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MedicareFind. The Search is Over.
The Search is Over.
HCPro, Inc. has announced the launch of MedicareFind (www.medicarefind.com), a new Web-based regulatory database that allows healthcare managers to quickly locate, access, and keep up with Medicare reimbursement rules and regulations.
MedicareFind expands HCPro’s products and services that assist healthcare providers with monitoring and responding to the changing regulatory environment in which they work. The Web site features a uniquely robust, flexible, and easy-to-use search engine combined with a vast and constantly updated database of documents. Users will find the specific regulatory source authority document they need quickly instead of scrolling through pages of search results.
MedicareFind first debuted in April at The Health Care Compliance Association’s annual Compliance Institute in Las Vegas. Institute attendees stepped up to take a side-by-side challenge which pitted MedicareFind against the CMS Web site.
“MedicareFind found the right documents faster than a CMS search every time,” said Lauren McLeod, HCPro Group Publisher. “People found it easy to use and liked the filters that allowed them to narrow their search by agency, document type, and date. They told us it was easier to quickly determine whether the document met their needs because they saw all the pertinent details about the document in the search results.”
HCPro regulatory experts and developers worked with 50 development partners — professionals from healthcare organizations across the nation — throughout the development of MedicareFind. McLeod said the partners have been an integral part of the development process, from determining which rules and regulations to include in the database to testing the site design and the search features.
With shrinking workforces and limited budgets, MedicareFind was developed in response to the need for a solution that offers increased productivity and time saved searching for the regulatory compliance guidance.
MedicareFind is available to single users or as a multi-user or site license, and HCPro will offer free trials at the database Web site (www.medicarefind.com) For more information about MedicareFind, visit www.medicarefind.com.
CMS issues FY 2010 IPPS proposed rule
Hospitals to see lower payment updates but few changes to MS-DRGs, HACs, and the POA.
The long-awaited fiscal year (FY) 2010 Inpatient Prospective Payment System (IPPS) proposed rule is out, and with it comes good and bad news for hospitals.
Although there aren’t a whole slew of changes related to Medicare Severity DRGs (MS-DRG), hospital acquired conditions (HAC), and the present on admission (POA) indicator, hospitals will see historically low payment updates with a phased-in documentation and coding adjustment (DCA) to take place over time.
A slow rate of economic inflation and an increase in aggregate payments due to changes in hospital coding practices that do not reflect increases in patient severity of illness (SOI) are the reasons for the low updates, according to a CMS press release announcing the rule late Friday afternoon.
“We understand hospitals will be concerned about lower than historical payment update amounts,” said Charlene Frizzera, CMS acting administrator in a CMS press release. “However, we are proposing an adjustment that minimizes the effects on FY 2010 payments while still meeting the requirements of the law, which may mean larger reductions in the next two years.”
Payment updates
The proposed update for acute care hospitals means an update of 2.1% for inflation minus a DCA of 1.9 percentage points. Long-term care hospitals will see a proposed update of 2.4% for inflation minus a DCA of 1.8 percentage points. These DCA adjustments reflect the differences between the changes in documentation and coding that do not reflect real changes in case-mix for discharges occurring during FY 2008, according to CMS.
Experts agree that these low rates won’t help hospitals struggling to keep their doors open in the midst of a worsening economy. “Hospitals that are counting on some sort of increase won’t really see anything this year,” says Kimberly Hoy, JD, CPC, director of Medicare compliance for HCPro, Inc. in Marblehead, MA. “Payments are going to stay flat, and that’s going to be tough for a lot of hospitals.”
“The increase was practically eliminated by CMS’ contention that improved documentation and coding for MS-DRGs resulted in an underserved 2.5% improvement in reimbursement,” says James Kennedy, MD, CCS, director of FTI Healthcare in Atlanta.
The Medicare Actuary found based on analysis of 2008 data that additional coding did not reflect actual changes in SOI increased total payments under IPPS by 2.5% in FY 2008 and will further increase total payments in FY 2009. The percentage of cases with a major complication/comorbidity (MCC) increased by 5% while the percentage of cases without an MCC or complication/comorbidity decreased. The proposed lower updates would help ensure that estimated aggregate payments to hospitals will not increase solely as a result of MS-DRGs, according to CMS.
