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3/18/2014 ER & Inpt surgeryAttack these two places with a pro-pt status focus,not placing and chasing.Develop internal flows to attack: ER - how much UR coverage ? 24/7? or utilize ER leadRNs or house supervisors. No pt is given a bed without ptstatus ‘blessed.’ Integrated CDI program will help withcross training. Inpt surgery – all daily inpt surgery schedules are reviewedby UR to review outpt being scheduled as outpt. Involve the internal UR leaders and PA for patterns. Sr leadership will have to be prepared to push thru theregulation with any problematic providers.RAC 2014 Lots of ‘chatter’ but evaluate this process flow.1st question: Can the pt go home safely from theER? Assess the reasons the provider (ER docconsults with the provider directing care) anddocument same. (Risk factors, history of likecondition with outcome, presenting factors, plan )2nd question: Can the ER physician (after consultingwith the admitting) attest/certify that the pt needsto ‘be in the hospital’ for an estimated 2 midnightsto resolve the condition?3rd question: If no, move to OBS and evaluateclosely. If yes, move to inpt with other elementsof the inpt certification.RAC 2014 25Effective DOS 10-13Physician certification isrequired with every inptorder.Challenges – doctordirecting/knowledge of pt’scare must sign/”ordering”status privileges.At beginning of inpt andwhen converting from obsand prior to discharge.with the record stillsupporting inpt LOCDiscuss ordering privileges,TO/VO with authentication 26Key elements of thecertification:Must order ‘inpt’ w/Authentication of Inpt order.Anticipated LOS –(2 MN or 1MN with 1 outpt MN)Reason foradmission HUGEAnticipated D/C destinationand needs (D/C note ok) CAH – may be reasonably d/cor transferred in 96 hrs.Separate form? Not requiredIncorporated into existingdocumentation ‘somewhere?”Consistency always form(Hospital certification/CMS)RAC 2014279

3/18/20145 W’s – Recovery Analytics What are we treating? Diagnosis Where is the treatment needed? Inpt orobs? Why is treatment needed?Acute/chronic/risk How are we treating it? What & whyactive tx When do you think they’ll get better?Estimated LOSRAC 201428Use for both OBS and Inpt – clarification of order and intent. Consistency. SAMPLEDate/TimePatient StatusDate of Service:Check appropriate box for patient status:Place in Outpatient ObservationDiagnosis:Reason for Placement:INPATIENT ADMISSION CERTIFICATION /Medicare onlyMust be completed by provider for Inpatient AdmissionsBox A This patient is admitted for inpatient services. The patient is medically appropriate and meets medicalnecessity for inpatient admission in accordance with CMS section 42 C.F.R §412.3.I reasonably expect the patient will require inpatient services that span a period of time over two midnights. Myrationale for determining that inpatient admission is necessary is noted in the section below. Additionaldocumentation will be found in progress notes and admission history and physical.Primary Diagnosis:Expected Length of Stay: (MEDICARE ONLY)Select One:2 Midnights (MN) Inpatient1 MN Outpatient (ER or Obs) and 1MN InpatientFor Initial Certification (CAH only)I Expect the Length of Stay to Not Exceed 96 hrsFor Re-CertificationThe Length of Stay is Exceeding 96 hrsAdmit to Inpatient Services (Medical)PROVIDER MUST COMPLETE CERTIFICATIONPlans for Post-Hospital Care: See Discharge SummarySupportive Findings to Primary Diagnosis: [examples: co-morbidities, abnormal findings, diagnosticabnormalities, exacerbations, new onset of disease with (co-morbidities)]Level of CareAcute CareTelemetryReason for Admission:Attending Provider (Print Name)(Note: if the ER provider does not have ‘admitting privileges, only transitionalprivileges”, important that this include a statement: Spoke with theadmitting/attending , and we concur with the admission status.” ER providersigns.PCP (Print Name)PCP (Print Name)Provider SignatureProvider SignatureCertifying Provider Signature (this 2nd signature required for inpatient admissions as the provider who isdirecting care.)Date/TimeDate/TimeRAC 2014 2midnight presumption“Under the 2 midnightpresumption, inpt hospitalclaims with lengths of staygreater than 2 midnightsafter formal admissionfollowing the order will bepresumed generallyappropriate for Part Apayment and will not be thefocus of medical reviewefforts absent evidence ofsystematic gaming, abuseor delays in the provision ofcare.Pg 50959 29Benchmark of 2 midnights“the decision to admit thebeneficiary should be basedon the cumulative timespent at the hospitalbeginning with the initialoutpt service. In otherwords, if the physicianmakes the decision to admitafter the pt arrived at thehospital and beganreceiving services, he or sheshould consider the timealready spent receivingthose services in estimatingthe pt’s total expected LOS.Pg 50956RAC 20143010

