Transcript QIO Program PPT Template Version 1 - Livanta BFCC-QIO

Two-Midnight Rule Process
Pam Applegate, MA, RHIT
Senior Program Director
Two-Midnight Rule
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October 2013: Two-Midnight Rule is implemented
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Adopted for inpatient admissions occurring on or after
October 1, 2013 (fiscal year 2014)
FY 2014 Hospital IPPS Final Rule CMS-1599-F established
two distinct, but related, medical review policies
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2-Midnight presumption: claims with LOS >2 midnights after
formal admission order are presumed to be appropriate for Part
A payment and are not the focus of medical review efforts
2-Midnight benchmark: provides guidance to Medicare review
contractors to identify inpatient admissions generally appropriate
for Part A payment under CMS-1599-F, as revised by CMS1633-F
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Two-Midnight Rule
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October 2015: Responsibility for reviews of <2
midnight inpatient stays transitioned from MACs to
QIOs
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MAC reviews were prospective (pre-pay)
QIO reviews are retrospective (post-pay)
Inpatient claims have three dates
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From Date (Date patient started receiving services)
Admission Date (Date inpatient order is written)
Thru Date (Discharge Date)
A claim is subject to review under < 2 midnight inpatient stay if
the date of admission to the date of discharge is less than 2
days (0-1 day length of stay)
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Two-Midnight Cycles
• There are two 6-month review cycles per year
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October – March
April – September
Hospitals will be sampled no more than once in a
6-month cycle
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Two-Midnight Universes
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Paid claims with 0-1 day LOS are supplied to the QIO
monthly
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October 2015 universes contained claims from May 2015
November 2015 universes contained claims from June 2015
December 2015 universes contained claims from October 2015
January 2016 universes contained claims from November 2015
February 2016 universes contained claims from December 2015
March 2016 universes contained claims from January 2016
Future universes will most likely continue to follow a two-month
lag period
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Two-Midnight Sampling
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Monthly sample is chosen
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0-day stays are prioritized, as directed by CMS
Large hospitals – 25 claim sample
Average hospitals – 10 claim sample
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Sampled claims may be pulled from multiple universes to
reach desired number of claims for the hospital – so one
sample may contain discharges from multiple months
If a hospital has less than the required number of claims for
sampling within a 6-month cycle, it will not be sampled
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2M Medical Record Requests
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Monthly samples are imported into the CMS-supplied
Case Review Information System (CRIS) and medical
record requests are generated
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Medical Record contact information for these requests is stored
in the government system and updated as hospitals request
The government system only allows for one Medical Record
contact and one QIO Liaison – cannot be unique for different
claim types
One envelope is mailed via USPS and contains instructions for
submitting the medical records along with a cover sheet for each
record requested
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Note that the cover sheet lists the From and Thru Dates
Medical records are due 30 days from the request
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2M Submission Instructions
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2M Example Cover Sheet
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Record Request Follow-Up
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Around day 15 of an outstanding medical record
request, Livanta calls the provider to ensure that the
request was received and is in process
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We can then fax the request and cover sheets to the provider,
if needed
Around day 30 Livanta will send a Technical Denial
Warning letter to the provider with cover sheets of
outstanding records
Around day 45 if the records have still not been
received, a technical denial letter is sent to the
beneficiary, provider, and MAC
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Reopening Technical Denials
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If Livanta receives the medical record for which a
technical denial has been issued, the case will be
reopened, provided the final determination for the
sample has not yet been mailed
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If the technical denial is reopened, the beneficiary,
the provider, and the MAC are notified that the
record will be reviewed
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2M Review Process
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Medical records are first screened by our Registered Nurse
Review Coordinators who check for the following:
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Admission Order requirements are met
Two-Midnight Benchmark is met
InterQual or MCG may be used to support medical necessity
for approval of the admission
No inpatient order = billing error
Independent licensed practicing physician reviewers
who are board-certified with hospital privileges make
the final determination on any case not clearly
meeting the requirements of the Two-Midnight Rule
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Two-Midnight Rule Benchmark
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Two-Midnight Benchmark
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Provides guidance to Medicare review contractors for
identifying when an inpatient admission is generally
appropriate for payment under Part A
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Patient admitted for an Inpatient-Only procedure
Medical record supports the admitting physician’s determination
that the patient requires inpatient care despite the lack of a twomidnight expectation – case-by-case exception
Complex medical factors such as history, comorbidities, severity
of signs and symptoms, current medical needs, risk of an
adverse event – all can support need for inpatient hospital care
Physician expects medically necessary acute hospital services
will be needed for 2 or more midnights as supported by
documentation in the record
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Two-Midnight Rule Benchmark
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Two-Midnight Benchmark
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Unforeseen Circumstances – death, transfer to another
hospital, discharge against medical advice (AMA), clinical
improvement, election of hospice care
Based upon physician’s expectation of the required duration
of medically necessary acute hospital services at the time the
inpatient order is written
Reasonableness of the inpatient admission based on the
information known to the physician at the time the inpatient
order is written – may be inferred from medical
documentation (care plan, orders, notes, etc.)