Still, it’s as though CMS is penalizing hospitals for documentation and coding improvement, Kennedy says. “It’s as if no good deed goes unpunished,” he says. “Hospitals that took care of these sick patients and had rigorous clinical documentation and coding integrity processes in place in 2007 will see their reimbursement decline. CMS is penalizing their ethical and compliance efforts to improve disease definition, documentation, and reporting.”
Clinical documentation improvement programs as well as more diligent efforts by HIM are most likely the reasons behind more accurate coding that led to higher payments, agrees Shannon McCall, RHIA, CCS, CCS-P, CPC-I, director of HIM and coding for HCPro, Inc. in Marblehead, MA. “CMS may have underestimated that facilities would create such effective clinical documentation improvement programs,” she says. “I think those programs were an integral part of all of this.”
And in light of decreased payment updates, hospitals that don’t currently have a clinical documentation program will need to think seriously about implementing one, says Gloryanne Bryant, RHIA, CCS, CHW senior director of corporate coding and HIM compliance in San Francisco. “Hospitals will need to assess their current efforts to capture patient severity and acuity through documentation and coding to see if opportunities remain,” she says.
HAC and the POA indicator
Although payment updates may reach historic lows, other proposed changes remain minimal. CMS proposes not to add or remove any categories of HACs, although it does propose to add two diagnoses in the falls and trauma category—torus fracture of ulna (813.46) and torus fracture of radius/ulna (813.47), both of which are CC conditions.
“I was surprised CMS didn’t mention additional exploration of adding ventilator-associated pneumonia as an HAC,” McCall says. The reason may be because CMS is most likely continuing to gather data on the condition for which it assigned a code (ICD-9-CM code 997.31) as of October 1, 2008, she adds. This condition failed to meet the criteria of being reasonably preventable according to evidence-based guidelines.
CMS also proposes not to make any changes to the payment implications of the POA indicator. It will continue to pay the CC/MCC MS-DRGs for HACs coded with Y (yes) and W (clinically undetermined) and not pay the CC/MCC MS-DRGs for those HACs coded with N (no) and U (insufficient documentation) indicators.
“This is a little of a relief in that this will allow hospitals more time to analyze their POA data similar to efforts that CMS and AHRQ will undertake,” Bryant says. “The proposed rule has a good review of the rationale and payment process for HAC and POA, which might be useful for hospital providers to review.”
MS-DRG changes
Although there are no major proposed changes to MS-DRGs, CMS does invite public comment regarding moving ICD-9-CM procedure code 88.59 (intraoperative fluorescence vascular angiography [IFVA]) from MS-DRGs 235 and 236 (coronary bypass without cardiac catheterization with and without MCC, respectively) into the following two MS-DRGs:
- MS-DRG 233 (coronary bypass with cardiac catheterization with MCC)
- MS-DRG 234 (coronary bypass with cardiac catheterization without MCC)
IFVA technology is used to test cardiac graft patency and technical adequacy at the time of coronary artery bypass grafting (CABG). Although this system does not involve fluoroscopy or cardiac catheterization, the manufacturer and clinical studies suggest that it yields results that are similar to those achieved with selective coronary arteriography and cardiac catheterization.
However, CMS analysis has found that these cases would be overpaid if reclassified. The cases in MS-DRGs 235 and 236 did not actually have a cardiac catheterization performed, a proposal to reassign cases identified by procedure code 88.59 would result in lowering the relative weights of cases in MS-DRGs 233 and 234 where a cardiac catheterization is truly performed. CMS, however, invites public comment regarding this proposal.
CMS analysis does, however, support the reclassification of procedure codes 80.05 (arthrotomy for removal of prosthesis without replacement, hip) and 80.06 (arthrotomy for removal of prosthesis without replacement, knee) from their current assignments under MS-DRGs 480, 481, and 482 (hip and femur procedures except major joint with MCC, CC, and without MCC/CC respectively) and MS-DRGs 495, 496, and 497 (local excision of internal fixation device except hip and femur with MCC, with CC, and without CC/MCC respectively) to the following MS-DRGs:
- MS-DRGs 463, 464, and 465 (wound debridement and skin graft except hand, for musculo-connective tissue disease with MCC, with CC, and without CC/MCC respectively)
In addition, CMS proposes to re-title ICD-9-CM procedure codes 80.05 and 80.06 respectively to “arthrotomy for removal of prosthesis without replacement, hip or knee.”
