Finding your lost revenue and keeping it 1

Finding your lost revenue and keeping it 1

CAHs have similar services = same as OPPS hospitals CAHs have different claim submission rules for outpt to inpt but documentation of billable services are the same. CAHs are paid differently than the OPPS hospital, but the rule for billable services are the same. EXCEPTION: J codes/pharmacy are only required for LCD/NCD drugs; G codes for OBS. CAHS are paid by billed charges/outpt. 2

CHARGE CAPTURE Does the order match the service that matches the billed item/UB- the 3 step! (charge/chart audit) Hot spots for audit: Wastage – SDV vs MDV; SDV wastage must be documented to bill. No ability to bill wastage with MDV. JW modifier is not required /MAC specific. (CMS pub 100 -04 Chpt 17, section 40) Nursing, pharmacy, RT, imaging, anesthesia = hot! Original order changed after receipt. . Did referring physician’s order change in the record? Protocol – must be ordered pt specific (OB, LAB, Imaging, RT, pharmacy, others? 3

Lost Charges/Revenue Daily Charge Reconciliation Cost of Late Charges And easy chart/charge audit ideas to identify documentation challenges and charge alignment 4

Recovery – house wide – up to 4 -6 hrs Nursing services in ancillary areas Drug Administration – Observation OB –HBC scheduled visits, delivery rates/levels, labor levels, unplanned Hospital based clinics – E&M visits Blood transfusion – house wide Scheduled procedures done in the ER OR – Implantables & invoice reconciliation OR – unscheduled, interrupted/7 x modifer Ancillary – reduced/52 modifier 5

Department Benchmark UB 04 audits: Compare 10 UB-04/billing documents against the itemized statement– Outpt areas 1 st (Obs, ER, Surgery, Hospital based clinics/IV therapy/Chemo) Look for potential lost charges (ER: sutures but no procedure) Look for billing combinations that were missed: 250/pharmacy –how was it given? IV Infusion, injection Look for non-billable items present: Medicare outpt self administered medications/pt pays; routine supplies Look for descriptions that won’t pass the ‘Mom’ test Look for charges that are not uniform across the facility 6

BRAINSTORM –LOST CHARGES Not ‘new revenue’ but lost revenue Question: “What services are we currently not billing for or costs that we are not covering? ” Brainstorm with department heads, compile a master list and start looking – primarily outpatient but limited inpt. 7

Nursing is not good at charge capture. . so… Aggressively look for ways to move ownership with nursing still responsible for charting, not charging: Lab – Blood Transfusions/36430. Auto have Blood products/P + 36430 bill together. (Safety net: billing edit to reject any claims without both 390 and 391 present. ) Charge Capture Analyst – identifies charges, completes charge ticket and logs all lost charges due to missing documentation. Nursing’s partnership is to ensure the start and stop times of each bag are present. CCA ‘s partnership is charge capture. WORKS! 8

Daily Dept-Specific Audits: Compare scheduled/resulted/completed patients against charges generated. (2 day lag) Manual schedules or automated Registrations with no charges. Why? Ensure each patient activity is accounted for. 9

LOST CHARGE Focus on high stress/severity of illness areas Focus on labor intensive processes Ask all depts to look for potential lost revenue Code Blue – how is nursing assuring charges made it to the bill? Drugs? Supplies? 92950/Cardiac Arrest? Procedures done? “Sticky” for supplies – nursing has them on their clothing. Who do they belong to? How many go down on the sheets? Patient complaints – once research, corrected claim –but is research done to determine who the charge really does belong to? 10

Drug adm – nursing floating outside the care area. Who is completing the charge ticket? OB – look at the aspects of outpt : ER to OB; scheduled visits; post inpt discharge/lactation HBC visit, delivery rates Scheduled visits in the ER – bill as a HBC visit Drop in pts for after care as an outpt – bill as a HBC visit (suture removal, follow up care) All Drug Adm and Blood –outpt housewide Physician orders, medically necessary services, E&M leveling for all HBC visits, incident to the physician 11

