Transcript same date of service

Cahaba GBA’s
2014 Medicare Expo
August 6-7, 2014 – Chattanooga, TN
Two Midnight Rule
As directed a copy of the presentation is available for viewing or download on the Cahaba
GBA website
Disclaimer
This resource is not a legal document. The presentation
was prepared as a tool to assist providers and was
current at the time of creation.
Responsibility for correct claims submission lies with the
provider of services.
Reproduction of this material for profit is prohibited;
providers are encouraged to share this education with
staff.
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Topics
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Medical Review
Comprehensive Error Rate Testing (CERT)
Two Midnight Rule
Resources
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Preventing Improper Payments
The Affordable Care Act of 2010
• Proposals to protect the Medicare Trust Fund
• Authority to recover overpayments
Social Security Act
• Sections 1833(e), 1842(a)(2)(B), and 1862(a)(1)(A)
Centers for Medicare and Medicaid Services (CMS)
• Protect the Medicare Trust Fund
• Identify inappropriate payments
• Take corrective actions
Payment Accuracy: www.paymentaccuracy.gov/about-improper-payments
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Medical Review
Goal
Reduce payment errors by identifying and addressing billing errors
related to coverage and coding of services
Data Driven
o
o
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Indentify vulnerabilities
Identify questionable billing patterns
Prevent and/or address provider errors
Reduce paid claims error rate
Publish Local Coverage Determinations (LCD)
Medical Review and Education - Overview: www.cms.gov/Medical-Review/
Program Integrity Manual - Pub. 100-08 - Medical Review Program:
www.cms.gov/manuals/downloads/pim83c03.pdf
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Comprehensive Error Rate Testing (CERT)
CERT
Protect, Measure, Assess, Evaluate
Documentation Contractor
Requests Medical
Records
Review Contractor
Reviews Medical
Records
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Part A Review-All States: February 2014
Service
Al , GA, TNShort Term
HospitalsCondition
Code 07
Error Rate
Denial Rationale
33.60%
Per Pub 100-04, Ch. 11
Medicare Claims Processing
Manual (Processing Hospice
Claims) § 50 Billing and
Payment for Services Unrelated
to Terminal Illness.
High Dollar
Amount
Services related to a hospice
terminal diagnosis provided
during a hospice period are
included in the hospice
payment and are not paid
separately.
Action Required
Condition code 07
should be used for any
Medicare covered
services not related to
the treatment of
condition for which
hospice was elected.
Fiscal Year 2014 Inpatient Rule
2014 Hospital Inpatient Prospective Payment System (IPPS)
• Update for 2014 Medicare payment policies for inpatient stays
• General Acute Care
• Long Term Care Hospitals (LTACHs)
• Inpatient Psychiatric Hospitals
• Critical Access Hospitals (CAHs)
• Goal is to improve value and quality in hospital payments
• Provides clarification about when a patient should be admitted to the
hospital
• Addresses concerns regarding extended Medicare Beneficiary stays in
the hospital outpatient department
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Two Midnight Rule
Medicare Part A payment will be presumed appropriate if:
• Physician expects the patient’s treatment to require hospital
stay exceeding a two midnight benchmark or requires a
procedure on the inpatient only list
• Admits patient based on that expectation
• Formal physician order is required to begin inpatient status
• Physician Certification
• Clear Documentation supporting medical necessity of
admission and expectation
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Two Midnight Rule
Any stay less than 2 midnights after inpatient order:
• Allows physician to consider all time patient has spent in
the hospital as outpatient in guiding their two midnight
expectation
• Observation
• Emergency Room
• Operating Room
• Other Treatment Area
• Applies to admissions with dates of service on or after
October 1, 2013
CMS Issues FY 2014 Inpatient Payment Rule
http://www.cahabagba.com/news/cms-issues-fy-2014-inpatient-payment-rule/
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Two Midnight Rule
Inpatient Order Requirements
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Required for inpatient coverage and Part A payment
Inpatient status begin when order is written
Must specify admission to inpatient status
No retroactive orders allowed
Who may write the order?