CC/MCC changes
Hospitals will also see minimal changes to the CC/MCC and CC exclusions list. The only proposed deletions from this list include those made to accommodate new codes that now have a 5th digit for added specificity.
Noteworthy proposed additions to the MCC list include:
- Puerperal sepsis and septic thrombophlebitis (670.22, 670.24, 670.32, and 670.34)
- Omphalocele (756.72)
- Gastroschsis (756.73)
- Severe hypoxic-ischemic encephalopathy (768.73)
- Bilious vomiting in newborn (779.32)
Noteworthy proposed additions to the CC list include:
- Chronic pulmonary embolism (416.2)
- Chronic venous embolism and thrombosis of upper and lower extremities: axillary, subclavian, jugular veins, etc. (453.5x, 453.6x, and 453.7x)
- Acute venous embolism and thrombosis of upper and lower extremities: axillary, subclavian, jugular veins, etc. (453.8x)
- Puerperal endometritis (670.1x)
- Hypoxic-ischemic encephalopathy, unspecified (768.70)
- Mild hypoxic-ischemic encephalopathy (768.71)
- Moderate hypoxic-ischemic encephalopathy (768.72)
The addition of several chronic conditions was surprising, McCall says. “Generally, CMS doesn’t include chronic conditions on the CC/MCC list,” she adds. “Chronic conditions generally don’t meet the criteria (requires intensive monitoring, complex services, or extensive care from multiple caregivers).”
ICD-9-CM code changes
The proposed rule includes changes to more than 100 diagnoses codes, with various changes to ICD-9-CM codes for neoplasms and newborn conditions, as well as several new V codes.
Noteworthy changes include:
- 5th digits to specify the type of antidepressants in a poisoning, such as MAOIs or SSRIs
- 5th digits to specify the type of psychostimulants in a poisoning, such as caffeine, amphetamine, and methylphenidate
- New code 995.24 (failed moderate sedation during procedure)
“I was surprised that they didn’t make any changes to the heart failure codes because they discussed these codes extensively during the ICD-9-CM Coordination and Maintenance meeting,” McCall says. “But just because they didn’t discuss them in the proposed rule doesn’t mean they can’t add them [in the final rule].”
The deadline for public comments on the proposed new codes—including changes to heart failure codes—discussed during the March 11-12, 2009 meeting is June 12.
Noteworthy proposed changes include new V codes for:
- History of failed moderate sedation
- History of underimmunization status
- Encounter for fertility preservation counseling or procedure
- Fitting and adjustment of lap band
- Foster care status
- Family disruption due to death of family member or prolonged absence
- Counseling for parent-biological child versus adopted
- Personal history of estrogen therapy
- Personal history of inhaled or systemic steroids
All in all, the proposed changes are minimal compared with previous years, and this could be indicative of the fact that ICD-9 cannot accommodate additional code expansion, McCall says. The highly anticipated implementation of ICD-10 in 2013 could also be a contributing factor. “CMS is going to have to revamp the entire system for ICD-10. It makes me wonder whether CMS will begin to decrease the number of changes it proposes each year for this very reason.”
Wrong surgery edits
CMS proposes to implement three new E codes to denote wrong surgery, such as surgery on the wrong body part, surgery performed on the wrong patient, or the wrong surgery performed on a patient. The E codes include:
- E876.5 (Performance of wrong operation [procedure] on correct patient)
- E876.6 (Performance of operation [procedure] on patient not scheduled for surgery)
- E876.7 (Performance of correct operation [procedure] on wrong side/body part)
These E codes come in the wake of three new National Coverage Determinations that CMS published to indicate that it would not pay for these types of wrong surgeries. Unlike HACs that yield no additional payment, wrong surgeries yield no payment at all, Hoy says.
As with HACs and conditions that are not POA, these edits represent another example of CMS’ intentions to not reimburse hospitals for mistakes made during the patient stay, McCall says.
