All Entries in the "Access Q&A" Category
Important Message from Medicare Notice: Inpatient transfers
Q: Two hospitals have different Medicare ID (provider) numbers. Patients are transferred from one facility to the other for other inpatient care. Sometimes, patients are returned to the initiating facility, while other times they remain at the second facility to later be discharged or moved to a lower level of care. Does the sending hospital need to issue a follow-up copy of the Important Message from Medicare (IM)? Does the receiving facility need to issue a new IM?
A: Regardless of the hospital affiliation, the receiving hospital/unit would provide a new IM if the transfer involves different Medicare ID (provider) numbers. However, no follow-up copy is needed prior to leaving the sending hospital/unit if the transfer is an inpatient to inpatient hospital level of care. The hospital/unit ultimately responsible for discharging (releasing or lowering the level of care) the patient would provide the follow-up copy if more than 2 days have passed since the last IM was delivered.
Whenever the sending and receiving unit has the same provider number, no follow-up copy and no new IM is required. Hospitals would operate as if it is continual inpatient care from the same facility.
This answer was provided by the Centers for Medicare and Medicaid Services from their frequently asked questions resource. For more frequently asked questions and answers from CMS on the Important Message from Medicare, click here.
E-mailing patient information during registration processes
Q: A provider affiliated with or employed by a covered entity would like to e-mail patient demographic information to the covered entity’s registration department to expedite the registration process for his patients. Is this HIPAA-compliant?
A: Such e-mails from the provider to the covered entity’s registration department would comply with the security rule’s implementation specification relating to securely transmitting patient information only if the provider sent the e-mail from inside the organization (within a closed network or not over the Internet) or if he encrypted the e-mail before transmitting it from another site over an open network or the Internet.
It is wise to encrypt transmissions within an organization if the information is especially sensitive, but HIPAA does not require this.
Editor’s note: Chris Apgar, president of Portland, OR-based Apgar & Associates, LLC, answered this question. This is not legal advice. Consult your attorney for legal matters.
Can you report on more than one PQRI measure at the same visit?
Yes, and in fact, that would be in order in certain situations [for the physician quality reporting initiative (PQRI)]. For example, if the eligible professional had selected to report on the cluster of diabetes measures or the cluster of heart failure measures.
If the patient is being treated for those conditions during that visit, then all of those measures could or even should be reported in order to get to the 80% threshold for the measures that have been selected by that participating professional.
This question was answered by Thomas B. Valuck, MD, MHSA, JD, medical officer and senior advisor to Herb Kuhn at the Center for Medicare and Medicaid Services.
How should we discipline staff who remove medical records from the facility?
Q: What is an appropriate disciplinary action to enforce for staff members who take medical records out of the facility/office?
A: You should have a written policy that allows for the removal of medical records from the facility only under subpoena or court order. Incorporate this policy into medical staff policies or the medical staff rules and regulations. Individuals who violate this policy should face the same corrective action steps as those who violate other policies, such as verbal or written counseling, probation, and discharge.
Editor’s note: Mary Brandt, president of Bellaire, TX-based Brandt & Associates, LLC, answered this question. This is not legal advice. Consult your attorney for legal matters.
Prepare for mandatory present on admission reporting
Q: Do you have any information on the present on admission (POA) indicator? Is it required? Do we have to report it on the UB-04 form or on the 837? If so, which loop and segment?
A: POA information will be mandatory for all states by January 2008. The POA information will appear as a modifier on some diagnosis codes (some diagnosis codes are exempt), and hospitals must submit this information to their payers in the current format (for most hospitals this will be on a UB-04 claim form).
Report whether a condition was POA using the following modifiers:
- Y: Yes (present at the time of inpatient admission)
- N: No (not present at the time of inpatient admission)
- U: Unknown (documentation is insufficient to determine if condition is present at time of inpatient admission)
- W: Clinically undetermined (provider is unable to clinically determine whether condition was present at time of inpatient admission or not)
- 1: Unreported/Not used (exempt from POA reporting)
AHA Coding Clinic, Fourth Quarter, 2006 (pp. 241-255) provides an extensive explanation and reporting guidelines for POA. CMS has also published information on POA, including Medlearn Matters article number MM5499(http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5499.pdf) and Transmittal 1240.