• Physician or other practitioner
o Licensed by State to admit patients
o Granted admitting privileges in the hospital
o Knowledgeable about the hospital course, medical plan
of care, and current condition at the time of admission
o Non-Physician practitioner would still need cosignature if incident to ordering physician
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Two Midnight Rule
Non-Physician Practitioners/Residents
• No admitting privileges
o May under state laws or hospital by laws write initial orders to initiate
inpatient admission
o Order must be documented following collaboration with ordering
physician
Must identify the qualified physician
Qualified physician must co-sign order before discharge
Authenticated order by qualified physician will satisfy order part of
the physician certification as long as he/she meets requirements for a
certifying physician
• Example:
• Admit to inpatient per Dr. Smith
• Admit to inpatient v.o./t.o. Dr. Smith
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Two Midnight Rule
Physician Certification
• Condition of payment
o Required for Part A payment under section 1814(a) of the Social
Security Act
o Indicates that inpatient services were medically necessary
• Content
o
o
o
o
Authentication of physician order
Reason for inpatient services
Estimated time required in hospital
Plan for post-hospital care if appropriate
Physician Order and Certification Requirements
http://cms.gov/center/provider-type/hospital-center.html
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Two Midnight Rule
Physician Certification (cont)
• Authorization to sign certification
o A physician who is a doctor of medicine or osteopathy
o A dentist in the circumstances specified in 42 CFR 424.13(d)
o A doctor of podiatric medicine if his or her certification is
consistent with the functions he or she is authorized to
perform under State law
All of which are responsible for case or by another physician
with knowledge of the case and is authorized by the responsible
physician or hospital’s medical staff
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Medical Record Documentation
• All entries in the medical record must be complete in order to:
o Justify admission
o Justify continued hospitalization
o Support the diagnosis
o Describe the patient’s progress
o Describe the patient’s response to medications; and medical intervention
• All entries in the medical record must be legible
o Illegible entries in the medical record may be misread or misinterpreted
o Misread or misinterpretation could lead to medical errors or other
adverse patient events
• All entries in the medical record must be dated, timed, and signed
o By the individual that provided or evaluated the service
o Handwritten or electronically
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Two Midnight Rule
Reviewing Hospital Claims for Inpatient Status
• General Rule for 0-1 Midnight stays
o Inappropriate for inpatient admission if estimated
length is between 0-1 midnight stays regardless of the
time the patient arrived or if they used a bed
o Exception
o Inpatient only List
o Unforeseen Events
o Rare and Unusual Circumstances
o Medicare Administrative Contractor will deny these
inappropriate admissions as directed by CMS unless
these exceptions apply.
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Two Midnight Rule
Reviewing Hospital Claims for Inpatient Status
• Short Stay Admissions
o Less than two midnights
o May be appropriate for Part A payment if unforeseen
circumstances results in a shorter stay than the
physician’s reasonably expectation of two midnights
Death
Transfer to another hospital
Discharged against medical advice (AMA)
Clinical Improvement
Hospice Election
o Rare and unusual circumstances
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Two Midnight Rule
Rare and Unusual Circumstances
• Newly Initiated Mechanical Ventilation
o Excludes anticipated intubations related to minor surgical
procedures or other treatment
o CMS does recognize that additional rare and unusual
circumstances exist that have not been identified
o For suggestions to additional rare and unusual
circumstances, please email CMS at
[email protected]
o Subject: “Suggestion exceptions to the two midnight rule”
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Scenario Example
• 70 y.o. male enters the emergency room for shortness of
breath on 01/03/2014. Patient is triaged and placed in one
of the ED rooms at 11:00 p.m. Shortly after, patient is
evaluated by physician at 11:15 p.m. Physician writes the
order to admit patient as IP after a chest x-ray determined
patient has a dx of pneumonia. MD expects patient to be in
the hospital past two midnights. He receives IP services and
is discharged on 01/07/2014.
• Since the MD expects patient to receive medical necessary
services for at least two midnights based on his condition,
then Part A payment for inpatient will be presumed
appropriate. (Notice: Patient stayed past two midnights
after IP order was written).
