Training Programs
Audits & Assessments
Regulatory MonitoringArchive for June, 2009
Frequently asked questions
CMS issued several new/updated frequently asked questions (FAQ).
CMS issues contractor instructions for 835 adoption
On June 26, CMS instructed contractors to make system changes required for implementation of the next version of Health Insurance Portability and Accountability Act (HIPAA) standard for transaction 835.
Effective date: October 1, 2009
Implementation date: April 6, 2009 for VMS; July 6, 2009 for MCS, FISS
CMS re-issues OPPS update
On June 23, CMS rescinded and replaced its previous OPPS update to the Claims Processing Manual due to some incorrect information regarding HCPCS code Q4115. All other information remains the same.
Effective date: July 1, 2009
Implementation date: July 6, 2009
View a related MLN Matters article.
MLN Matters articles
CMS released two MLN Matters articles related to transmittals previously outlined in Medicare Weekly Update.
Inpatient Part B benefit – limited services payable under Part B to hospital inpatients
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc.
Although there were several transmittals and other CMS issuances published during the past week, they were primarily technical in nature rather than of general interest. Having just completed an MBC-H course in Chicago, I was reminded of a topic that I have wanted to discuss for some time. Although not new--that is, there have been no recent changes—there are several things that participants seem surprised about when we discuss them in class. Under the limited inpatient Part B benefit, hospitals can bill Medicare for certain nonphysician services furnished by a hospital (directly or under arrangements) to an inpatient of the hospital when these services are not covered under Part A.
Go to the MedicareMentor Blog to read the rest of this week's note.
Use a change-of-status form to ensure compliance when reporting condition code 44
A change-of-status form will help ensure that a hospital meets all of the criteria for reporting condition code 44, says Judith Kares, JD, CPC, regulatory specialist at HCPro, Inc., in Marblehead, MA. The form should include the following:
- A statement about the hospital’s decision to change the patient’s status from inpatient to outpatient, including appropriate rationale
- Information about how this decision will affect the patient medically and financially
- Documentation that the hospital informed the patient’s physician of the status change and asked him or her to offer input
- A place for two required signatures, one from a utilization review (UR) committee member and the other from the patient’s attending physician or an additional UR committee member
Keep the original form in the patient’s medical record and provide copies to the patient and his or her physician, Kares says. Keep a third copy in the UR committee records.
Editor’s note: This article was adapted from the June issue of Briefings on Coding Compliance Strategies.
CMS releases RAC audit phase-in strategy: Complex reviews to arrive as soon as August
CMS released further information June 24 on its RAC Web site letting healthcare providers know when they can expect RACs to begin auditing. The new “CMS RAC Review Phase-in Strategy,” details different types of reviews and dates CMS anticipates the reviews will begin in various areas of the country.
The new information is consistent with CMS’ previous indications that some providers may begin to undergo automated review this month.
According to the CMS, the earliest possible dates for RAC reviews in yellow and green states are:
- June 2009-Automated reviews of black and white issues
- August or September 2009-Complex reviews for DRG validation
- August or September 2009-Complex review for coding errors
- Fiscal year 2010, which begins October 1, 2009-Complex reviews for durable medical equipment (DME) medical necessity
- Calendar year 2010-Complex reviews for medical necessity
The earliest possible dates for reviews in blue states generally fall a bit later:
- August 2009-Automated reviews of black and white issues
- October or November 2009-Complex reviews for DRG validation
- October or November 2009-Complex review for coding errors
- Fiscal year 2010-Complex reviews for DME medical necessity
- Calendar year 2010-Complex reviews for medical necessity
CMS also reaffirmed that before RACs actively begin auditing in a particular state, outreach educational sessions must occur in that area.
Although the schedule calls for automated reviews as early as this month, any issue a RAC reviews must be vetted through the CMS’ “Issue Review Board.” In addition, RACs must post the approved issues to their Web sites before the reviews can begin.
“Providers should check their RAC’s Web site often for any newly approved issues for review to anticipate their vulnerability to reviews and take backs,” says Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.
Even though CMS has delayed the rollout of certain types of complex reviews, providers shouldn’t ease off on their RAC preparation activities.
“Use the time wisely to continue performing your own internal vulnerability audits and ensure that all of your policies and procedures are up-to-date. Consider this a little extra time to get your facility ready for those appeals,” says Tanja Twist, MBA/HCM, director of patient financial services at Methodist Hospital of Southern California.
