Download Consider Two-Step Process for Compliance With Medical Necessity

Volume 22, Number 42 • November 25, 2013
Weekly News and Compliance Strategies on CMS/OIG Regulations, Enforcement Actions and Audits
Contents
3
Hospital’s Approach to
Certification Is an Order
With Extra Language
3
CMS Transmittals
And Regulations
4
Reward Program for
Medical Supplies Leads
To $1M Settlement
5
Another Halifax Comp Deal
Gets Different Response
From Judge
7
Revamping Queries to
Get Ready for ICD-10
8
News Briefs
Focusing Attention on Operative Notes,
Queries May Improve ICD-10 Compliance
Because there’s only one ICD-9 code for atrial fibrillation and it’s not a complication or comorbidity (CC), coders generally take it at face value. That will change when
ICD-10 takes effect on Oct. 1, 2014, when physicians have the opportunity to describe
the atrial fibrillation as paroxysmal, chronic or persistent. If it’s documented and coded
as “persistent,” atrial fib is a CC, which may generate more MS-DRG reimbursement.
But getting there could require more querying, so hospitals may want to slip a few more
words into queries now to get physicians accustomed to being more specific in their
documentation when ICD-10 goes live.
That’s one example of how ICD-10 will change the way that hospitals think about
diagnoses and procedures, with procedure codes in particular undergoing a complete
overhaul. The common denominator is the need for more specific documentation in
the medical records, including more detail in the operative episodes. Improvements
hospitals make now will bear fruit in the future and may have immediate benefits in the
remaining months under ICD-9.
“Plant the seeds for physicians,” says consultant Sandra Routhier, a certified coder
and former hospital information management director. For example, she says, “start
introducing ICD-10 terms into queries.”
ICD-10 coding is divided into diagnosis codes (ICD-10-CM) and procedure codes
(ICD-10-PCS). “The diagnosis piece of ICD-10 is like ICD-9 on steroids because,” Routhier says, “there is more specificity, code description revisions and some codes were
continued on p. 6
PUBLISHER’S NOTE:
RMC will not be published
next week. The next issue
will be dated Dec. 9. Happy
Thanksgiving!
Managing Editor
Nina Youngstrom
[email protected]
Contributing Editor
Francie Fernald
Executive Editor
Jill Brown
Consider Two-Step Process for Compliance
With Medical Necessity and Two Midnights
The meaning of “medical necessity” has been cast in a new light because of its
relationship to the anticipated length of a patient’s stay under the 2014 inpatient prospective payment system (IPPS) regulation. Although most Medicare auditors are not
permitted to review admissions for the time being (with a limited exception), they are
free to evaluate the medical necessity of the services, which is confusing because the
concepts overlap. Presumably physicians wouldn’t sign an order and certify their expectation that the patient requires two midnights in the hospital unless, by definition, it
was medically necessary. But auditors, who are temporarily on a short leash under the
two-midnight rule, may come to a different conclusion.
In Medicare Transmittal 1315, released Nov. 15, CMS says that Medicare administrative contractors (MACs), recovery audit contractors (RACs) and the new supplemental medical review contractor (SMRC) won’t conduct postpayment “patient-status
reviews” on inpatient claims with dates of admission between Oct. 1 and Dec. 31. They
will, however, continue other reviews, including audits for coding compliance, medical
necessity of surgical procedures provided to hospitalized beneficiaries and evidence
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2 Report on Medicare Compliance
of gaming (i.e., delaying care to cross the two-midnight
threshold). Meanwhile, MACs are doing small-scale
prepayment audits of zero and one-day stays (RMC
11/11/13, p. 1), while RACs have been told to drop audits
of admission necessity through March 31, 2014.
That still leaves the ground shifting under hospitals,
which are worried auditors will say more hospital services weren’t medically necessary at all.
“My expectation is that recovery auditors will argue
in their denials that inpatient admissions were not medically necessary based on either the intensity of services or
severity of illness or that the provider’s expectation that
the need for hospital services would transcend two midnights was not reasonable,” says Keith Knuth, M.D., case
management medical adviser at Community Health Network in Indianapolis. It makes no sense to him because
medical necessity is “the essence” of the two-midnight
benchmark and presumption. According to the 2014 IPPS
regulation, which took effect Oct. 1, CMS generally will
assume inpatient admissions that cross two midnights
are medically necessary unless they are delayed on
purpose (RMC 8/12/13, p. 1). “It is our opinion that both
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November 25, 2013
medical necessity and two midnights deserve consideration in the decision to admit inpatients,” Knuth says.