3/18/2014 It never has and never will mean – “meeting clinicalguidelines” (Interqual or Milliman)It has always meant – the physician’s documentation tosupport inpt level of care in the admit order or admit note.SO –if UR says: Pt does not meet Criteria – this means: Doctorcannot certify/attest to a medically appropriate 2 midnightstay – right?11/1/2013 Section 3, E. Note: “It is not necessary for abeneficiary to meet an inpatient "level of care" by screeningtool, in order for Part A payment to be appropriate“Hint: 1st test: Can attest/certify estimated LOS of 2midnights? THEN check clinical guidelines to help clarify anymedical qualifiers but the physician’s order with ROA –trumps criteria.RAC 2014 If the beneficiary hasalready passed the 1midnight as an outpt, thephysician should considerthe 2nd midnightbenchmark met if he or sheexpects the beneficiary torequire an additionalmidnight in the hospital.(MN must be documentedand done)Note: presumption 2midnights AFTER obs. 1midnight after 1 midnightOBS at risk for inpt auditPg 50946 .the judgment of thephysician and the physician’ sorder for inpt admissionshould be based on theexpectation of care surpassingthe 2 midnights with BOTH theexpectation of time and theunderlying need for medicalcare supported by complexmedical factors such as historyand comorbidities, the severityof signs and symptoms ,current medical needs and therisk of an adverse event. Pg50944RAC 2014 412.3 (e) (2) (see p. 50965of Final Rule) – “If anunforeseen circumstance,such as a beneficiary’sdeath or transfer, results ina shorter beneficiary staythan the physician’sexpectation of at least 2midnights, the patient maybe considered to beappropriately treated on aninpatient basis, and hospitalinpatient payment may bemade under Medicare PartA.” (Thx, Accretive)”31 32Can 1 day stay inptsstill occur?YES -but as the regsclearly state, anticipate anaudit as it should be ahighly uncommonoccurrence.1 MN as outpt or OBS and 1MN as inpt inptJust because a patient dies, istransferred for tertiary care, orleaves AMA, (paraphrased fromLCD L27548) it does not changethe presentation of clinicalfactors/criteria that went into thephysician’s complex medicaldecision to admit to an inpatientstatus. (Thx, Appeals Masters)RAC 20143311

3/18/2014 Lots of discussion on : “My patient is very sick, atrisk but I don’t think they will need 2 midnights. I checkedwith Interqual/UR and it meets their definition of an inpt. Iam admitting and highly anticipate they will only need 1midnight.” (nope, not an inpt/obs and monitor closely)CMS has stated: Rare and unusual. 2 outlineddefinitions at this time: inpt only surgeries andinitiation of mechanical ventilator with 1 midnight.They are still working on how to address transfersout & hospice referral. NOTE: transferring inhospital must still meet their own 2 MN threshold.The transferring out hospital’s LOS does not count.(RAC Summit/12-13)RAC 2014CAH: must use the 2 MNpresumption/benchmark PLUScertification to reasonablyexpect the pt to transfer ordischarge within 96 hrs. Iflonger, re-do but should beunusual cases. (Watch HR3991/eliminate)Delays: WeekendsIf delayed due toconvenience/systemicdelays/weekends/late tests,do not count toward 2 MNthreshold. If need to stay andnot safe to discharge, ANDneed test that is being helduntil Monday, midnight counts.BUT TELL THE STORY WELL.1)2)3)Embed questions from theoptional certification formwithin the electronicorders or use the manualform.Empower UR staff toassist with complianceKnow which proceduresare riskiest, such as cathlab procedures and outptsurgeries that ‘stay thenight’.34Long obs:Pt in in Obs for 2midnights. 1st Q: did the pt have48 hrs of billable obs or just hrsin a bed?2nd Q: Was the regulation for OBSmet? (OBS is: Active physicianinvolvement/ongoing assessment.)If MET- then the pt was eligible toconvert to INP after the firstmidnight with the physician‘attesting’ of the need formedically appropriate care fication-and-Order-09-05-13.pdf(WPS Excellent Audio 11-11-13)RAC 20144)5)6)7)8)35Target physicians in theED.Hire internal physicianadvisors to assist witheducation.Understand theimplications for transfersUse internal audits toidentify problem areasLearn from the probes andhammer the messagehomeRAC 20143612