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Scenario Example
• 45 y.o. female went to the emergency room on 1/2/2014
with complaint of chest pain. Hx of HTN, Smoking and
Stents. She was triaged and placed in a ED room at 03:00
p.m. Began receiving services. Cardiac enzymes were
ordered. Physician wrote an order to admit patient as
observation to the unit at 05:00 p.m. Patient is receiving
observation services on floor past midnight. The next
morning, 1/03/2014, physician evaluates patient and
decides to admit her as IP based on results of cardiac panel.
• The patient was in observation status for one midnight. Per
CMS guidelines, Physician appropriately assessed her
condition the following day and determined she needed IP
care, in which he wrote the order for admission. This way,
the two midnight benchmark will be met when reviewed if
she stays past the 2nd midnight.
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Scenario Example
• Patient comes into ED and is observation from 9am to
12 noon. Patient is admitted inpatient and then
discharged later that day. The UR reviews and
determines that this needs to be a re-bill. How are we
supposed to bill when it is the same date of service?
• Under A/B rebilling, you can bill a 121 and 131 with
the same date of service. You will need to bill the
121 claim first and let it finish processing. Once it
has completed processing, then bill the 131 TOB.
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM8445.pdf
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Updates
Two Midnight Benchmark for:
• Hospital to Hospital Transfers
• Off Campus Emergency Department
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Updates
Three Day Qualifying Stay-SNF
• If patient is receiving medically necessary services:
• Appropriate for the patient to remain in hospital
• Bed available at SNF
• Not appropriate to hold patient for the sole purpose
of qualifying for 3 day qualifying SNF stay if
patient is not receiving medically necessary care
• Bed not available at SNF
• It is appropriate for patient to remain in hospital
until bed is available
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Probe Review
Two Midnight Benchmark Review:
• For stays less than two midnights after formal inpatient order is
written:
o Subject to Medical Review BUT
• Cahaba GBA Medical Reviewers will consider the time the
patient spent receiving ER, Outpatient, or Observation services
in determining if two midnight benchmark was met
o Clock begins when patient begins receiving services
Triage activities such as checking vital signs does not count
Waiting period in the ER does not count
Must be receiving medically necessary services responsive to
the patient’s clinical presentation
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Probe and Educate
Patient Status Reviews
• Extended until March 31, 2015
• Pre-Payment Review
o 10 claims for most hospitals
o 25 claims for larger hospitals
• ADR letters will be sent out via mail or electronically in FISS
o Edit number 5Pxxx will be listed on the ADR
• Providers will receive a summary letter explaining each denial
• Cahaba GBA will offer 1:1 education and will repeat the probe
process if necessary
Probe and Educate Process-Article
http://www.cahabagba.com/news/update-probe-educate-process/
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Probe and Educate
Patient Status Reviews
• Reviews conducted by MAC’s to determine
hospital’s compliance with new rule
o Focuses on appropriateness of inpatient treatment
versus outpatient treatment
• Hospital’s compliance will be assessed by the
following three criteria:
1. Admission order requirements
2. Certification requirements
3. Two midnight benchmark
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Probe and Educate
• Updated Guidance-01/30/2014
o Inpatient Probe and Educate Claims
o Re-Openings
o Appeals
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Probe and Educate
• Common issue with compliance
o Documentation of expectation of two midnight stay
o Documentation related to patient’s illness that caused the
physician to expect that inpatient admission
o Remember: Document, Document, Document
o “If it is was not documented, then it was not done”
o Denial
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Denials
• Inpatient Admission
o Not reasonable and necessary
• Part B Billing
o Inpatient
o Outpatient
o 3 day payment window
• Timely Billing Guidelines
o 1 year from date of service
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Probe and Educate
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Please Take Our Survey
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Resource
• Centers for Medicare and Medicaid Services:
Inpatient Hospital Review
http://cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/Medical-Review/InpatientHospitalReviews.html
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Questions
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Thank You
The Part A Provider Outreach and
Education staff would like to thank
you for participating in today’s event.
Provider Contact Center: 1-877-567-7271
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