To sort it out, consider using a two-step process, says
Ron Hirsch, M.D., vice president of the Regulations and
Education group at Physician Advisory Services. The
first step is determining whether patients need to be in
the hospital at all, regardless of whether it’s inpatient or
outpatient status. If not — perhaps it’s a social admission
— send the patients home, or place them in observation
after they sign an advanced beneficiary notice accepting
financial responsibility for the services because Medicare
won’t pay. “The hospital becomes like a hotel,” according
to Hirsch.
When patients pass step one, they need to be in the
hospital in some way, shape or form. The second step
in the process is determining whether they will cross
two midnights. If not, they fail step two and belong in
observation, he says. After one midnight, if they are
stable, send them home, but if not, admit them before the
second midnight. “My motto is, ‘no patient who needs
to be in the hospital should spend two midnights in the
hospital without being admitted as an inpatient,’” Hirsch
says. “The key word is ‘need’ — if they need to be in the
hospital, not ‘want’ to be in the hospital — want to because of patient convenience, physician convenience or
hospital convenience” (e.g., hospitals worried about their
patient satisfaction ratings may be reluctant to send patients packing even when the admission is unwarranted).
The medical necessity is implicit in whether the patient
needs to be in the hospital at all.
Physician Expectations Are Everything
Compliance with the two-midnight rule hinges
on the physician’s expectations for the patient’s length
of stay, and this is the game changer. In the context of
IPPS 2014, CMS has repeatedly said that when length
of stay is uncertain, patients initially should be placed
in observation, says Michael Taylor, M.D., president of
Medical Audit & Review Solutions in West Chester, Pa.
That’s counter to the way many hospitals historically
interpreted the Medicare Benefit Policy Manual (Chapter
One, Section 10). “If the patient had a high level of risk,
that favored inpatient admission, even if the physician
was not certain the patient would spend several days in
the hospital,” Taylor says. “What has become clear from
the new rule and associated guidance is that CMS is now
looking at a time-based presumption instead of level-ofcare distinctions between inpatient and observation.”
For example, according to CMS, the unit where care is
provided — ICU, a telemetry floor or a medical-surgical
inpatient unit — is not a critical element in the admission
decision, he says. Patients who present with respiratory
failure from an overdose of alcohol or a short-acting
benzodiazepine may need intubation and a mechanical
EDITORIAL ADVISORY BOARD: JEFFREY FITZGERALD, Polsinelli Shughart, EDWARD GAINES, Esq., Medical Management Professionals, Inc., DEBI HINSON, Corporate VP and Chief
Compliance Officer for Regency Hospital Company in Alpharetta, GA, MARION KRUSE, FTI Healthcare, RICHARD KUSSEROW, President, Strategic Management Systems, Alexandria,
Va., WALTER METZ, CPA, MS, JD, Brookhaven Memorial Hospital Medical Center, MARK PASTIN, PhD, Council of Ethical Organizations, CHERYL RICE, Corporate Responsibility Officer for
Catholic Health Partners in Cincinnati, Ohio, ANDREW RUSKIN, Esq., Morgan, Lewis & Bockius LLP, BOB WADE, Esq., Krieg DeVault, D. McCARTY THORNTON, Esq., Sonnenschein Nath
& Rosenthal, JULIE E. CHICOINE, JD, RN, CPC, Compliance Director, Ohio State University Medical Center, WENDY TROUT, CPA, Director Corporate Compliance, WellSpan Health, AMI
ZUMKHAWALA–COOK, Chief Compliance Officer for Holy Spirit Health System
November 25, 2013
Report on Medicare Compliance
vent in the ICU, but they could recover in a few hours.
Under the two-midnight rule, high-risk intensive-care
patients of short duration are appropriate for observation
services, Taylor says.
