All Entries in the "Level of Care" Category

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.

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?

Condition code 44 – The continuing saga

On August 28, CMS issued Medicare Claims Processing Manual (MCPM) transmittal 1803, which is the October 2009 update to the Outpatient Prospective Payment System (OPPS). CMS included minor revisions to those sections of Chapter 1 of the MCPM that relate to condition code 44.

As you will recall, condition code 44 is used when a patient’s initial inpatient status is successfully changed to outpatient for purposes of billing and payment. This generally occurs when case management and other utilization review personnel were not available (weekends and holidays) at the time that the admission decision was made, and it is later determined that the patient does not meet Medicare’s inpatient guidelines. Condition code 44 is reported on the subsequent outpatient (013X) type of bill that is submitted to recover for the services provided in the inpatient setting.

Those inpatient services are covered and reimbursed on the same terms and conditions as if they actually had been provided in the outpatient setting, so long as all of the following criteria are met:

• The decision to change status must be made by the hospital’s “utilization review committee” (UR committee). One “member” of the UR committee can make the decision, with the attending physician’s agreement; in all other cases, the decision must be made by at least two “members.” The change in status must be made prior to discharge or release of the patient and before the hospital has submitted a claim for the inpatient admission;
• A physician must concur with the decision;
• The physician’s concurrence must be documented in the patient’s medical record; and
• The UR committee must provide written notice to the hospital, the patient and the patient’s physician within two days (but not later than the patient’s discharge or release from the hospital) of the change and its impact on the patient, including financial liability for applicable deductible and coinsurance amounts.

In the transmittal issued on August 28, CMS stated that although one physician member of the UR committee is empowered to make the decision to change status, the physician member who makes the decision must be different from the concurring physician, who is the physician responsible for the care of the patient. Based upon this most recent statement, it is not clear what the effect would be if the physician responsible for the care of the patient did not concur with the change in status.

The regulations that set out the hospital’s conditions of participation (CoP), which call for the establishment of a UR committee, along with the scope of its responsibility and authority (including change of status), indicate that, in all other circumstances, the change in status decision must be made by two members of the UR committee. Presumably, this is the procedure that a hospital should follow if it were unable to obtain the agreement of the patient’s physician to change the status of care from inpatient to outpatient.

Hospitals are encouraged to have at least two signatures on the documentation for the change in status: (1) when the attending physician concurs, signatures of both the attending physician and the physician member of the UR committee who made the change in status decision; or (2) when the attending physician does not concur, signatures of the two physician members of the UR committee who made the decision to change status.

Hospitals are also encouraged to confirm with their FI/MAC that the process as outlined above, particularly when the patient’s physician does not concur, meets the requirements of a condition code 44 change in status.

Editor’s note: This article was written by Judith Kares, an, instructor for HCPro’s Medicare Boot Camp – Hospital Version. It was originally published on the MedicareMentor blog. Read the original post here.

Documentation requirements for critcal care services

Editor’s Note: This blog was originally posted by Melissa Varnavas, CPC, the associate director of the Association for Clinical Documentation Improvement Specialists, for the ACDIS Blog. Read the original post here.

In the July 23 issue of CDI Strategies, Robert S. Gold, MD, founder of DCBA, Inc., in Atlanta, offered a tip to help CDI specialists gain physician support for improved documentation in the medical record regarding critical care. In a subsequent e-mail, Gold added comments from his “guru” on physician professional billing, Paul Dickson, MD.

Here is the amended information:

Critical care does not include ongoing monitoring of a patient who has stabilized, regardless of how many organs have failed in the past, but have now stabilized, how many lines and tubes were inserted, or how many devices were instituted. When the patient is stable, it is not critical care.

Too many physicians, however, do not realize that we can bill:

• Critical care delivery by time increments for the first encounter
• Additional critical care when the patient crashes again
• A level three subsequent visit for noncritical care in addition to the critical care delivery on the same day

Any usual evaluation and management (E/M) service appropriate for services and documentation provided may be billed prior to a critical episode, but not vice versa. Consider the following case study.