Rework – to the individual dept, to PFS and the pt –as they get corrected bills/EOBs Reprocessing the claim, lost productivity Lost Revenue with limited accountability Decreased patient satisfaction Track and trend repeat late activity, dept specific Do dept heads know what a late charge is? 12

ROUTINE VS NON-ROUTINE SUPPLIES—HELP! The Medicare Reimbursement Manual defines Routine Services in 2202. 6 on page 22 -7: “Inpatient routine services in a hospital or skilled nursing facility generally are those services included by the provider in a daily service charge— sometimes referred to as the “room and board” charge. Routine services are composed of two broad components: (1) general routine services, and (2) special care units (SCU’s), including coronary care units (CCU’s) and intensive care units (ICU’s). Included in routine services are the regular room, dietary and nursing services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate charge is not customarily made. “In recognition of the extraordinary care furnished to intensive care, coronary care, and other special care hospital inpatients, the costs of routine services furnished in these units are separately determined. If the unit does not meet the definition of a special care unit (see § 2202. 7), then the cost of such service cannot be included in a separate cost center, but must be included in the general routine service cost center. “ (See § 2203. 1 for further discussion of routine services in an SNF. ) 13

Top At Risk Issues for Pt Status Audits 14

• • • 2 MN rule is alive and well AND we are looking ‘back to the future’ with an enhanced definition of ‘rare and unusual. ’ Still use the physician’s documentation of ‘why an inpt’ but if the provider cannot estimate 2 MN /Presumption –then declare an inpt with rationale for ‘severity of the condition/intensity of the care’ that will require in hospital care. HUGE AUDIT RISK! No change to SNF; no Short stay DRG Effective 1 -1 -16/back to the future of ‘rare and unusual’ documentation to support inpt without 2 MN/presumption. Effective 10 -1 -15 –changes in auditing short stay P&E – 0 and 1 MN stays QIO (level 2 appeal) review 10 -25 charts; denies or approves Calls hospital to set up review QIO tells MAC to recoup denied claim # of denials determines referral to RAC (but not before 1 -16 DOS) MAC sends overpayment letter with appeal rights. Then Appeal levels begin: MAC/level 1; QIO/level 2; ALJ/level 3… Preferred as some physician involvement at the QIO RACs are not involved until a referral occurs – patterns of denials 15

Each payer has their own set of ‘criteria’ for coverage. (United, Blues, Part C Medicare, PEPPER/Traditional Medicare is targeting 1 day surgical, 2 day Surgical, same day medical, and same day surgery, etc. ) Each payer has their own standards for appeals Each payer determines if the documentation supports the service that was billed. Documentation to tell a strong pt story – but be aware of the enhanced payer Education 2016 16

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ALL PAYERS MEDICARE Admit to inpatient Diagnosis Reason for Admit/Plan for why an inpt (dx or multiple dx) need 2 MNs/Presumption or an additional MN/Benchmark to resolve the condition. (Hint: Pre-created ques in the “Clarify” that the LOS is an CPOE order set = excellent) Education 2016 ONLY estimated 2 MN/Presumption “Clarify’ that after the 1 st outpt MN, a 2 nd ‘in hospital’ MN is required/Benchmark After 1 -1 -15, provider still outlines why the 2 MN, what is the plan that will take 2 MN. No longer ‘certify’ but still needs to clarify the order/signed prior to discharge and rationale for the 2 MN. (Do certify 20 day mark/outlier) Critical Access Hospital – must still certify initial 96 hrs and again, at the 96 hr mark. 18

Does the physician clearly state: Why an inpt? What is the plan that will take 2 MN/Medicare? For non. Medicare – why can’t the pt be treated safely as an outpt. (Same issues as Medicare-just no 2 MN declaration) Medicare/only-If the pt needs a 2 nd MN after 1 MN as an outpt – what is occurring with the pt’s condition that will ‘push the pt’ to stay a 2 nd MN? Convert to inpt and include: Why? Mgd Care Medicare/Part. C/Medicare Advantage – HIGH AT RISK. What criteria are they using? Get it in the contract! NOT SUBJECT TO TRADITIONAL Medicare rules Commercial Mgd Care or Commercial- who knows? Makes their own rules for disallowed charges. 19