You can read Transmittal 1240 on the CMS Web site at: http://www.cms.hhs.gov/Transmittals/downloads/R1240CP.pdf. It states the following:
Effective for acute care inpatient PPS discharges on or after October 1, 2008, the Secretary cannot assign cases with these conditions to a higher paying DRG unless they were present on admission.
This instruction will require hospitals to begin reporting the POA code on claims with discharges beginning on or after October 1, 2007. Although hospitals must report the POA code on the claim, the information will not be used by claims processing systems until January 1, 2008. Beginning with claims with discharges on or after January 1, 2008, if hospitals do not report a valid POA code for each diagnosis on the claim, the claim will continue to process. However, hospitals will be provided with a remark code on their remittance advice advising them that they did not correctly submit the POA code on the claim.
Beginning April 1, 2008, if hospitals do not report a valid POA code for each diagnosis on the claim, the claim will be returned to the hospital for correct submission of POA information. Direct data entry (DDE) screens cannot be updated to include a space for entering POA information until January 1, 2008. Therefore, hospitals that submit claims via DDE will be unable to submit the POA indicator on October 1, 2007. These hospitals must begin submitting the POA indicator on January 1, 2008.
For more information on reporting POA, see the ICD-9-CM Official Guidelines for Coding and Reporting at the Department of Health and Human Services Centers for Disease Control and Prevention Web site: http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide06.pdf. Scroll down to p. 91 to find the POA guidelines.
Editor’s note: This question was answered by the APCs Weekly Monitor panel of experts.
Are hospitals bound by InterQual criteria when determining patient status?
Q: I have a question about what to do when a physician writes orders to admit a patient to the hospital as an inpatient, but the patient did not meet InterQual criteria for inpatient status. Instead, the patient should have been admitted to observation. This typically occurs when the physician is not well informed on InterQual criteria.
I know we can change the patient’s status while he or she is still in-house and if the physician writes an order to change to observation status. But what if the patient is discharged, the case manager reviews the chart before the bill goes out, and he or she finds that it does not meet inpatient criteria and should have been in observation instead? Can the hospital correct the billing to reflect the appropriate status (observation, not inpatient) so that Medicare is appropriately billed according to InterQual criteria?
A: The Medicare Benefit Policy Manual (100-2, chapter 1, section 10) states that inpatients are generally expected to remain at least overnight; that physicians are responsible for deciding whether the patient should be admitted; and that physicians should use generally use a 24-hour period as a benchmark for admission (i.e., they should order admission for patients who are expected to need hospital care for 24 hours or more, and treat other patients on an outpatient basis.) You can find the complete reference here: http://www.cms.hhs.gov/manuals/Downloads/bp102c01.pdf
The Medicare Benefit Policy Manual (100-2, chapter 6, section 20.5) also defines the observation level of care for Medicare patients. It states the following:
Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation status is commonly assigned to patients who present to the emergency department and who then require a significant period of treatment or monitoring before a decision is made concerning their admission or discharge.
It also states that, “In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours.” You can find the complete reference here: http://www.cms.hhs.gov/manuals/Downloads/bp102c06.pdf
CMS does not mention InterQual or any other level of care criteria in either definition. Hospitals frequently use level of care criteria as an objective tool to help make decisions regarding whether an individual’s condition is severe enough, or the services provided are intense enough, to be admitted to a specific level of care. CMS still maintains that a physician’s judgment should be the determining factor.
Consider querying the physician to help determine whether he or she truly felt the patient should be admitted as an inpatient. If the physician documentation is consistent with this intent, then the inpatient level of care may be appropriate, despite the fact that it does not meet InterQual criteria. This is why most level-of-care criteria provides for some form of secondary/physician review to account for situations in which a patient’s condition or care does not meet criteria, but the attending physician believes the ordered level of care is what is needed.
Medicare contracts with Quality Improvement Organizations (QIOs) to evaluate medical records for level-of-care appropriateness. The QIO reviews documentation to determine whether there is consistency between the physician’s order, the physician’s intent, the services provided, the medical necessity of the services, and the patient type billed by the facility. Some QIOs do use InterQual criteria as an objective tool, but must also take into account the physician’s decision-making process.