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Two-Midnight Rule Benchmark
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2M Rule Benchmark and Outpatient Time
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The record must first support the determination that the
patient required acute hospital services to qualify for Part A
payment
If the patient required acute hospital services, Livanta will
consider the pre-admission time such as services provided
under observation, treatment in the ED, and/or procedures in
the operating room or other treatment area of the hospital
For patients transferred to another hospital, the time care
began at the initial hospital will be taken into account
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2M Review Timelines/Delays
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Delay in initial sampling – first medical records not
requested until mid to late November 2015
Three monthly samples requested within 3 weeks
initially – overwhelmed our Mailroom and delayed
getting records ready for review
Reviews began in earnest in mid-December 2015
QIO has obligation to complete medical review of
a record within 30 days of medical record receipt
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We are not yet hitting this target due to the confluence of
multiple samples and Mailroom delays
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Stratification
• After determinations are made for a hospital’s entire sample, the
Initial Review Results Letter is sent to the QIO Liaison, with a
determination for each sampled claim and stratification results
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“Minor” concern hospitals have <10.01% errors
– May submit additional information within 20 days
– No 1:1 education required
“Moderate” concern hospitals have >10% but <20.01% errors
– May submit additional information within 20 days
– May request 1:1 educational session within 20 days
– May submit additional information after 1:1 session within 10 days
“Major” concern hospitals have >20% errors
– May submit additional information within 20 days
– Must attend 1:1 educational session (required)
– May submit additional information after 1:1 session within 10 days
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Initial Review Results Letter
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Initial Review Results Letter
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Initial Review Results Letter
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Education Process
• Livanta’s 2M Nurse Educator will reach out to
the QIO Liaison at the time of scheduling the
education session
• To ensure receipt of the letter
• To entertain any questions about the process, and
• To establish of line of communication
• The QIO has 90 days from the completion of a
hospital’s sample to supply provider education
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Provider Education
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Livanta conducted the first provider education
sessions in early February 2016
Livanta Medical Directors present the review
findings on the preliminarily denied claims on a
case-by-case basis
Hospital participation and feedback is expected
and welcomed
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The hospital has 10 days to respond with additional
information after the 1:1 education session
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Final Determination Letters
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Final Determination Letters
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Admission Denial Letters
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After the Final Determination letter has been
mailed to the provider, an Admission Denial letter
is mailed for each denied claim to the beneficiary,
the hospital, and the MAC
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RAC Referrals
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BFCC-QIOs shall rate and stratify providers for
education and corrective action based upon the
results of the completed claim reviews
BFCC-QIOs will refer to the Recovery Audit
Contractor providers that consistently demonstrate a
high denial rate
• Failing to adhere to the Two Midnight rule
• Failing to improve performance after BFCC-QIO educational
intervention has been rendered
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Referral to the RAC must be upon CMS direction
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RAC Referral Process
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Although the exact process for RAC referral is still
being refined, it will involve the QIO discussing
potential referrals with CMS and noting any
extenuating circumstances
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It is important to note that the timing of the
education session and subsequent samples and
reviews for a provider may necessitate several
cycles of reviews before RAC referral is supported
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Case Review Examples
Alisa Davis, RN
Redetermination Manager, Area 1
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Denial Example
Case 1 – Syncope
• This 75-year-old female was brought in by ambulance due to a
syncopal episode. She had a history of vertigo, hypertension, and
thyroid disease. The patient was admitted to observation status.
• This admission did not meet the Two-Midnight Rule criteria
because at the time of inpatient admission the patient’s
condition had improved, and there was no anticipation of an
additional midnight stay. Our physician reviewer concluded that
there were no acute findings at the time of the emergency
department evaluation and the patient went home the next day.
There was no indication that the patient would need to stay 2
midnights.
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Denial Example
Case 2 – Mental Status Changes
• This 77-year-old male presented to the emergency department
due to mental status changes. He had a history of stroke, transient
ischemic attacks (TIAs), dementia, and a recent right neck mass
biopsy.