Sometimes the expectations for patients are counterintuitive. “Chest pain will be an interesting diagnosis
under the two-midnight benchmark,” Knuth says. Some
seriously ill patients will be ready for discharge before
two midnights. Suppose a patient presents to the emergency room at 12:30 am, where he is diagnosed with ST
elevation myocardial infarction (STEMI), a severe form of
acute coronary syndrome. The patient is sent “emergently” to the cardiac catheterization lab, gets a stent inserted,
stabilizes and is sent home the next day. “As sick as that
patient was — and he or she was at tremendous risk
during the hospital stay, with a high degree of severity of
illness and intensity of services — the patient didn’t need
hospital care across two midnights. The two-midnight
rule would be inappropriate for payment under Medicare Part A,” Knuth says.
Conversely, Knuth says, a chest-pain patient with a
non-STEMI (a less severe heart attack) may wind up in
the hospital for two midnights because he is too risky for
discharge until the evaluation is complete.
“You can see where the patient is literally having
a heart attack and losing myocardium every minute
ended up being an outpatient, yet the patient who is not
at the same risk is an inpatient because their diagnostic
evaluation took longer,” he says. “These scenarios are
challenging to health care delivery systems under this
regulation.” One caveat: chest-pain patients kept for two
midnights — over the weekend, for example — because
3
diagnostic tests were not available until Monday would
be outpatients.
It’s interesting that the Medicare transmittal includes
the supplemental medical review contractor (SMRC)
— the new kid on the Medicare audit block — and that
it has added two MS-DRGs to the list of approved issues (spinal fusions and chronic obstructive pulmonary
disease), says Jessica Gustafson, an attorney with The
Health Law Partners in Southfield, Mich. “They will be
part of the audit vernacular,” she says. Providers should
stay tuned, because StrategicHealthSolutions, which has
the SMRC contract, is branching out into MS-DRG coding and, apparently, inpatient medical necessity reviews,
Gustafson says. And judging by its hiring and expansion
plans, SMRC will have its hands in many audits.
Contact Knuth at [email protected], Hirsch
at [email protected] and Taylor at Michael.taylor@
marsauditor.com. G
Hospital’s Approach to Certification
Is an Order With Extra Language
There was much debate at Community Health
Network in Indianapolis over how to comply with the
physician certification requirement in the 2014 inpatient
prospective payment system (IPPS) rule. Other hospitals
seemed to be taking one of two paths — asking physicians to sign a form specifying how long they expected
the patient to stay in the hospital or getting comfortable
with the idea that the requisite two midnights were implied by signed admission orders.
Ultimately, Community Health Network opted for
a hybrid, says Keith Knuth, M.D., case management
CMS Transmittals and Federal Register Regulations
Nov. 15 – Nov. 21
Live links to the following documents are included on RMC’s subscriber-only Web page at www.AISHealth.com. Please click on “CMS Transmittals
and Regulations” in the right column.
Transmittals
(R) indicates a replacement transmittal.
Pub. 100-01, Medicare General Information, Eligibility and
Entitlement Manual
• Update to Medicare Deductible, Coinsurance and Premium Rates
for 2014, Trans. 82GI, CR 8527 (Nov. 15, 2013; eff. Jan. 1;
impl. Jan. 6, 2014)
Pub. 100-03, National Coverage Determinations
• Bariatric Surgery for Treatment of Co-Morbid Conditions Related to
Morbid Obesity, Trans. 157NCD, CR 8484 (Nov. 15; eff. Sept. 24;
impl. Dec. 17, 2013)
Pub. 100-04, Medicare Claims Processing Manual
• Updates to the Medicare Claims Processing Internet-Only Manual,
Trans. 2815CP, CR 8490 (Nov. 15, 2013; eff./impl. March 18,
2014)
• Bariatric Surgery for Treatment of Co-Morbid Conditions Related to
Morbid Obesity, Trans. 2816CP, CR 8484 (Nov. 15; eff. Sept. 24;
impl. Dec. 17, 2013)
Pub. 100-20, One-Time Notification
• Immediate Suspension of Postpayment Patient Status Reviews
of Inpatient Hospital Admissions 10/1/13-12/31/13, Trans.
1315OTN, CR 8508 (Nov. 15; eff. Oct. 1; impl. Dec. 2, 2013)
• Use of Claim Adjustment Reason Code 23, Trans. 1318OTN, CR
8297 (Nov. 15, 2013; eff. April 1; impl. April 7, 2014)
• Implementation of the Award for the Jurisdiction K Part A and Part
B Medicare Administrative Contractor to National Government
Services (R), Trans. 1314OTN, CR 8303 (Nov. 13; eff. Oct. 1;
impl. Oct. 7, 2013)
Federal Register
• No rules published.
