All Entries Tagged With: "Medicare"

Hospitals must begin using revised ABN form November 1

CMS has released a new advance beneficiary notice (ABN) form that hospitals must use beginning in November. The form is currently available for immediate use.

The changes affect the ABN form’s format, but not its substance, Judith Kares, JD, wrote in a blog post for Medicare Mentor. Kares, an expert in Medicare rules and regulations, is an HCPro Medicare Boot Camp-Hospital Version^® instructor.

“The purpose of an ABN is to provide prior notice to a beneficiary (or his or her representative, in the event that the beneficiary is not competent) when the provider believes that Medicare will not pay for certain Part B outpatient services because limitation on liability applies,” Kares said in an earlier post. Limitation on liability applies when Part B outpatient services fall within one of three categories:

• The services do not meet Medicare’s medical necessity guidelines for a patient’s condition;
• The frequency of  a screening service exceeds Medicare coverage for that benefit; or
• The services are custodial.

The intent of the ABN form is to explain to patients that a provider anticipates Medicare will not pay for certain services. Patients will be responsible for payment to providers when they (or their representatives) opt to receive these services.

Use of the ABN form is more common in outpatient settings, but case managers may issue it to observation patients. For example, an observation patient who refuses to leave the hospital may receive an ABN form that explains Medicare will not pay for custodial care.

CMS will allow providers that have supplies of the current form may continue using it until November.  However, ABN forms with a March 2008 release date issued on or after November 1, 2011 will be invalid.

Learn more about ABN and other patient notification forms during HCPro’s August 9 audio conference, “Delivering Inpatient Notifications: Manage The Important Message from Medicare and HINNs”. For more information, visit www.hcmarketplace.com/prod-9598/Delivering-Inpatient-Notifications.html.

Provider-friendly change to tracking observation hours

Editor’s note: The following article is adapted from a blog by Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance at HCPro, Inc., that appeared on Medicare Mentor.

In the July OPPS update, CMS made a very provider-friendly manual change to the section on counting observation hours. CMS amended Medicare Claims Processing Manual, Chapter 4 – Part B Hospital (Including Inpatient Hospital Part B and OPPS), §290.2.2 Reporting Hours of Observation, to allow providers to use average times when determining the amount of time to subtract from observation time for other procedures.

Providers have struggled with this issue since CMS added a clarification to the manual in 2008 that requires providers to subtract time for procedures that require active monitoring and interrupt observation care. Providers struggled with determining which procedures required active monitoring and how much time to subtract for these procedures.

In early 2010, CMS published FAQ 9974, addressing the issue regarding which procedures require sufficient active monitoring to necessitate subtraction from overall observation time. The specific question related to drug administration services. CMS said hospitals must determine service-by-service whether a particular drug administration service required active monitoring because services with the same HCPCS code may or may not need active monitoring. It provided examples of an antibiotic infusion as something that doesn’t require active monitoring and a complex drug infusion titration as something that does.

But this left the issue of how much time to subtract once a hospital determined that a service did indeed require active monitoring. The manual indicated that the beginning and end times of observation, or more likely the procedures, would require documentation to calculate total observation time. However, this was problematic for many of these bedside procedures…For instance for a procedure such as a PICC line placement, providers normally document all pertinent details about the procedure, but don’t necessarily document when they entered or left the room.

The most recent change to the manual will be a welcome change for providers who have struggled with this. CMS now allows providers to use an average time for these procedures that interrupt observation. The new manual section give providers the option of documenting start and stop times or using an average time when subtracting these procedures.

Providers who wish to use this new option, should consider putting in place policies indicating which procedures will be deducted and the average time to be deducted for those procedures.   This may be as simple as updating an existing policy on observation billing, with an addendum with the procedures and their times.

In developing their listing of procedures and average times, the provider should look for the procedures they provided in conjunction with observation by looking at reports for past billing for observation cases.  When determining the average times for those procedures, the provider may need to use several sources including the CPT book, staff interviews and hospital protocols.   Though it doesn’t appear required, it will be useful for future updating to note what resource was used to establish the average time for each particular procedure.

One last note about the July OPPS update; CMS manualized  a topic I discussed a couple of months ago about inpatient only procedures on an outpatient basis within the three day payment window.  At that time, the guidance I was reporting was from the Medical Director of a specific MAC, but CMS has now added this to the Claims Processing Manual, making this a national policy.  For more information see my previous post.

