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By Judith Kares, an regulatory specialist for HCPro, Inc.
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 the services provided in the inpatient setting.
In January 2007, the University of North Carolina (UNC) Hospitals in Chapel Hill implemented a standardized, electronic assessment tool to aid its case managers in providing thorough and consistent patient assessments.
Beverly Wagner, RN, BSN, CCM, ACM, clinical care management educator at UNC Hospitals, and colleagues developed the tool with staff members to ensure their buy-in. The result was the brief assessment tool (BAT). The BAT made documentation easier and more consistent; patient assessment documentation rose immediately. “We had a nice surge from about 8% of discharges having measurable assessment documentation to about 30%,” says Wagner. “But we kind of hit a plateau there.”
Check out the September 2009 issue of Case Management Monthly to read the full article, and discover the benefits of becoming a Case Management Monthly subscriber.
A. No. My understanding is as follows. When you are able to successfully change the patient's status from inpatient to outpatient, using condition code 44, services provided in the inpatient setting are covered and payable on the same terms and conditions as if they had been provided in the outpatient setting. Because the hospital did not meet the observation order requirement, however, it may not convert that period of inpatient care to observation. Therefore, there should be no separate line item reported on the subsequent outpatient claim for observation services. All of the ancillary services, however, would generally be billable, subject to outpatient coverage and payment provisions.
There’s been a lot of buzz recently surrounding possible regulations restricting payments to hospitals for readmissions within 30 days of discharge. Many experts say it’s only a matter of time before there is legislation reducing or eliminating reimbursement to hospitals for preventable readmissions.
Case Management Monthly discussed this topic with several experts who have been involved in this issue since CMS first started working with it through the 9th Scope of Work; CMS continues to study it as the Transitions of Care pilot project. Among these experts were Alicia Goroski, MPH, the project director for the Care Transitions Quality Improvement Organization (QIO) support contractor at the Colorado Foundation for Medical Care, and Doug Brown, BS, MHS, the government task lead for the Care Transitions Theme.
Q. What is the basic background of CMS’ 9th Scope of Work?
AG: The 9th Statement/Scope of Work started on August 1, 2008. The Care Transitions Theme was a subnational theme, which means it was competitively bid and not awarded to every state. There were 14 QIOs, or 14 states, selected to participate in this project. For the project, the participating QIOs defined a community based on a set of ZIP codes.
One of the overall goals of this project is to reduce the 30-day readmission rate for Medicare beneficiaries residing in the identified ZIP codes.
There are more measures to this project than simply reducing 30-day hospital readmissions. We’re also looking at patient satisfaction using four of the questions from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey.
DB: One of the outcome measures at the 28-month mark is to evaluate whether the QIO’s work has had an effect on patient satisfaction. To do this, we have two measures. One looks at medication management and the other at discharge planning and whether the patient felt the hospital addressed his or her needs.
Check out the August 2009 issue of Case Management Monthly to read the full article, and discover the benefits of becoming a Case Management Monthly subscriber.
Nearly 500 Medicaid audits are under way in 17 states, and the program will roll out to the entire country through the end of the year, according CMS representatives who spoke on the Medicaid Integrity Program Special Open Door Forum on July 15.
CMS hopes to identify additional contractors within the next few days. These contractors, known as Medicaid Integrity Contractors, are firms CMS has chosen to carry out the following Medicaid Integrity Program goals:
- Review provider actions to determine whether fraud, waste, or abuse may have occurred
- Audit provider claims
- Identify overpayments
- Educate those involved in Medicaid administration, providers, managed care entities, beneficiaries and others with respect to payment integrity and quality of care
There are three types of contractors: Review, audit, and education MICs. The review MICs analyze data and identify issues to pass on to audit MICs to pursue, according to CMS. Education MICs will educate providers and others on Medicaid payment integrity and quality of care.
Read the rest of this post, or share your thoughts on this topic.
This article is adapted from HCPro’s newest resource for hospital case managers—http://blogs.hcpro.com/casemanagement/—a free blog dedicated to connecting hospital case managers to industry pacesetters, peers, and best practices.
Browse more blog posts at www.CaseMangementMentor.com.
Case managers wear many hats. They identify problems or gaps in community resources that affect outcomes and strive to mitigate changes. They also work with the interdisciplinary team to anticipate discharge and plan for care needs.
However, when obstacles impede facilitating the identified plan of care, physician advisors (PA) can step in and assist case managers.
PAs can lend expertise and:
- Educate case managers about signs, symptoms, and how patients might progress along the trajectory of care for a certain disease;
- Suggest possible options for negotiating resources to assist meeting patient needs for discharge; and
- Discuss financial concerns that might affect the organization.
PAs also should work with attending physicians to understand the complexity of patient needs and identify barriers that could impede discharge of complex patients.
Editor’s note: This tip was adapted from HCPro’s book, Optimizing the Physician Advisor in Case Management: A Guide to Creating and Sustaining Measurable Program Results, available on HCMarketplace.com.
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