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4 Report on Medicare Compliance
medical adviser. “There doesn’t need to be checklist or
separate form to meet certification requirements as long
as they are met somewhere in the medical records that is
easily identifiable,” he says, echoing CMS’s statements
in its Sept. 5 subregulatory guidance (RMC 9/16/13, p.
1). As an insurance policy, Community Health Network
appended a statement to admission orders that says
the inpatient admission complies with 1599-f (the 2014
IPPS rule) and the services are reasonable and necessary.
By signing inpatient admission orders, physicians are
implying the two-midnight expectation. Other certification requirements, including the reason for the inpatient
services and plans for post-hospital care (RMC 9/2/13, p.
1), are dependent on the provider’s good documentation,
Knuth says.
This approach makes sense because the reason for
admission is already in the history and physical (H&P)
under the assessment and care plan, and the post-hospital care plan can be found in the discharge summary. As
for estimated length of stay, “our position is it’s implied
by the inpatient order itself,” he says. “You would not
admit an inpatient but for the expectation that the inpatient service will transcend two midnights.”
Knuth says he and his colleagues “thought about,
discussed and debated” whether they should create
a separate field in the electronic health record system
where physicians would enter their two-midnight
expectation, “but we decided it probably was not the
best and most transparent way to meet that part of the
certification.”
Once the decision was made, Community Health
Networks had to get the message out to physicians. They
are not thinking about length of stay when treating patients and admitting them to the hospital, Knuth says.
“It’s a different paradigm for providers to grapple with,”
he says, and underscores the “paramount importance of
their documentation” as hospitals cope with audits, the
two-midnight rule and ICD-10. “Provider education is
just an absolute in the environment we are in,” he says.
Here are three provider-education strategies:
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November 25, 2013
u Short messages about the two-midnight rule run intermittently on the flat-screen television in physician staff
lounges at Community Health Network. There’s a running loop of what amounts to billboard ads, Knuth says.
They convey information to physicians, such as “we are
on bed diversion because we are full up” and “there is a
shortage of this drug so please be prudent in your use.”
Now they are educating physicians on the two-midnight
rule.
u E-learning modules are developed. Community Health
Network developed a module for the two-midnight
rule and certification requirement. Like all the modules,
physicians and others can access them on any desktop
computer on their own time, and get a little continuing
medical education credit in the process.
u Teaching moments arise with utilization review
nurses. In the course of their work, UR nurses explain
the two-midnight rule to providers or reinforce it. When
the patient’s observation stay is nearing the second midnight, the UR nurse can query the attending physician:
”It’s getting late and your notes don’t indicate the patient
will be discharged. It looks like he will spend another
midnight in the hospital. Should the patient be made an
inpatient? Can you support that in your progress note?”
Knuth says that kind of conversation and “just-in-time
education” is happening on a daily basis. It’s an opportunity for the UR nurse to say, “I’m asking because of the
two-midnight rule,” and elaborate.
Contact Knuth at [email protected]. G
Reward Program for Medical
Supplies Leads to $1M Settlement
Henry Schein, Inc., the world’s largest purveyor of
health care products and supplies to medical, dental and
veterinary practices, agreed to pay $1.14 million to settle
allegations that it violated the civil monetary penalty law
applicable to kickbacks.
The HHS Office of Inspector General had a bone to
pick with Henry Schein’s Medical Privileges Program.
Between Aug. 1, 2007, and Jan. 31, 2013, members of the
program got points every time they made a purchase
from Henry Schein, a publicly traded company that sells
its wares online. Members redeemed the points for more
supplies, which meant Henry Schein, Inc. “offered and
paid remuneration” to its customers, OIG alleged. The
points did not qualify as discounts or rebates under the
anti-kickback statute, according to the allegations in the
CMPL settlement. Henry Schein did not admit wrongdoing in the settlement.
“The OIG has a very narrow definition of the term
‘discount.’ It’s narrower than most people think it is,”
Web addresses cited in this issue are live links in the PDF version, which is accessible at RMC’s
subscriber-only page at http://aishealth.com/newsletters/reportonmedicarecompliance.
