Author Archive for Case Management Weekly

House approves healthcare reform bill

The House passed its version of the bill, can the Senate do the same?

The U.S. House of Representatives recently passed the healthcare reform bill (HR 3962) by a narrow margin (220–215). The bill’s estimated cost is more than $1 trillion over the next 10 years.

The Senate is working on its own version of the bill. If that version passes, then a congressional conference committee will meet to compromise on the two versions. If the committee reaches a compromise, it will send that bill would to both the House and Senate for another vote. If it passes both houses, the next step is President Obama’s desk for his signature.

Preliminary drafts of the Senate bill differ from the House version with respect to funding. how many individuals will be covered, and the availability of a public option.

Source: CNN

CMW news: Incomplete discharge summaries to blame for preventable errors

A study released by the Indiana University School of Medicine finds that hospital discharge summaries lack information important to patients’ continuity of care.

Indiana University School of Medicine researchers published their findings in the September issue of Journal of General Internal Medicine under the title Adequacy of Hospital Discharge Summaries in Documenting Tests with Pending Results and Outpatient Follow-up Providers.

The researchers reviewed 668 discharge summaries from two academic medical centers. They found that the hospitals discharged nearly 41% of the patients with test results pending—9% of those tests required changes with respect to patient care. However, the hospitals documented only 16% of those tests in patient discharge summaries. Only 13% of summaries included all pending tests.

Researchers say without that information, primary care physicians can’t provide the appropriate care patients need after discharge.

"Errors in communication reportedly contribute to over half of all preventable adverse events and are associated with twice as many deaths when compared with errors due to clinical inadequacy,” researchers conclude in their report.

Source: American Academy of Professional Coders and American Medical Association

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.

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!

University of Chicago’s ED diversion plan scrutinized

The American College of Emergency Physicians says the University of Chicago Medical Center’s (UCMC) new diversion plan for its ED—moving patients with non-urgent needs to community hospitals and clinics—comes dangerously close to violating the Emergency Medical Treatment and Active Labor Act (EMTALA).

EMTALA dictates that hospital emergency departments provide emergency treatment to patients, regardless of the patients’ ability to pay. The complaint comes afterUCMC sent a patient who was attacked by a pit bull to another hospital for surgery. The American College of Emergency Physicians argues this practice comes dangerously close to “patient dumping.”

But UCMC maintains that its program is designed to treat patients at the appropriate location in a tough economic atmosphere.

Source: Chicago Tribune

Do you consider UCMC's program to be patient dumping?

CMW News: The RAC is back on track

The Centers for Medicare & Medicaid Services announced on February 6 that the contract protests over the Recovery Audit Contractors (RAC) have been settled and the implementation of the RAC program will now be continued.

The RAC jurisdictions are as follows:

Region A:  Diversified Collection Services (DCS)
Region B:  CGI Technologies and Solutions, Inc.
Region C:  Connolly Consulting, Inc.
Region D:  HealthDataInsights, Inc. [more]

CMW News: Insured cancer patients struggle to afford treatment

Patients with cancer undergo many expensive treatments and tests and often find themselves bankrupt even if they have insurance, according to a new report.

The report, released by the Kaiser Family Foundation and the American Cancer Society followed 20 typical cancer patients. Of those patients, nine had insurance through an employer, one paid for employer coverage through COBRA, seven had individual insurance, two received coverage through a state high-risk insurance pool, and one became uninsured. [more]

CMW Tip of the Week: Case management deliverables

This week’s tip, an “Ask the Expert,” comes from Karen Zander, RN, MS, CMAC, FAAN.

Q: Why does case management have to prove itself with deliverables?

A: Case management is in a position of having to continuously defend and justify its existence. This saps energy and distracts from case management’s full potential. Because it is relatively invisible, the director must constantly present data, educate the executive team about options, and negotiate resources to do the job well. Through the executive team, and ultimately the CEO, the board will eventually learn about the ever-increasing value of case management services. [more]

CMW Sneak Peek: Harnessing technology to advance case management

You know the drill: rally for improved documentation practices at your facility, train everyone on proper documentation procedures, and become foiled by inexplicably incomplete records, illegible handwriting, and records that are lost in transition. But you’re not alone. This is exactly what case managers at Cleveland Clinic dealt with.

“We used to handwrite all of our documents and referrals,” says Joyce Lewis, RN, case manager at Cleveland Clinic’s postop cardio thoracic unit. “Sometimes things worked out well, but other times, it was extremely cumbersome” due to incomplete patient care records and significant delays in placing patients who required some sort of postacute care. [more]

CMW News: Patients unable to recognize physicians, study finds

A new study conducted by the University of Chicago and published in the Annals of Internal Medicine showed that 75% of hospital patients are unable to name a single physician in charge of their care.

Of the 75% who said they could name a physician, only 40% of them got a name right. Additionally, those who were able to name a physician were more likely to be unsatisfied with their care. [more]