Managed Medicare Plans/Part C = HUGE They do not have to adapt Traditional coverage rules. Treat them like a Commercial Payers – get precerts, determine if they are using ‘ 2 MN’ rule methodology and/or clinical guidelines. Update contracts to CLEARLY outline the tools used to determine: what is an inpt. Always use: Physician order with rationale for why? (Sound familiar? ? ) Big increase in denials… WHAT IS THE PAYER’S DEFINITON OF AN INPT! 2015 20

USA July 27 th reported 2 huge potential purchases: Hot issues with denials or lack of inpt certifications: Long LOS in obs with no ‘rules’ for conversion to inpt Each payer gets to define their own coverage rules Following the 2 MN Medicare Traditional rule AND clinical guidelines. (EITHER Interqual or Milliman. ) Levels of appeal clearly included – clarify why not following the 5 levels within CMS’s process. Timelines for each and who does what. Denials of coverage ‘after discharge’ as the pt ended up getting better faster/not as sick as presented on 1 st contact/ other Anthem BX purchase of Cigna HAVE AN ATTORNEY READY !! Aetna purchase of Humana Making United the last of the 3 powerhouse companies. WATCH: Denial for the catch phrase: not medically necessary! MEANS? Negotiating will be more difficult. Ensure there is arbitration in all contracts. Define an inpt-with no ability to do retro denials ‘after discharge. ” Timelines to certify inpt status. 2015 21

2 midnight presumption “Under the 2 midnight presumption, inpt hospital claims with lengths of stay greater than 2 midnights after formal admission following the order will be presumed generally appropriate for Part A payment and will not be the focus of medical review efforts absent evidence of systematic gaming, abuse or delays in the provision of care. CLEARLY –At the point of conversion – WHY AN INPT for a 2 nd MN? Then if d/c early – what unexpected? Pg 2015 Benchmark of 2 midnights The new Medicare Inpt “the decision to admit the beneficiary should be based on the cumulative time spent at the hospital beginning with the initial outpt service. In other words, if the physician makes the decision to admit after the pt arrived at the hospital and began receiving services, he or she should consider the time already spent receiving those services in estimating the pt’s total expected LOS. Pg 50956 22

EX) Pt is an outpt and is receiving observation services at 10 pm on 12 -1 -13 and is still receiving obs services at 1 min past midnight on 12 -2 -13 and continues as an outpt until admission. Pt is admitted as an inpt on 12 -2 -13 at 3 am under the expectation the pt will require medically necessary hospital services for an additional midnight. Pt is discharged on 12 -3 at 8 am. Total time in the hospital meets the 2 MN benchmark. . regardless of Interqual or Milliman criteria. ER, Observation, outpt surgery = all included in the 2 MN Benchmark. 2015 Ex) Pt is an outpt surgical encounter at 6 pm on 12 -21 -13 is still in the outpt encounter at 1 min past midnight on 12 -22 -13 and continues as a outpt until admission. Pt is admitted as an inpt on 12 -22 at 1 am under the expectation that the pt will required medically necessary hospital services for an additional midnight. Pt is discharged on 1223 -13 at 8 am. Total time in the hospital meets the 2 MN benchmark. . regardless of Interqual or Milliman criteria. 23