• This admission did not meet the Two-Midnight Rule criteria
because the patient had no evidence of a stroke or TIA present on
admission and he was admitted for a work-up to rule out a TIA.
This diagnostic testing could have been provided at an
observation level of care. Our physician reviewer concluded that
the patient’s evaluation in the emergency department was
unremarkable, and he was discharged the following day after his
mental status was cleared.
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Denial Example
Case 3 – Elective Procedure
• This 82-year-old female was admitted electively for an anorectal
examination under anesthesia and a rigid proctosigmoidoscopy.
The patient had a history of diabetes and was recently diagnosed
with a rectal mass found to be positive for adenocarcinoma.
• This admission did not meet the Two-Midnight Rule criteria
because the patient was admitted following an outpatient
procedure with no documentation of complications or unstable
comorbid conditions. The patient was discharged in less than 24
hours as expected. The procedure was not on the CMS inpatient
only list.
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Denial Rationale Examples
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This admission did not meet the Two-Midnight Rule criteria because the treatment of pain
control, IV hydration, monitoring of lab results, and a gastroenterology consultation did not
require an inpatient admission and could have been done in observation status.
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This admission did not meet the Two-Midnight Rule criteria because the patient was admitted
to inpatient status following an outpatient surgical procedure with no documentation of
complications or unstable comorbid conditions. The patient was discharged within 24 hours as
expected.
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This admission did not meet the Two-Midnight Rule criteria because the patient’s condition was
improved prior to admission, and there was no indication that a 2 midnight stay was
anticipated. The patient’s ongoing inpatient care for diagnostic testing and oral medications
could have been provided at an outpatient level of care.
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This admission did not meet the Two-Midnight Rule criteria because the patient’s care for mild
CHF exacerbation without significant acute symptoms did not require an inpatient level of care.
The patient’s care could have been provided at an observation level of care.
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Good Documentation Example
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A 72-year-old female patient presented on May 04, 2015 to have an implantable
cardioverter defibrillator for severe ischemic cardiomyopathy.
The patient’s history included myocardial infarction, coronary artery disease,
chronic systolic heart failure, hypercholesterolemia, multi-vessel coronary artery
disease, status post diagonal vessel PCI in March as distal LAD balloon
angioplasty pleural effusion, and chronic kidney disease, stage 3.
Her vital signs were: Temperature 98.3, blood pressure 121/84, heart rate 80,
oxygen saturation 97% on 2 liters of oxygen.
The patient’s laboratory results were: white blood cells 9.8, hemoglobin 9,
hematocrit 23, platelet count 172, sodium 133, potassium 4.4, blood urea nitrogen
127, and creatinine 2.32.
The original order for the patient was observation status however, the patient
developed acute chronic systolic heart failure, anemia, and acute kidney injury post
procedure and on May 6, 2015 at 0951, the patient was admitted to inpatient.
The patient was discharged on May 7, 2015.
This claim meets the guidelines for the Two-Midnight Rule.
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Documentation Supporting
Admission
Condition
Observation
Inpatient
Atrial Fibrillation
Rapid response to treatment
Recurrent bouts or associated with another
event, such as MI or PE
Chest Pain
Negative Workup
Positive troponins or EKG changes
COPD Exacerbation
Responds to treatment
Does not respond to treatment or is
associated with pneumonia
VTE or Small PE
Uncomplicated and responds to treatment
PE with hemodynamic compromise or not
eligible for Thrombin inhibitors
GI Bleed
Chronic with normal BP and Hct
Acute requiring transfusion and intervention
Abdominal Pain
Negative Workup
Acute findings (rebound tenderness, free
fluid, or signs of inflammatory or obstructive
process on CT
Acute neurological condition or
Altered Mental Status
Negative Workup
Head and/or carotid imaging, TEE, active
therapy
Electrolyte Disturbance
Early response
Persistent abnormalities
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Key Points for Education
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Part A reimbursement is based on the continued need
for acute hospital services for a second midnight
Document what happens between the first and second
midnight to warrant continued acute hospital services
Documentation of reassessment at 18-30 hours after
initial decision (observation or inpatient) helps us
understand decision-making process
Patient status changes require documentation of the
thought process for the change to support the decision
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Livanta 2M Contacts
Website: Livanta.com or BFCCQIOarea1.com
Area 1 Helpline: 1-866-602-1510
Area 1 Redetermination Manager: Alisa Davis
[email protected]
UR/2M/Senior Program Director: Pam Applegate
[email protected]
Please feel free to contact us regarding status of your reviews
and/or hospital contact updates
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Questions?
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