Editor’s note: Twist and Hoy will be speaking at the upcoming conference, “Medicare Compliance Forum: A Strategic Approach to RACs, Observation Status and the Role of Physician Advisors,” which will be held in Atlanta this October. Twist will also be featured in the July 21 HCPro audio conference, “Medicare Appeals: Practical and Compliant Procedures for Overturning Denials.”
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What is our volume of claims that fall under each RAC-identified issue? Once RACs begin posting the issues they intend to audit on their Web sites, determine whether your hospital’s volume in these areas (e.g., one-day stays) is high, says Camille Cohen, MBA, MSW, CHC, compliance solutions manager at 3M Health Information Systems in Salt Lake City. Your claims might be compliant, but a RAC could still request a large number of records because of your high volume. Responding to the requests could have considerable operational ramifications, including having to track and respond to those requests, she says.
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Do we need to hire additional staff members? This is a difficult question to answer for HIM directors, primarily because record requests could arrive arbitrarily or separately throughout a 45-day period. Because of the inconsistency, assessing whether an additional staff member is needed may be difficult, says Cohen. However, directors can and should begin to track the timing of requests upon receipt. “Initially, you may see more sporadic requests because the RACs are gearing up. After that, there may be more of a pattern to it,” she says. And don’t be afraid to seek help outside the HIM department. “There may be some function that you can off-load during a high peak time,” she says. Consulting firms you have worked with in the past may be another option.
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Will we require staff members to review records before we send them to the RAC? Reviewing records before staff members send them to the RAC adds processing time, but is wise because it helps ensure that the response is complete and no documentation is missing, says Cohen. This extra step also helps identify potential inaccuracies before the RAC does.
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Who will we assign to process record requests? Identifying the individual who will receive record requests is important to ensure compliance with the 45-day response time, says Cohen. Directors should pay close attention to the initial letter because RACs will use it to communicate the specific request limit for each organization. Hospitals may identify the designated contact person by registering this information on their RAC’s Web site. Create a process and assign a backup contact person for days when the designated individual is out of the office, says Cohen. In addition, some hospitals may decide to use a post office box for all RAC-related communications. Currently, RACs will communicate with hospitals via the U.S. Postal Service only. Using a post office box can help prevent lost and misplaced letters in a busy mailroom.
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Will we monitor the total number of requests we receive every 45 days? RACs may request a maximum of 200 records every 45 days, so ensure that they don’t exceed this limit is important. “In the demonstration program, some of the RACs made mistakes,” Cohen says.
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Which format should we use when responding to record requests? CMS requires that RACs have the ability to accept paper records and scanned images on a CD or DVD. Beginning in 2010, RACs must also accept imaged records electronically, according to the advisory. Hospitals must decide which (e.g., paper, DVD, or CD) is most feasible. This decision is particularly important for hospitals with a hybrid paper and electronic record, says Cohen. Sending your record in more than one format is inadvisable because it requires that someone outside your hospital is responsible for combining information. “Either print your electronic or scanned record or scan your print copy so you can ensure everything is together before sending it to the RACs,” Cohen says.
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Will we retain a copy of records we send to the RACs? Retaining a copy of records you’ve sent to your RAC can be helpful in case the RAC doesn’t receive them and when appealing denials, says Cohen. Hospitals should ensure that they store copied information securely, regardless of whether it is a paper duplicate or a scanned image, she says.
Despite a recession and continued crowding, a new study shows that the average wait time in the nation's emergency departments fell by two minutes in 2008 to 4:03. Even with the long waits, Press Ganey's Emergency Department Pulse Report 2009 finds that patient satisfaction rose in 2008, continuing a five-year improvement trend.
Leigh Vinocur, MD, on the emergency physician faculty at the University of Maryland School of Medicine, says she's not surprised that patients leave the ED satisfied.
"First of all, they probably can't get in to see a primary care doctor," says Vinocur, who is also a national spokesperson for the American College of Emergency Physicians. "And when you go to a doctor's office, he decides you could need a CT scan or a neurologist and you're waiting another few weeks for a referral.
"So, even though people are waiting four and five hours in the ER, they have an idea they are going to have a diagnosis when they leave. That doesn't always happen. But we can do a lot of procedures and things while you are there to get closer to the diagnosis," she says.
Read the full story by HealthLeaders Media’s John Commins.
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