Going beyond the common medical necessity thought process

Many case management professionals are familiar with Title XVIII the Social Security Act, 42 U.S.C. 1395 section 1862 (a)(1)(a), which states:

No Payment may be made under Part A or Part B for any expenses incurred for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Most healthcare professionals consider a service medically necessary if it:

• Meets the provisions of a Local Coverage Determination (LCD) or National Coverage Determination (NCD)
• Is provided at the proper level of care (i.e., inpatient or outpatient)

However, medical necessity acquires new meaning in the context of recent Medicare Administrative Contractor (MAC), Recovery Audit Contractor (RAC) and CERT denials of clinical scenarios that at face value appear reasonable and necessary. Contractors are denying services because physician documentation did not meet reasonable standards to perform the procedures.

Transforaminal epidural injection denials

Special Edition MLN Matters article SE1102 cites “Inappropriate Medicare Payments for Transforaminal Epidural Injection Services,” an August 2010 OIG report. The OIG analyzed a random sample of 433 records involving transforaminal epidural injection services provided in 2007 and found that 34% of transforaminal epidural injection allowed by Medicare didn’t meet Medicare documentation requirements.

Local Coverage Determination L30481, which governs transforaminal injections, states that documentation must meet the following requirements:

• Documentation in the medical record must contain the initial evaluation including history and physical examination, diagnosis, pain and disability of moderate to severe degree, site of injection with name and dosage of drug instilled, and the patient’s response to the prior injections.
• Documentation of conservative therapies that were tried and failed except in acute situations such as acute disc herniation with disabling and debilitating pain, herpes zoster and post herpetic neuralgia, reflex sympathetic dystrophy, post operative and obstetric pain and intractable pain secondary to carcinoma.
• Pre and post procedure evaluation documenting patient’s response to the injection, including pain level and ability to perform previously painful maneuvers must be included in the medical record

Other documentation errors highlighted in the OIG report include the following:

• 19% of transforaminal epidural injection services had a documentation error
  • 10% were undocumented
  • 9% were insufficiently documented
• 13% of injection services had a medical necessity error and 8% had a coding error resulting in overpayments.
• Documentation errors occurred more often in office settings
  • 41% of all errors occurred in physician’s offices
  • 28% of all errors occurred from care provided in facilities [more]

CMS answers questions about the second Important Message from Medicare

The American Case Management Association (ACMA) received a document from CMS that answers questions that ACMA members posed to the agency about delivering the Important Message from Medicare (IM).

The FAQ document is a result of ACMA’s efforts to clarify the cumbersome second delivery requirement. Medicare regulations state that hospitals must provide Medicare beneficiaries with the document at two points during the hospital stay:

• Within two days of admission
• Within  two day prior to discharge, but no later than four hours before the patient leaves the facility

The ACMA conducted a survey about the second delivery requirement and found that case managers generally think “the second IM process adds little value to patient care and adds to patient confusion and frustration.” Attendees of the 2010 NICM/ACMA National Conference echoed those sentiments during a special forum held at the event.

ACMA CEO L. Greg Cunningham took those concerns to a group of CMS administrators who then asked ACMA to create a prioritized list of the most pressing issues and concerns about the second delivery of the IM. The FAQ document addresses many of those pressing concerns.

CMS told the ACMA it is revising sections of the Medicare manual, which will include some of the questions developed by ACMA. CMS will release the revised manual later this year.

View the FAQ document here

CMS issues proposed rule requiring providers to give additional beneficiaries QIO contact info

Medicare-certified providers, including hospitals, home health agencies and others, may soon be required to provide contact information for the local Quality Improvement Organization (QIO) to outpatients and state surveyors.

The February 2 issue of the Federal Register contained a proposed rule that would require select Medicare-certified providers and suppliers to provide Medicare beneficiaries written notice about their right to contact a QIO with quality concerns. Currently, only hospitals inpatients receive QIO contact information, but the proposed rule would extend the requirement to hospital outpatients.

The proposed rule would also require hospitals inform all patients, including Medicare beneficiaries, about State agency contact information.

This proposed rule comes just weeks after CMS issued a proposed rule that would implement a hospital value-based purchasing program, which takes into account patient satisfaction scores. Proving patients with information about how to express quality concerns could be another way for CMS to capture quality across the continuum.

