient’s perspective.

Under the hospital VBP, CMS would evaluate a hospital’s performance during an identified performance period based on achievement or improvement relative to performance standards established for that period. Those hospitals that met the standards established for that period would receive incentive payments going forward.  These incentive payments would be funded through a reduction in base operating DRG payments for all hospital discharges, beginning with a 1% reduction to base operating DRG payments in FY 2013 and rising to a 2% reduction by FY 2017.

Proposed Quality Measures for FYs 2013 and 2014

For FY 2013, which would be the first year for implementation of the hospital VBP, CMS proposes to use 17 clinical process of care measures as well as 8 measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that documents patients’ experience of care. These specific quality measures are set out in Appendix A of the related fact sheet.

For FY 2014, in addition to those measures identified for FY 2013, CMS proposes to adopt three mortality outcome measures, eight hospital-acquired condition (HAC) measures, and nine Agency for Healthcare Research and Quality (AHRQ) measures.  These additional quality measures are also set out in Appendix A of the related fact sheet.

Proposed Performance Scoring

The proposed performance period would generally be a year, with some exceptions, including a nine-month performance period (July 1, 2011 through March 31, 2012) for incentive payments to be paid during FY 2013.

The scoring process appears to be the most complex aspect of the hospital VBP.  CMS proposes to score each hospital’s performance on each quality measure, which would be evaluated based on the higher of its achievement score in the performance period or its improvement score.  The latter would be determined by comparing the hospital’s score in the performance period with its score during a baseline period of performance.

For each of the proposed clinical process and patient experience of care measures that apply to a hospital for FY 2013, CMS proposes that a hospital would earn 0-10 points for achievement, based on where its performance for the measure fell within an achievement range (which is a scale between an achievement threshold and a benchmark).  With regard to the improvement score, CMS proposes that a hospital would earn 0-9 points for improvement, based on how much its performance on the measure during the performance period improved from its performance on the measure during the baseline period.  Finally, CMS would calculate a Total Performance Score (TPS) for each hospital, which would involve combining and weighting relevant factors.

Proposed Incentive Payments

After calculating each hospital’s TPS, CMS would translate that TPS into a value-based incentive payment using a linear exchange function.  For FY 2013, CMS proposes to notify each hospital of the

1. Estimated amount of its value-based incentive payment through its QualityNet account at least 60 days prior to Oct. 1, 2012; and
2. Exact amount of its value-based incentive payment on or about Nov. 1, 2012.

Because of the complexity of the proposed rules and the significant potential impact on inpatient reimbursement, hospitals are strongly encouraged to review these rules in considerable detail and to provide all relevant comments, together with supporting data, to CMS within the comment period.

Meet face-to-face requirement for home healthcare services

The new year is upon us and with it comes a new requirement for Medicare patients who require home healthcare services.

A provision of the Affordable Care Act mandates that certifying physicians document that they or an allowed non-physician practitioner (NPP) has had a face-to-face encounter with the patient before certifying eligibility for the home health benefit. This encounter must occur within 90 days before the start of care or 30 days afterward.

The goal of the new rule is increasing physician involvement in patient care, according to Jackie Birmingham, RN, MS, is vice president of regulatory monitoring and clinical leadership at Curaspan Health Group. Birmingham wrote about the new requirement in the current issue of Curaspan Connections.

Birmingham writes:

I’m old enough to remember house calls, and while I know they won’t return, I still believe physician involvement—contact with patients—should be at the very foundation of health-care delivery. Apparently lawmakers, looking for (more) ways to cut costs and increase accountability, agree but found that’s not always the case. So, we now have this new regulation that micro-manages providers.

Hospital case managers can meet this requirement in the following ways:

• Determine who will perform the face-to-face encounter as part of the discharge process
• Develop a policy for documenting encounters and transmission of documentation to home-health agencies.

Remember that without certification, there’s no reimbursement. Home healthcare agencies will be looking for documentation; otherwise, they may not accept patients Birmingham writes. This can cause throughput problems as patients linger in hospitals, or patients may be sent home without services, only to be readmitted.

Applying for the Community-Based Care Transitions Program

Assuming Republicans in Congress don’t make good on their promise to defund and repeal the Affordable Care Act, 2011 will bring new initiatives designed to improve quality of care. One such initiative is the Community-Based Care Transitions Program (CCTP) demonstration project, which will fund efforts to improve transitions from hospitals and reduce readmissions.

Acute care hospitals with high readmission rates can claim a piece of the $500 million allocated to the program if they can demonstrate a relationship with community-based organizations. Selected hospitals will be expected to report process and outcome measures on their results and participate in an ongoing learning collaborative. CMS also expects participants to perform the following tasks:

• Initiate care transition services no later than 24 hours before discharge
• Provide timely, culturally, and linguistically competent post-discharge education
• Ensure timely and productive interactions between patients and providers
• Review and manage patient medications
• Support patient-centered self-management

How to apply

Linda Magno, Director of the Medicare Demonstrations Program Group at CMS said in early December 2010 that CMS would release a solicitation of applications by the end of the year, but it failed to do so. However, that doesn’t mean interested facilities shouldn’t begin to gather the necessary application information.

Applicants must complete a root-cause analysis that identifies factors that contribute to a high readmission rate in a community. Applicants also must draft a proposal that explains their plans:

• To address root causes
• To work with accountable care organizations and medical homes
• To align the organization’s care transition program with other related initiatives

Magno said CMS expects applicants to show they are ready to implement their initiatives immediately. Hospitals that have already established relationships with a CBO and begun to train staff on improving transitions are more likely to be accepted.

Section 3026 of the Affordable Care Act directs CMS to give preference to physician group practices and other applicants that meet the following requirements:

• Participate in a program administered by the HHS Administration on Aging
• Provide services to medically underserved populations, small communities, and rural areas