3/18/2014 After an uneventful,but late outpt invasiveprocedure, physicianorders to ‘stay thenight’. This is a FREEservice as the pt hasno medical reason tobe in a bed. Time todischarge .Liability risk for havinga non billable pt in thehospital. Have the pt stay thenight and do the testin the am or Mon/wkd.What is the clinicalreason to ‘stay thenight?” If not anunplanned eventleading to OBS, a FREEservice.Is there another clinicalreason to be in a bed?Document it well withcorrect status RAC 2014 Outpt surgery.After routine recovery(up to 4-6 hrs), doctororders the pt to ‘staythe night.”What did the doctorreally want? Who isreviewing every ‘pt in abed’ after the 4-6 hrsof RR? Why still inhouse? Cath LabDoctor hasroutinely had thepatient the pt stayovernight.Historically billed aa 1 day inpt stay.Explore options –inpt, outpt or obs.RAC 2014 AHA’s to CMS:Sept 26th: “Statement onTwo Midnight Rule”Included are Sept 18thsituations with‘assumptions.” Pending“CMS’s long standingguidance has been thatreviewers should evaluatethe physician’sexpectations based on theinformation available to theadmitting practitioner at thetime of admission. “ 3738Fed Reg, 8-19-13 R&R“Impacts of change inAdmissions and MedicalReview Criteria” (Chpt 100-04 pg 50592)Due to estimated increaseof 220M , reducedpayment of .02%. (CFOsare very nervous they aregoing to loose many inptsrather than have the gain asoutlined by CMS in finalregs.)PS OBS still does not counttoward 3 midnite/SNFRAC 20143913

3/18/2014 Transmittal 1315, CR8508,Nov 15, 2013“Immediate suspension ofPost Payment Pt Statusreviews of inpt hospitaladmissions 10-1-13 thru12-31-13.”RAC And SMRC -Can audit:Evidence of gamingOther non pt status –coding, medical necessityof surgical cases, mandatedtherapy reviews) EOB remarks/PatientDenying Part A for an inptadmission subject to CMSruling 1455-R:MSN 36.8“Your inpt admission stay is denied.Sinceyou didn’t know Medicare would denythese services, you aren’t responsible.Your provider may resubmit this claimunder Part B. You may be responsiblefor coinsurance and deductible forcovered services.” Denying Part B clam subjectto CMS ruling 1455-R. 36.9“This claim for inpt services was originallydenied by Medicare and resubmitted byyour provider under Part B. You areresponsible for any coinsurance anddeductible for covered services.”RAC 2014 Services unavailableWeekends & HolidaysPatient safety40Consultants unavailableEquipment downPatient & family issue(Thanks, Dr Salvador, DE hospital & PA/UR bootcamp faculty)RAC 2014 Certification form – always.Consistently start andclarify the pt story.UR in the ER – alwaysinvolved prior to placement.Hospitalist – always see thept rapidly/less than 2 hrsfrom referral to inpt.Integrated CDI program –one ongoing audit, onevoice for edDedicated beds for OBS.OBS hasn’t changed at all.UR assigned to closelymonitor every OBS thatexceeds the first midnight. 41Grow an internal physicianadvisor—NOW! Ongoingeducation, URsupport/intervention effective changeActively involve nursing asthe eyes of the pt story24/7.Actively involve surgeryscheduling to ‘spot’ anycommon outpt surgeriesbeing scheduled as inpt.Beef up the UR committeeBeef up the UR ‘s role,separate from case mgt.Front end RAC 20144214