November 25, 2013
says attorney Sandy Teplitzky, who represented Henry
Schein. OIG prefers discounts to be given at the time of
purchase — paying ninety cents instead of $1, for example — rather than paying a dollar and earning three
cents toward a future purchase. “I disagreed because
there is also the term ‘rebate’ in the discount safe harbor.
I thought this was a rebate,” which is immune from a
kickback enforcement action, says Teplitzky, who is with
Ober Kaler in Baltimore.
He says OIG worries that reward programs encourage providers to buy items they don’t need. Teplitzky
notes that very few products Henry Schein sells are
separately billable, “but OIG’s argument is when doctors submit a bill for services, that includes an overhead
component,” including supplies. “I disagreed all the way
through the settlement.”
Contact Teplitzky at [email protected]. G
Another Halifax Compensation Deal
Gets Different Response From Judge
A federal judge on Nov. 18 said a jury will decide
whether three neurosurgeons employed by Halifax Hospital Medical Center were compensated in violation of
the Stark law. U.S. District Judge Gregory Presnell for the
Middle District of Florida declined to throw out the Department of Justice’s allegations and said the matter will
proceed to trial March 3.
The ruling came down five days after the judge
found that compensation received by six medical oncologists employed by Halifax violated the Stark law (RMC
11/18/13, p. 3). In a victory for the Department of Justice,
which had filed a motion for partial summary judgment,
the judge concluded the hospital’s bonus arrangement
did not fit within the bona fide employment exception of
the Stark law because the bonus pool was not restricted
to the oncologists’ personally performed services. The
bonus pool was divided up only based on those services.
Therefore, the judge ruled the oncologists were prohibited from making referrals to the hospital and the hospital was prohibited from submitting claims to Medicare
arising from these referrals for the facility fee. However,
the court found “genuine issues of material fact” that still
need to be resolved, including the extent of the violation
based on the filings. The court also denied summary
judgment to the government on each of its theories of
recovery — the False Claims Act, payment by mistake of
fact, or unjust enrichment.
The two new motions for summary judgment stem
from DOJ’s false claims lawsuit against Halifax Hospital
and its subsidiary, Halifax Staffing, of Daytona Beach,
Fla. The case was filed in 2009 by whistleblower Elin
Baklid-Kunz, director of physician services at Halifax
Report on Medicare Compliance
5
Staffing, who accused the hospital of violating the Stark
and anti-kickback laws and billing Medicare for medically unnecessary admissions. The Department of Justice
intervened only in the Stark part of the lawsuit, alleging
that Halifax’s compensation agreements with three neurosurgeons and six medical oncologists included salary
plus incentives based on the volume or value of their
referrals (RMC 9/26/11, p. 1). The whistleblower pressed
on, and all allegations will be presented in one trial.
The Nov. 18 ruling was prompted by Halifax Hospital’s motion for summary judgment. It had asked
the judge to throw out the Stark allegations against the
neurosurgeons. The hospital argued they are bona fide
employees “in all respects — i.e., the employment was
for identifiable services, the compensation was consistent
with fair-market value and did not take referrals into
account, and the agreements would have been commercially reasonable even in the absence of any referrals,”
the judge said. The government countered that this is a
matter of debate and the court agreed. The government’s
expert witness on physician compensation says that for
several years, the neurosurgeons “appear to have been
paid more than twice as much as neurosurgeons at the
90th percentile of their specialty despite collections from
their work falling below…that rank,” the judge states.
Judge Did Not Rule on MD Comp and Stark
In contrast to last week’s ruling, the judge did not
opine on whether the neurosurgeons’ compensation
violates Stark. The difference between the two rulings is
in the methodology of the compensation, says Atlanta
attorney Alan Rumph, who is with Baker Donelson. The
neurosurgeons were paid 100% of collections. “There
is nothing inherently wrong with a percentage of collections for personally performed services,” he says,
but it’s not surprising that the 100% figure has attracted
scrutiny. As the judge noted, “this allowed the neurosurgeons to...keep 100% of their collections with no
overhead expense.” Rumph says that the doctors providing significant charity care and assuming onerous call
burdens could possibly, as the hospital argues, justify this
level of compensation. But he generally favors the now
more common compensation methodologies based on
work RVUs. Hospitals have to ensure the compensation
doesn’t take into account the volume or value of referrals.
The judge in Halifax found the compensation methodology for the oncologists to be prohibited as a matter
of law, because the bonus pool included revenues from
designated health services referred by the oncologists.