Quality measures
CMS proposes to add four new measures for which hospitals must submit data under the Reporting Hospital Quality Data for Annual Payment Update program to receive the full market basket update, including:
- SCIP: Infection-9 (Postoperative Urinary Catheter Removal on Post Operative Day 1 or 2)
- SCIP: Infection-10 (Perioperative Temperature Management)
- Participation in a systematic clinical database registry for stroke care
- Participation in a systematic clinical database registry for nursing sensitive care
The SCIP measures, in particular, are designed to assess practices that reduce the risk of infections that surgical patients could acquire in the hospital. They have high relevance to the Medicare population, and address the growing concern regarding hospital acquired infections, according to CMS.
Other noteworthy changes
CMS proposes changes to regulations that affect payment adjustments to teaching hospitals and disproportionate share hospitals. It also clarifies the regulations implementing the Emergency Medical Treatment and Labor Act. CMS also proposes to add new cost centers to distinguish high cost supply items as part of an effort to revise and update the its cost report.
To view the rule, click here. CMS will accept comments until June 30.
Revenue Cycle Institute announces ‘Medicare Compliance Forum: A Strategic Approach to RACs, Observation Status and the Role of Physician Advisors’
The Revenue Cycle Institute is bringing its three biggest Medicare compliance educational offerings together in one huge event!
The “Medicare Compliance Forum: A Strategic Approach to RACs, Observation Status and the Role of Physician Advisors” will be held October 26-27, 2009, at the Westin Buckhead Atlanta.
The one and a-half day seminar is comprised of three hot button tracks that will provide solutions to today’s toughest regulatory challenges:
- The Recovery Audit Contractor program
- Observation status
- Physician advisors: Highly customized sessions for physician advisors to learn key aspects of Medicare compliance. New this year!
Attendees sign up for one track and get all three!
This one-of-a-kind seminar is designed to provide the most comprehensive and uniquely-tailored experience. The Medicare Compliance Forum provides three distinguished tracks:
- RAC Track: Defend your organization from RAC takebacks. This track will provide you with the critical strategies and helpful tools direct from professionals who have been through the demonstration project and are ready to take on the permanent program. No more boring overviews-Get something tangible you can take back to your organization. Get tried-and-true recommendations and valuable tools to help you and your team be prepared when RACs head your way.
- Observation Status Track: Know the rules of engagement. The challenge of properly classifying a patient as observation or inpatient affects both the clinical and financial success of a hospital. Our distinguished speakers hail from administrative, compliance, financial, and clinical backgrounds to bring you an exceptionally well-rounded program designed to help you master one-day stays and observation status.
- Physician Advisor Track: Understand the Medicare regulations that affect physician advisors. Physician Advisors and their organizations need to work together to reduce risk and protect revenue. This track features interactive sessions to educate physician advisors, VPMAs, and other professionals on RACs, observation status, pay for performance, and other important Medicare regulations. Attendees will also learn the skills and qualities and roles and responsibilities of an effective physician advisor.
Sign up for one track and you can pick and choose which sessions to attend from any of the tracks. Plus, attendees will receive all the materials to take back from every session, every track.
Click here to find out more about the 2009 Medicare Compliance Forum.
Revenue Cycle Institute releases new White Papers on Incident to and E/M auditing
The HCPro Revenue Cycle Institute has just released two new White Papers:
- “Incident To in Provider-Based Departments: Meet Medicare’s ordering, supervision, and follow-up requirements,” by Kimberly Anderwood Hoy, director of Medicare and compliance for HCPro
- “Evaluation and Management Auditing: Ensure appropriate coding and reimbursement for your practice,” by Joe Rivet, CPC, CCS-P, CEMC, CICA, regulatory specialist at HCPro, Inc, and instructor of HCPro’s new Evaluation and Management Boot Camp
To download the White Papers, visit the Revenue Cycle Institute Web site.
CMS updates RAC outreach schedule
CMS has updated its RAC education and outreach schedule. The schedule contains new information regarding which type of healthcare provider (e.g., hospitals, physicians, skilled nursing facilities, etc.) should attend the various session, as well as who will present during the session.