A patient presents to the cardiac care unit after a coronary artery bypass graft. The patient is intubated with a left ventricular assist device still in place but is not active and receives low-dose dopamine for renal perfusion. The patient’s vital signs are stable with a little hypotension due to lack of vascular tone due to residual effects of anesthesia, however, it is easily controlled. The external pacer is in place, chest tubes are in place to underwater seal, and diluted urine is flowing through the Foley. A physician accepts the patient onto the intensive care unit (ICU) and performs an evaluation. The patient is not critically ill. However, the patient is on a respirator, and the physician manages that respirator. This may be ventilator management 94002-3 alone, and no E /M service may be billed with these codes.

In this case, the patient does not have acute respiratory failure. Writing the words “acute respiratory failure,” means a condition exists that involves the respiratory tree due to a disease process. If, indeed, the patient does have acute respiratory failure due to a disease process when he underwent the surgery, then it is appropriate to document that, if it still exists. If this is not the case, then the presence of the words “acute respiratory failure” will give the heart surgeon a black mark since the condition would be considered a complication of the surgery. [more]

Do you use Milliman?

We are looking for case management departments that use Milliman Care Guidelines for a future project. If your facility uses Milliman, please get in touch with me.

Ben Amirault
bamirault@hcpro.com
781-639-1872 x3934

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.

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

Medical necessity beyond screening criteria

An underlying foundation for case management is the practical and consistent use of commercially available screening criteria as guidance for initial admission patient status designation as well as continued stay determinations. I call your attention to the term “guidance” from the perspective of Medicare and the Recovery Audit Contractors (RAC).

In a RAC Special Open Door Forum held by Medicare on April 9th, several comments by Medicare representatives and RAC representatives, including the medical director for Health Data Insights, make it very clear that the screening criteria will not be used in and of itself to determine medical necessity or lack thereof for inpatient hospitalization. Consider the HDI medical director comment regarding his organization’s application of screening criteria in the medical necessity determination process:

“We follow CMS guidelines which are that these different products are guidelines. They’re not conclusive for a decision to or for a finding or not a finding.  We have contracts with both Milliman and Interqual and intend to use those along with clinical review judgment and of course, first and foremost the CMS guidelines.”

The implications for the case manager

Unequivocally, screening criteria should be applied and followed as part of the patient status
designation determination process. Just the same, the physician’s clinical judgment, medical-
decision making and clinical impression can and must be incorporated in this decision-making
guidance process.

The real challenge faced by case managers is the physician’s medical record documentation of the same. Commonly, the documentation available to the case manager upon initial and continued stay chart review fails to accurately and completely capture and represent the patient’s true clinical acuity, risk of morbidity and mortality, and other physician clinical concerns that ultimately led the physician decision to admit the patient to the hospital. This lack of focus in clinical documentation further challenges the case manger in providing objective guidance in the complex, arbitrary patient designation status process. [more]

Case study: Avoidable days

The following case study uses InterQual® commercial screening criteria as an example.

InterQual is a set of clinical, criteria-based guidelines that give hospitals suggestions for the most appropriate level of care based on the patient’s medical needs and stability. It is a common language for practitioners that, if used correctly, will help a hospital reduce medically unnecessary acute days, improve the quality of discharges, promote patient safety, and reduce denials from third-party payers.

InterQual’s medical necessity criteria are:

• Severity of Illness (SI): Criteria that consist of objective, clinical indicators of illness, which focus on an individual patient’s clinical presentation rather than diagnosis
• Intensity of Service (IS): Criteria that consist of monitoring and therapeutic services, singularly or in combination, which can only be administered at a specific level of care
  • Stand-alone IS criteria: Criteria that consist of services that should only be provided in an acute care hospital, given that the SI supported an inpatient admission
  • *(Asterisked) IS criteria: Criteria that consist of services that could be provided at a lower level of care based on the type of service or the patient’s stability
• Discharge Screens (DS): Criteria for determining clinical stability and level of care appropriateness

The three criteria patterns are:

1. Does not meet IS and meets DS. This pattern represents patients ready for the next level of care with unnecessary and avoidable days. This is the most common pattern and may represent unnecessary utilization.