When hospitals employ physicians, compensation can’t
directly or indirectly take into account income from referrals of designated health services, Rumph says. But if
hospitals own a separate legal entity that qualifies as a
“group practice” under Stark, the physicians may receive
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6 Report on Medicare Compliance
a share of the group’s designated health services income,
as long as it’s only indirectly related to their referrals.
Rumph says that the Halifax oncologists’ compensation
would appear to have satisfied the indirect requirement,
had they been employed by a group practice. The “price”
for such increased flexibility in compensation, he notes,
is loss of the higher reimbursement generally available
for physicians who work in provider-based clinics, which
are not “group practices.”
Contact Rumph at [email protected]. G
ICD-10 Requires New Strategies
continued from p. 1
moved to new chapters. But all in all, the classification
systems are very similar.”
ICD-10-PCS, however, is a “whole new ball of wax.
It’s a very different classification system for procedural
coding, and that’s where I fear for hospitals.” Surgical
procedures tend to be high-volume and high-weighted
MS-DRGs, which means they generate more reimbursement than medical MS-DRGs, she says. ICD-10-PCS
requires physicians to document the objective of the procedure (which is the “root operation” of the PCS code), as
well as the body part, the surgical approach, and whether
any device was inserted.
Physicians must be very specific in their operative
reports to ensure accurate ICD-10-PCS and MS-DRG
assignments, Routhier says. Suppose a patient presented
with an incarcerated incisional hernia. During the open
hernia repair, the surgeon stated that “an area of approximately 3 cm of ischemic necrotic bowel was found.” The
procedure was listed on the operative report as “repair
of incarcerated incisional hernia with partial small bowel
resection.” The coder reviewed the operative report, but
there was nothing about which portion of the small bowel (duodenum, jejunum or ileum) was removed.
How would it be coded now vs. under ICD-10?
Routhier explains the differences:
u ICD-9-CM: Procedure code 45.62 is the only code option that exists for reporting the partial resection of the
small intestine for this scenario. As a result, the hospital
would assign MS-DRG 331 (major small & large bowel
procedures without CC/MCC) with a relative weight of
1.6380.
u ICD-10-PCS: Removal of the small intestine can be
classified to the root operation of excision (cutting out or
off a portion of a body part) or resection (cutting out or
off all of a body part), Routhier says. The specific body
part values available for assignment of the 4th character
of the PCS code include duodenum, jejunum and ileum.
The root operation (excision or resection depending on
whether all or a portion of the body part was removed)
November 25, 2013
and the specific body part (the small bowel — duodenum, jejunum or ileum) excised affects the DRG assignment. There are a few MS-DRG options if the partial
small bowel resection was further specified by the surgeon, depending on what he or she documented. They
include:
(1) A portion of the duodenum body part: Assignment of procedure code 0DB90ZZ for excision of duodenum using open approach would result in MS-DRG 328
(stomach, esophageal & duodenal procedures without
CC/MCC) with a relative weight of 1.4765.
(2) All of the duodenum body part: Assignment of
procedure code 0DT90ZZ for resection of the duodenum
using open approach would result in MS-DRG 331 (major small & large bowel procedures without CC/MCC)
with a relative weight of 1.6380.
(3) A portion of the jejunum body part: Assignment
of procedure code 0DBA0ZZ for excision of jejunum
using open approach would result in MS-DRG 349 (anal
& stomal procedures without CC/MCC) with a relative
weight of 0.8834.
(4) All of the jejunum body part: Assignment of procedure code 0DTA0ZZ for resection of the jejunum using
the open approach would result in MS-DRG 331 (major
small & large bowel procedures without CC/MCC) with
a relative weight of 1.6380.
Physicians Must Connect the Dots Under ICD-10
For their part, ICD-10-CM diagnosis codes require
significant changes in documentation. For example, physicians may fail to link a patient’s diagnosis with underlying causes or manifestations in their documentation,
Routhier says. Because ICD-10 has combination codes —
a single code that includes both diagnosis and the cause
or manifestation — the stakes are higher for physicians
to link them. For example, under ICD-9 coders use two
codes to report diabetes with renal nephropathy — one
code for diabetes with renal manifestations and one code
for the manifestation (e.g., nephropathy) — but there
is one combination code in ICD-10. Sometimes doctors
write diabetes and nephropathy as diagnoses but don’t
connect the dots with phrases like “due to” or “associated with.”