Impact on hospital case managers

In order to meet the proposed change, Sandra McCune, BSN, RN, utilization management specialist at Lakeland HealthCare in St. Joseph, MI, suggests adding the QIO contact information to existing forms, such as the consent for admission and consent for treatment forms. There is no proposed specific form that providers must use, unlike the Important Message from Medicare.

“A copy of the consent form is already maintained in the patient’s record, so that should satisfy the requirement to document that the info was given,” McCune says.

The proposed rule also states that the same contact information must be given at discharge and/or the end of care. McCune suggests adding the QIO contact information to the discharge and post care instructions.

CMS is accepting comments on the proposed rule. To submit a comment, view the instructions in the Federal Register.

Case managers say medically necessary readmissions are being denied

We all know that Medicare will not pay for preventable readmissions that occur within 30 days. But many providers are reporting that certain Medicare managed care plans are also denying medically necessary readmissions.

Several case managers on the American Case Management Association’s LearningLink listserv have shared their experiences on the subject. Most say they have received denial letters of readmissions that occur within 30 days regardless of whether the reason for the second stay relates to the first.

According to some LearningLink contributors, attempts to appeal the denials fall on deaf ears. Providers have presented clinical evidence that shows the admissions are appropriate, meet criteria, and not related to the original admission, but contractors have not reversed the denials.

Has this been happening at your facility?

Resources to help keep up with healthcare reform regulations

In March, President Obama signed the Patient Protection and Affordable Care Act into law. Shorty after that, the House and Senate passed the Health Care and Education Reconciliation Act which amended the former statute.

HHS and other government agencies will follow these acts with plenty of rulemaking and guidance. Check out these two resources to help prepare for the changes.

Health Reform EasyFind link

To help providers keep up-to-date with the regulations, MedicareFind has created a new Health Reform EasyFind link page to the website. This resource page will automatically update itself with any new issuances (e.g., transmittals, proposed rules, Open Door Forum transcripts) related to healthcare reform so you can incorporate changes into your workflow.

Only MedicareFind users can click the links to read the actual documents, but non-users can still use the link as a reference point to see the latest news.

Healthcare reform timeline

If you are looking for a tool that looks into the future, the Kaiser Family Foundation created a detailed timeline that stretches to 2015 and later.

The timeline provides the implementation dates for provisions contained in the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act.

View the Kaiser Family Foundation’s Health Reform Implementation Timeline

Taking on the RACs: It’s all about teamwork

For the past two years, we at Jennie Edmundson Hospital have been planning and preparing for the RAC audits. It has been a classic example of “hurry up and wait”.  Now, the wait is over.

Responding to the first letter

On January 30, we received our first request letter from Health Data Insight (HDI); the Region D RAC. The letter requested eight medical records for detailed review of improper or incorrect Medicare billing or coding. This was the RAC review team’s cue.

Our RAC audit team consists of

• The health information management (HIM) director
• The coding supervisor
• The physician advisor
• The senior revenue cycle director.

The team’s first step was following the directions in the request letter and sending the medical information HGI requested for all eight claims. Six requested claims were from 2009 and two were from 2008. HDI received the requested medical records February 24.

On April 5, we received a review result letter from HDI. HDI’s review determined that we had used incorrect diagnoses codes and assigned an incorrect DRG. The difference between our DRG assignment and HDI’s proposed DRG assignment was more than $4,000.

The team reviewed the medical record, diagnoses codes, and DRG. We all agreed that our coding was appropriate. We drafted a letter that supported our medical judgment and faxed it to HDI April 22.

This occurred during the discussion period. HDI requires providers send a fax that meets its specifications and includes a cover sheet during the discussion period. We tracked our request on HDI’s website and saw no indication that it had received our fax. Approximately two weeks after sending the fax, I called HDI to confirm receipt. HDI said that it had received our fax and that a response would require up to 30 days.

Preparing for future audits

We did not receive correspondence on the remaining seven requests until April 22. The good news is that we received a letter indicating that we correctly coded and billed four of the records. We sent faxes that support our coding and billing of the remaining three May 14.

While we found this to be a fairly simple process to follow, this was our first request. As more requests come in, the processes will become more complex. Our team approach and documented procedures will help simplify the process for us.

The RACs are just the beginning of the audit process. There are many more Medicare and Medicaid audit contractors coming. Commercial payers are also getting into the auditing game and some contractors will be doing audits for Medicare, Medicaid, and commercial payers.

All the different auditors will have different rules and timelines. Have a contact person, who knows how to identify the different audit types, receive all the audit letters. Getting process initiated up front and using a team approach will lead to a more successful, less stressful audit process.