2. Meets IS and meets DS. This pattern represents patients who may be ready for a lower level of care, but who are still receiving acute care services. This pattern may represent overutilization.

3. Does not meet IS and does not meet DS. This pattern represents patients who are acutely ill and may not be receiving acute care services necessary for definitive treatment. This pattern may represent underutilization.

For example:

8/07/09 IS cardiac monitor, Lasix 20 mg PO BID, 2LO2/NC*
_____________________________________________________________________
DS NSR (82), RR 20, O2 sat 97% RA, eating 80% of meals, 1.3 kg Ø

On this day (8/07/09), the patient does not meet IS and meets DS. Fortunately, since the case manager was monitoring the patient yesterday, the discharge has been preplanned and everything is ready to go. There will be no potential avoidable day (PAD) assigned to this case.

But what if the attending physician refused to discharge the patient on this day (8/07/09)?

In general, if the DS is met and the discharge is not scheduled or is not included in the immediate plan of care, the case manager must contact the attending physician regarding the discharge plans or justification for continued stay. If the attending physician does not agree with the case manager’s assessment of discharge readiness and cannot justify a continued stay, the case should be referred to the physician advisor (PA). If the PA concurs with the case manager’s findings, the attending physician must be contacted to discuss the case. The PA may approve a continued stay based on medical judgment and not the criteria. The PA should document the outcome of his or her review and rationale for the decision on a PA referral form. If the PA concurs with the case manager, then:

a. A PAD is assigned to the attending physician
b. The case manager and PA follow the hospital and QIO procedure for issuing a Medicare continued stay denial letter, if necessary

This patient (let’s call her Mrs. B) had an LOS of two days. This is a very short LOS, but as you can see from the previous scenario, Mrs. B did not need to stay another day in the hospital. She was stable and safe to go home—and home is a much safer place than a hospital.

Editor’s note: This case study was adapted from The Avoidable Day Analyzer: Data Identification Tools for Effective Case Management, Second edition.Order your copy today online at HCMarketplace.

Manual changes related to condition code 44

I’d like to turn my attention to the manual changes related to condition code 44, as promised. Overall, the changes were designed to incorporate discussion and FAQs that were previously published in MLN Matters Article SE0622. In this respect, the changes to the manual have very few surprises. Almost everything added came directly from SE0622 and nothing added was really anything new. With that said, however, I do think that hospital case managers and anyone involved in condition code 44 cases or billing for cases with changed status should review the changes carefully to be sure they are following all the guidance provided.

One of the disappointing things about the changes is that they did not address the issue of whether the period of time from the inpatient order up to the time the patient is changed to outpatient and the observation order is written can be billed as observation time. The language stating that the entire episode of care should be billed as outpatient remains unchanged and nothing was added to clarify it. However, if we carefully consider the other changes made to the observation sections, I think we can discern that CMS does not mean for these hours of care to be billed as observation.

The statement that the entire episode be billed as outpatient would seem to be saying that any service that was rendered during the episode of care should be billed under the outpatient billing, coding and coverage rules. For instance, if the patient had an x-ray during the time prior to being changed to an outpatient, this x-ray would be billed on a revenue code line with a HCPCS code, in accordance with any outpatient edits and policies that might exist. An order for the x-ray would be required and it would be subject to the outpatient medical necessity coverage rules like any other outpatient x-ray.

Applying this same analysis to the observation services, they would be billed as outpatient services on a revenue code line for observation with the appropriate observation HCPCS code. To be billed to Medicare they would have to meet all the coverage and billing requirements, just like the x-ray. This is where the new changes to the observation section of the manual perhaps add a bit of clarity, though the issue is still not crystal clear. The revisions to Claims Processing Manual, Chapter 4 § 290.4.1, indicate that G0378 is used when observation services are “ordered and provided”, with the word “ordered” added. Additionally, revisions to Claims Processing Manual, Chapter 4 § 290.2.2 indicates that time is calculated from when the services are initiated in accordance with the physician’s order. Both of these changes emphasize that an order is required for the observation services to be billed, and seem to indicate that order must be received before time for the services can be counted. [more]