CMS will update the RAC schedule as new sessions become available. You can always view the most recent version on the CMS Web site.
Free tools: Physician advisor job description, documentation review program
Take advantage of two free tools to help you ensure your physician advisors are on top of their game, courtesy of the Association of Clinical Documentation Improvement Specialists (ACDIS).
Click here to download a sample physician advisor job description.
Click here to download a sample physician advisor documentation review program.
For further training on the roles and responsibilities of physician advisors, consider attending an upcoming audio conference “Clinical Documentation Improvement for Physician Advisors,” sponsored by the ACDIS. The April 14 audio conference will show you how physician advisors can make an enormous difference in improving initial documentation and physician response rates to queries; however the position must be structured correctly in order for it to work well. For more information on this audio conference, visit HCMarketplace.
Condition Code 44 - Let’s focus on process
By Judith Kares, JD, CPC, regulatory specialist for HCPro, Inc.
This is the first of two additional posts that will focus on Condition Code 44. Last week, Kimberly Hoy, director of Medicare and compliance for HCPro, Inc, brought up some additional questions about the conversion of inpatient hours to observation time, following a Condition Code 44 change of inpatient status to outpatient care. That article prompted several additional questions from readers, including questions about the process that hospitals need to follow in order to assure that they receive essentially the same reimbursement for those inpatient services as they would have received if the services actually had been provided in the outpatient setting.
Rather than following up on the specific questions, let’s take a quick look at the so-called Condition Code 44 process, which is actually established as part of hospitals’ Conditions of Participation with Medicare. Under the related regulations, the change in status decision must be made by hospitals’ “Utilization Review Committee.” Those individuals specifically authorized to become “members” of the UR Committee are designated by profession and include the following: doctors of medicine and osteopathy (of which there must be at least two members), as well as doctors of dental medicine and/or surgery, podiatry, and optometry; chiropractors; and clinical psychologists. No non-practitioners are included in the regulations as qualifying for “membership” on the UR Committee.
Whether an individual qualifies as a member of the UR Committee is important, because the change of status decision can be made by one member of the UR Committee, so long as the patient’s attending physician concurs with the decision (or does not present their views [presumably in opposition to the decision] when given an opportunity). In all other cases, the decision to change the patient’s status must be made by at least two members of the UR Committee.
In an MLN Matters Article intended to clarify the process, CMS noted that case managers, who are not licensed practitioners authorized under state law to admit patients to the hospital, do not have the authority to change a patient’s status from inpatient to outpatient. CMS did, however, encourage and endorse the participation of case management staff in the change of status process, particularly with regard to identifying and applying relevant inpatient criteria, facilitating communication between practitioners and the UR Committee, and assisting the UR Committee in the decision-making process.
Once the UR Committee has made the decision to change status, the hospital must meet the following additional criteria for the change in status to be effective:
- 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 agree with the decision; and
- The physician’s agreement must be documented in the patient’s medical record.
Assuming that all criteria are met, the hospital may submit a 13X outpatient claim for the services provided during the inpatient stay (assuming they meet relevant outpatient coverage criteria), reporting Condition Code 44 in one of the Condition Code FLs (FLs 18-28 on the UB-04) on the claim.
Next week we will continue our discussion of the Condition Code 44 process, focusing on some practical suggestions for how hospitals can efficiently implement an effective change in status process.
Related source authorities include the following:
- 42 C.F.R. Section 482.30(b)
- 42 C.F.R. Section 482.12(c)(1)
- Medicare Claims Processing Manual, Chapter 1, Section 50.3
- MLN Matters SE0622
CMS announces RAC Open Door Forums
CMS will be holding two Special Open Door Forums on RACs for Part A and Part B providers in April, according to the CMS Web site.
CMS will hold the RAC Open Door Forum for Part A providers on April 8 from 2:00-3:30 pm EST. CMS will follow with an Open Door Forum for part B providers the follow week, on April 14 from 2:00-3:30 pm EST. (Note that capacity is limited, so it is advisable to dial in to the call 15 minutes prior to the scheduled start time.)
CMS will use the Special Open Door Forum to provide additional information about the RAC program to providers, as well as introduce them to the new RACs, according to the CMS Web site.