Sometimes the ICD-10 classification system itself affects final MS-DRG reassignment, she says. For example,
hypertension can be described as malignant, benign or
unspecified. If it’s malignant (often called “accelerated”),
hypertension is a CC, but that won’t be the case with
ICD-10, which has one code for hypertension, she says.
“From a coding perspective, it won’t matter anymore if
the doctor says accelerated hypertension,” Routhier says.
“We won’t bother physicians with a query to further
specify this condition.”
Subscribers to RMC are eligible to receive up to 12 Continuing Education Credits per year, which count toward
certification by the Compliance Certification Board. For more information, contact CCB at 888-580-8373.
November 25, 2013
Some ICD-9 challenges will be carried over to ICD10, and fixing them is good for compliance for the next
10 months and after the switch is flipped. “If it’s coded
wrong in ICD-9, it probably will be coded wrong in ICD10,” Routhier says. “Those cases are at risk for improper
payment and recovery audit activity.” Coders rely on
physicians and their documentation to get it right, especially when it comes to the underlying reason for an
admission, which drives the principal diagnosis selection. Routhier recently reviewed a case where a diabetic
patient was admitted through the emergency room in
a coma from prolonged hypoglycemia. Because of the
coma, the patient was intubated and placed on a ventilator. In the list of final diagnoses, the attending physician
documented acute respiratory failure and the condition
was coded and sequenced with a principal diagnosis that
led to a high-paying ventilator MS-DRG. But the true
reason for the admission was diabetic coma. “The ER
physician and pulmonologist were clear the intubation
was done to protect the airway and the attending physician reiterated this in the hospital course section of the
discharge summary,” she says. As a result, the principal
diagnosis was wrong. That’s the sort of thing that still
Report on Medicare Compliance
7
goes on with ICD-9 coding and “will be problematic going into ICD-10.”
To nudge documentation toward ICD-10 readiness,
Routhier suggests revamping queries now. Start asking
physicians for the additional information they will need
to generate to take it to the next level (see box, below).
For example, coders may already query physicians to determine whether the respiratory failure they documented
is acute, chronic or acute on chronic. So why not go further and ask if it’s hypoxic or hypercapnic?
Some hospitals are coding cases under both ICD-9
and ICD-10 so they can get used to the new system and
identify where they need documentation specificity. At
one facility, every coder codes the first case of the day in
both ICD-9 and ICD-10. In physician and coder education, hospitals may want to focus on the high-volume
procedures and diagnoses most at risk of financial loss
after the transition, she says. Then do chart reviews
to identify documentation gaps in these areas. “You
wouldn’t want to waste your breath on areas they are
already documenting well.”
Contact Routhier at [email protected]. G
Revamping Queries to Get Ready for ICD-10
Consultant Sandra Routhier developed this example of how a query would be revised in preparation for the increased coding
specificity of ICD-10-CM. Contact her at [email protected].
Dear Doctor:
We need your assistance in determining the correct diagnosis for this patient’s inpatient encounter.
This patient was seen in the ED with agonal respirations with failed attempt to intubate. The ED physician documented
accessory muscle usage, respiratory distress, tachypnea, decreased breath sounds and wheezes in both lungs. Blood gases
revealed a pCO2 of 55. Patient was admitted to ICU on BiPAP.
The H&P states that the patient has a past medical history of “chronic respiratory failure.” The list of diagnoses in the daily
progress notes and discharge summary state: “acute on chronic dyspnea secondary to COPD exacerbation.” Pulmonary
consultation report includes a diagnosis of “respiratory failure.”
Based on these indications, please clarify if the documentation of the respiratory failure can be further specified by
• Acuity/Chronicity:
»» Acute, Chronic or Acute on Chronic
ƒƒ With Hypercapnia or with Hypoxia
• Unable to determine
• Other (please specify):�������������������������������������������������������������������������������
Physician response:����������������������������������������������������������������������������������������
���������������������������������������������������������������������������������������������������������
���������������������������������������������������������������������������������������������������������
���������������������������������������������������������������������������������������������������������
���������������������������������������������������������������������������������������������������������
Physician signature, date and time: ��������������������������������������������������������������������������
This document will become a part of the patient’s medical record.
Copyright © 2013 by Atlantic Information Services, Inc. All rights reserved.