Do you know what your organization’s audit processes are? Are you contemplating future audit trends?

ACMA takes second Important Message from Medicare concerns to CMS

The American Case Management Association (ACMA) CEO Greg Cunningham recently met with CMS officials to discuss the results of the ACMA Public Policy Committee’s survey about the second Important Message from Medicare (IM).

According the ACMA, CMS was “receptive to the feedback.” The results of the survey include the following:

• The majority of respondents (84%) report that case management is responsible for issuing the second IM
• More than half the respondents (59%) report that 10 minutes or less are required to issue each IM
• More than 77% of respondents report that they track IM compliance
  • Of those who track IM compliance 40% report a compliance rate between 76% and 100%
• Only 38% of respondents report increased numbers of appeals
• The majority report that less than 25% of patient appeals are successful
• Respondents generally feel the second IM process adds little value to patient care and adds to patient confusion and frustration

Read the full CMS Important Message / Appeal Rights Notification Requirement Survey Findings report.

CMS officials asked the association to gather a prioritized list of the most pressing concerns about the delivery of the second IM. The ACMA and CMS will then work together to address the 10 most pressing issues.

If you would like to contribute your thoughts on the second IM you have two options:

• The ACMA plans to have a dedicated IM forum at the upcoming 2010 NICM/ACMA National Conference in San Antonio. Attendees can use this opurtunity to voice there concerns. The forum will be held April 10 from 7:00-7:45 a.m.
• The ACMA will also accept concerns/recommendations via email. Send messages to tneese@acmaweb.org.

What meaningful use means to case management: Stage 1

Editor’s Note: In her first post, Barbara Aubry, RN, CPC, CHCQM, FAIHQ, regulatory analyst for 3M Health Information Systems, Inc, explained the meaningful use requirements, which must be met in order to qualify for the Medicare electronic health records (EHR) incentive program. The following is part two of Aubry’s analysis of CMS’s meaningful use requirements.

Let’s take a closer look at the proposed Stage 1 criteria for meaningful use and what it could mean for case managers. The following comes from the Health Information Technology: Initial Set of Standards, Implementation Specifications and Certification Criteria for Electronic Health Record Technology, 45CFR Part 170

Stage 1, which is slated to take effect in 2011,:

“focuses on electronically capturing health information in a coded format; using that information to track key clinical conditions and communicating that information for care coordination purposes (whether that information is structured or unstructured, but in structured format whenever feasible); consistent with other provisions of Medicare and Medicaid law, implementing clinical decision support tools to facilitate disease and medication management; and reporting clinical quality measures and public health information.”

Wow! It seems that CMS is looking to capture a lot of data that might not be readily available in current patient medical records. If we carefully read the paragraph again, the meaningful use requirements are actually good for case managers.

Consider the amount of time you currently spend trying to assemble information about any given patient. How many notes do you leave for physicians? How often do you need additional patient information to complete a report for a third party payer or to begin a discharge or transfer plan?

Theoretically, case management tasks would be easier if the electronic health records (EHR) contained the documentation that is required for care coordination. If we had access to a medical record that could easily capture patient history including diagnoses, treatment, response to intervention, admissions, discharge measures, and domicile status, it would help us work better and faster.

Some questions case managers might want to consider regarding Stage 1

Since implementation of Stage 1 could directly impact daily case management practice, I think it is important to explore some of the specifics:

• What are “key clinical conditions”? Is a key clinical condition one that is chronic, or must a key clinical condition have a risk of negative outcome? Is it dependent on medication or some other type of therapy? Who will make that determination?

• What exactly does CMS mean by “care coordination purposes”? Current medical documentation includes very few notes regarding care coordination other than those made by case managers, discharge planners, and social workers. Will physicians be willing to document their participation in care coordination? Again, who will be responsible for defining care coordination? Will there be a nationally accepted process or will the definition change depending on the individual state, third party payer, patient, or provider type?

• How will Stage 1 impact the current reporting of clinical quality measures? Will case managers become more or less involved in reporting quality measures?

If you are not already part of the EHR discussion at your facility, you might want to volunteer to join the team. Since a majority of the elements in Stage 1 touch upon the case management process, I believe case managers need to he involved in the discussion to make it more meaningful.

If you would like to review the entire document, it was posted in the January 13, Federal Register . Next time I will discuss Stage 2 and how that may impact our process.