NSETMI: “ According to the 2 MN, the admission status is determined by the expectation of care crossing 2 MNs and the need to be ‘in hospital. ’ In our facility, if the pt comes in under the wire such that he can have the cath that same day, he will only cross one MN before discharge, therefore, is discharged (as an outpt. ) However, if he comes in and crosses a MN before the cath (stabelizing), the cath is done the next day and the pt is discharged the following day (thus care crossing 2 MNs in hospital ) – then the pt is an inpt. RARE AND UNUSUAL: “I think the ‘exception’ to the 2 MN rule for ‘rare and unusual’ circumstances is a land mine waiting for a hospital to step on. As I have pointed out before, how can a hospital make a case that inpt care is required based on clinical presentation when CMS/Medicare says inpt and outpt care is distinguished only by LOS? The only exception CMS has acknowledged so far is unplanned mechanical ventilation and they said its because these cases usually required more than 2 MNs. This is why I have taught the staff to pay close attention to when a pt started receiving medical care to determine if the NSTEMI should be placed as inpt or outpt obs. In our facility, therefore some NSTEMI are inpts (because the care crossed 2 MNs based upon their time of presentation) and some are observation –(unplanned event needing beyond routine recovery /de) – because they had their cath on the same day of presentation. . did not cross 2 MN. ” Complete this sentence without implying that there’s a difference between inpt and outpt care: “This pt required inpt care regardless of the anticipated LOS because…. ” I say it can’t be done. That is why CMS won’t give an example. There isn’t one and they won’t admit their mistake either. If the pt needs ‘inpt care’, it’s going to be a patient who needs more than 2 MNs. If less than 2 MNs, why didn’t you order obs? ” RAC RELIEF Dr Steven Myerson 2 -20 -16 RAC RELIEF Debbie Jones, MD 2 -19 -16 Education 2016 24

2 MN presumption: ALWAYS ensure there is a clinical plan for why the pt needs 2 MN at the first point of contact. The plan is key! Ensure the ER provider and the Hospitalists or attending AGREE on the plan. . Handoffs need evaluated to ensure consistency. UR and PA involved. The care is then documented – with nursing and the provider – documenting the course of treatment/progression of care as it relates to the plan. SURPRISE: Clearly document the patient’s unexpected recovery; unexpected transfer out; unexpected response to treatment. Then, a beautiful inpt. 2 MN benchmark: ALWAYS ensure there is a clinical plan for why a 2 nd MN was medically appropriate/in hospital care after an outpt 1 st MN. The plan is the key ! The hospitalists/attending and UR need to communicate closely as the 2 nd MN approaches… DO NOT WAIT UNTIL the am of the 3 rd day. CAREFUL not to convert early on the 2 nd day and then discharge same day…no 2 nd MN. What was the plan? Was it met early? Note: Order takes effect when written. EX) Day 3 am, doctor converted to inpt. 10 mins later, discharged. How was the plan met in 10 mins? 25

After the 1 st MN as an outpt – anywhere – or the first MN in another facility and transferred in – “The decision to admit becomes easier as the time approaches the 2 nd MN, and the beneficaries in necessary hospitalization should NOT pass a 2 nd MN prior to the admission order being written. ’ (IPPS Final rule, pg 50946) Never, ever have a 2 nd medically appropriate MN in outpt. . convert, discharge or free… 2015 26

If the beneficiary has already passed the 1 midnight as an outpt, the physician should consider the 2 nd midnight benchmark met if he or she expects the beneficiary to require an additional midnight in the hospital. (MN must be documented and done) Note: presumption = 2 midnights AFTER obs. 1 midnight after 1 midnight OBS = at risk for inpt audit but still an inpt. Pg 50946 2015 . . the judgment of the physician and the physician’ s order for inpt admission should be based on the expectation of care surpassing the 2 midnights with BOTH the expectation of time and the underlying need for medical care supported by complex medical factors such as history and comorbidities, the severity of signs and symptoms , current medical needs and the risk of an adverse event. Pg 50944 27

It never has and never will mean – “meeting clinical guidelines” (Interqual or Milliman) It has always meant – the physician’s documentation to support inpt level of care in the admit order or admit note. SO –if UR says: Pt does not meet Criteria – this means: Doctor cannot certify/attest to a medically appropriate 2 midnight stay – right? 11/1/2013 Section 3, E. Note: “It is not necessary for a beneficiary to meet an inpatient "level of care" by screening tool, in order for Part A payment to be appropriate“ Hint: 1 st test: Can attest/certify estimated LOS of 2 midnights? THEN check clinical guidelines to help clarify any medical qualifiers… but the physician’s order with ROA – trumps criteria. RAC 2014 28