Please see the box on page 2 for permitted and prohibited uses of Report on Medicare Compliance content.
8 Report on Medicare Compliance
November 25, 2013
NEWS BRIEFS
u The Ensign Group, which operates skilled nursing facilities in the western United States, has
agreed to pay the U.S. government $48 million to
settle allegations that it submitted false claims
to Medicare for medically unnecessary therapy
services. For more than 10 years, six of Ensign’s
skilled nursing facilities allegedly provided therapy
to patients whose condition did not warrant it, billed
for services they did not provide and kept patients
in the facilities longer than was medically necessary,
according to a press release from the Department of
Justice. A second press release from the whistleblower’s attorneys provides details on what DOJ alleged
was “a corporate culture that improperly incentivized therapists.” According to Phillips & Cohen,
the firm that represented one of the whistleblowers
who initiated the false claims lawsuit against Mission Viejo, Calif.-based Ensign, the complaint alleged
that “each facility administrator was required by
company management to set what were called ‘Big
Hairy Audacious Goals’ for the number of Medicare
patients and the amount of Medicare reimbursement
per day....When goals were reached, administrators
were rewarded with benefits such as all-expensespaid trips to Hawaii, Alaska and other vacation
spots....One way that managers met their ‘audacious’
goals was to offer incentives to rehabilitation therapists and others to achieve high Medicare revenue
targets, which the therapists could do only by billing
at higher rates than was justified or by extending
rehab therapy for longer periods than the patients
needed....” The settlement closes two separate whistleblower lawsuits filed by former Ensign therapists
in 2006. In addition to the settlement payment — one
of the largest levied against a nursing home chain
— Ensign agreed to place all of its facilities under a
corporate integrity agreement with the HHS Office of
Inspector General. Ensign did not admit wrongdoing
in the settlement and, in a statement, denied “engaging in any illegal conduct” and emphasized its
investment in compliance. Visit http://tinyurl.com/
n9rpkdf.
u A carve-out from an exclusive contract between
a hospital and an anesthesiology group could
pose significant risk of illegal remuneration, the
OIG concluded in Advisory Opinion 13-15. The
anesthesiology group, which requested the advisory
opinion, had been the exclusive provider of most
anesthesia services, including electroconvulsive ther-
apy (ECT), to the hospital until a psychiatry group,
whose practice centered on ECT, relocated to the
hospital. In a 2012 contract renegotiation, the hospital
insisted on a carve-out — termed the “Additional
Anesthesiologist Provision” — that, among other
things, required the anesthesiology group either to
provide its services to the psychiatry group if the
hospital or the group determined it needed another
ECT anesthesiologist or to allow the hospital and
group to hire another anesthesiologist without violating the exclusivity provision of the anesthesiology
group’s contract. In accordance with the “Additional
Anesthesiologist Provision,” the anesthesiology
group later negotiated with the psychiatry group
to provide part-time services for ECT. It agreed to
reassign its billing rights to the psychiatry group.
The psychiatry group then would bill federal health
care programs and pay the anesthesiology group a
per diem rate, which, the anesthesiology group said,
was below fair market value. The psychiatry group
would retain the difference between what it paid
and the amount received from the federal health
care program. This arrangement, OIG said, “appears
to be designed to permit the Psychiatry Group to
do indirectly what it cannot do directly; that is, to
receive compensation, in the form of a portion of
Requestor’s anesthesia services revenues, in return
for the Psychiatry Group’s referrals of ECT patients
to Requestor for anesthesia services.” In an unusual
footnote, OIG warned providers about potential
anti-kickback violations arising from carve-outs from
exclusive service contracts. Visit http://tinyurl.com/
kbkepgq.
u The HHS OIG released the results of its study
of nursing homes’ rates of hospitalization of their
patients and concluded that high rates of hospitalization could signal quality problems. It recommended, and CMS agreed to: (1) develop a quality
measure that describes nursing home resident hospitalization rates, and (2) instruct state survey agencies
to review the proposed quality measure as part of the
survey and certification process. Visit http://tinyurl.
com/pkvtgte.
u Correction: An Oklahoma hospital self-disclosed
possible Stark law violations to CMS, not OIG, as
RMC reported in the Nov. 18 issue. The OIG does not
accept disclosures of Stark-only violations in its SelfDisclosure Protocol.
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