If you must change the patient’s status before he or she is discharged, report condition code 44 (”Inpatient admission changed to outpatient”). Medlearn Matters article SE0622, released on March 22, 2006, provides a full explanation of condition code 44, as well as its limitations. You can find it at the CMS Web site: www.cms.hhs.gov/MLNMattersArticles/downloads/SE0622.pdf
Condition code 44 requires the patient to still be in the hospital when his or her status is changed. CMS believes Medicare beneficiaries have the right to participate in treatment decisions and to know their treatment choices. They are also entitled to receive info about co-insurance and deductibles. If the change from inpatient to outpatient billing is made after the patient leaves the hospital, the patient is neither able to participate in the choice nor receive advance information about co-insurance and deductibles.
If the patient has truly been admitted inappropriately to the inpatient level of care and you discover it after the patient’s discharge, use the hospital utilization management process required by the Medicare Conditions of Participation (CoPs). You can find CoPs for hospitals, part 482.30, at the following Web site: http://www.access.gpo.gov/nara/cfr/waisidx_04/42cfr482_04.html.
Editor’s note: This question was answered by the APCs Weekly Monitor panel of experts.
Can patient access staff give out ED information over the phone?
Q: Can the hospital’s front desk receptionist give information to a caller asking whether a family member is in the emergency department?
A: Before giving out any information regarding a patient, the receptionist must be sure the patient has not asked to be a “no information” patient. It may be best to transfer these calls to the emergency department, so someone familiar with the patient can determine his or her wishes and the caller’s relationship to the patient.
Editor’s note: Mary Brandt, president of Bellaire, TX-based Brandt & Associates, LLC, answered this question. This is not legal advice. Consult your attorney for legal matters.
Any suggestions on non-scheduled patients who cannot make a deposit?
Q: Do you have any suggestions on non-scheduled X-Rays and walk-in lab self-pay patients that cannot make a deposit on time of service?
At this time, our hospital sees all patients, so asking them to return is not an realistic option for us. But is that what most hospital do on non-stat outpatient walk-in patients?
A: The level of the hospital’s commitment to resolution of self-pay balances at time of service will determine what options you have available to your staff. If the facility absolutely will not turn away a patient who fails to resolve an account prior to service, then you are limited in what you can do.
Options in addition to cash, check or credit card payment include signing a payment plan agreement, completing a loan application document, especially if balances for previous services are unresolved, completing a financial assistance application, mailing back a credit card authorization, etc.
The list can be as long as what you can put in place. What you can do is make the financial counseling experience a process that absolutely explores every option; if the patient gets upset, the reply is something like this: “I am sorry that you are upset, and I understand that you want to go for your test. However, we also want to make sure that we have explored all options with you so that your bill is resolved in the most appropriate manner.”
Editor’s note: Sandy Wolfskill, president of Wolfskill & Associates in Chardon, OH, answered this question.
Can someone e-mail patient information to a registration department?
Q: A provider affiliated with or employed by a covered entity would like to e-mail patient demographic information to the covered entity’s registration department to expedite the registration process for his patients. Is this HIPAA-compliant?
A: Such e-mails from the provider to the covered entity’s registration department would comply with the security rule’s implementation specification relating to securely transmitting patient information only if the provider sent the e-mail from inside the organization (within a closed network or not over the Internet) or if he encrypted the e-mail before transmitting it from another site over an open network or the Internet. It is wise to encrypt transmissions within an organization if the information is especially sensitive, but HIPAA does not require this.
Editor’s note: Chris Apgar, president of Portland, OR-based Apgar & Associates, LLC, answered this question. This is not legal advice. Consult your attorney for legal matters.
Are we required to include a disclaimer on all faxes?
Q: Does HIPAA require us to send a disclaimer with all faxes?
A: HIPAA does not specifically require you to print a privacy disclaimer on the cover sheet of all faxes. However, it does require you to take appropriate steps to protect the privacy of all PHI. So although HIPAA does not require it, it is sound privacy practice to include such a disclaimer on all confidential fax sheets that you send with documents including patient PHI.
Editor’s note: Chris Apgar, president of Portland, OR-based Apgar & Associates, LLC, answered this question. This is not legal advice. Consult your attorney for legal matters.