Transfer update: During Med. Learn call (2 -26 -14) CMS updated: receiving hospital CAN count time at a sending hospital toward their own 2 MN benchmark. Q 2. 2: How should providers calculate the 2 -midnight benchmark when the beneficiary has been transferred from another hospital? A 2. 2: The receiving hospital is allowed to take into account the pre-transfer time and care provided to the beneficiary at the initial hospital. That is, the start clock for transfers begins when the care begins in the initial hospital. Any excessive wait times or times spent in the hospital for nonmedically necessary services shall be excluded from the physician's admission decision. " 2015 Sending hospital – if there is knowledge that the pt is being transferred/next day, the pt is obs as only 1 MN is appropriate in the sending hospital Use Occurrence Code Span 72/field to identify the date of the 1 st MN/sending hospital. Place the date on the Inpt UB that may only have 1 additional MN for the receiving hospital. 2 MN Benchmark is now present on the 1 MN UB from the receiving hospital. Reference: SE 1117 revised MLNMatters “Correct provider billing of admission date and statement covers period. ” 29

5 PC 01 Documentation does not support services medically reasonable/necessary 5 PC 02 Insufficient documentation 5 PC 12 Order missing 5 PC 13 Order unsigned 5 PC 15 Certification not present 5 PC 17 J 5 No documentation of 2 -midnight expectation J 8 2015 30

Denial Reason % Denials JH % Denials JL Documentation did not support two midnight expectation (did not support physician certification of inpatient order) 56% 53% No Records Received 16% 17% Documentation did not support unforeseen circumstances interrupting stay 4% 3% No inpatient admission order 9% 15% Admission order not validated/signed 11% Other 4% 1% 2015 31

1 st round: 35% denial rate REASONS: 2 nd round: 36% denial rate REASONS: 55% failed to document need for 2 MN 40% failed to document need for 2 MN 45% failed admission order requirements 60% failed admission order requirements 48% signed after discharge 39% order missing from the record 35% order missing from record 13 % order not signed 17% order not validated 8% order not signed (as of 2 -11 -15) MAC recommendations: Providers document their decision making process. Paint a clear, concise picture of the pt. 2015 32

Begin with the 1 st point of contact – ER, direct or Surgery Why is the pt not safe to be discharged/ED? Why is the surgery an inpt if the CPT is not on the inpt only list? (Medicare only) What provider laid out a plan for why 2 MN for a direct admit to the floor? Did the hospitalist see the pt immediately? Did UR talk to the ordering provider? Who is validating status for transfers in? Who is asking both the sending and the receiving the 2 MN question? Count 1 st in sending. 33

Day Egusquiza, Pres Daylee 1@mindspring. com 208 -423 -9036 Free Info Line www. arsystemsdayegusquiza. com “Finding Health. Care Solutions… together” P. O. Box 2521 Twin Falls, ID 83303 (208) 423 -9036 daylee 1@mindspring. com 34

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At least quarterly, take a small sample and compare orders, against documentation of service, against actual billed service against the UB. Ensure they all match –consider: Protocol vulnerabilities LCD/NDC limitations Physician orders present Documentation to match the order Severity of illness /doctor w/intensity of services/nursing - inpt Evaluate the impacts of the hybrid medical record DEVELOP CORRECTIVE ACTION with compliance 36

For charge capture to work, each individual must understand their role in the process. Explore observing each area, 24 hr shift Develop charge capture internal manual – addressing manual process, order entry, and other, more unique processes – pods, HIM, etc. Develop feedback process for Deptspecific auditing 37

Using the ongoing department-specific audits, create tracking systems/T-N-T Accuracy of claims Revenue identified Lost charges lost no more! New understanding of ownership Change of culture REPORT progress at Dept head meetings 38

Diagramming the process flow for updating, changing, etc. the CDM-including assessment the volume of items for activity level. Reviews all new or change items to the CDM with a focus on standardizing like items, looking throughout the organization for other areas providing similar services and educating on same. (Focus on Routine supplies) Providing yearly department head education on CDM issues. Like-Item Pricing audits – as new items are added to specific area. FOCUS ON PATIENT FRIENDLY and SIMPLIFY! 39