3/18/2014 Palmetto /MAC just denied heart failure/shock and spinalfusion. ( DRG 391/Esophagitis, DRG 191 – COPD with CC.)4th RAC Medicaid ADR cycle – 25 recordsMAC – probe for DRG 290, 640, 641, 690, 688 –stroke casemix group.MD RAC denials for automated ‘hits’PERM requestIncrease with RAC automated and semi-automated denials –first activity in over a yr- over 200 accts deniedRAC Prepayment – OT, PT, ST , Therapy cap thresholdsFirst RAC post payment ADR in over a year – 272 records Drugs and biological – billed in multiple of dosages specifiedJ9171-billing 1 unit for every 1 mg/ptElective surgeryMinor surgery procedures and other treatment. (HUGE) (Thx, Jordan, NC8-13)RAC 201443Day Egusquiza, PresidentAR Systems, IncBox 2521Twin Falls, Id 83303208 423 9036daylee1@mindspring.comThanks for joining us!Free info line available.Plus our training website COMING SOON!JOIN US FOR UR/PA Bootcamp in ChicagoJuly 14-16 2014RAC 201444More implementation ideasPlus MAC audit hot topicsRAC 20144515

3/18/2014 Noridian/J3 has announced Probe audits forAZ, MT, ND, SD, UT, WYProbe for 1 day stays, 2 day stays, 3 day staysand high dollar (w/o definition of ) CAH 3day SNF /2013Prepayment auditing/2012: DRG 389, 313, 512, 191, 545,517, 243, 244, 227, 607, 445, 242, 921, 310, 23, 670 /?%A/B auditing: doctor and hospital claims audited(Kyroplasty)—Cert auditsWPS released a CERT review of EpiduralSteroid Injections w/large error rate. (1/31)(LCD30481). Prepayment 310, 313, 192, 690RAC 2014 46Highmark (Now Novitas Solutions) Probe for DRG 470/Major Joint Replacement orreattachment of lower extremity w/MCC. Need to documentend stage joint disease & failed conservative therapy. (EX:Trailblazer Transmittal ID 14362/LCD) Probe for DRG 244 Permanent Cardiac Pacemaker implantw/o CC or MCC. NEW: 313, 392, 292 (2012) Msg from provider: Have been having 100% prepaymentaudit payment for DRG 313/chest pain for almost 2 yearsnow. The site indicates they are being successful around90% of time at the 3rd level appeal/ALJ but it is taking about18 months. There does not appear to be a change with thepre-payment review even with the overturn rate. (per PAfacility history 9-11)RAC 2014 47Trailblazer/Novitas: to increase consistencyin Medicare reimbursement, effective 11-11,Trailblazer will begin cross-claim review ofthese services. The related Part B service(E&M, procedures) reported to Medicare willbe evaluated for reimbursement on a postpayment basis. Overpayments will berequested for services related to the inpt staythat are found to be in error.First Coast & HighMark/Novitas– similar3-12 TX hospital lost 470; provider recoupedRAC 20144816

3/18/2014NJ Hospital: We have had prepayment denials from Novitas (Highmark) in addition to our RAC denialsFor the Prepayment Denials, we send appeal with additional information from the doctor’s office notes.They are looking for 4 key elements: Level of Pain and Effect on ADLs Response to Treatment with Medications: NSAIDS and Injections Response to Treatment with other modalities: Assist Devices, Braces and PT X Ray FindingsIn the past, it was ok to just say “did not respond to conservative treatment”.Now they want details documented.NOTE: Med Learn SE1236 Documenting to support medically necessity of DRG 470American Association of Hip & Knee Surgeons/AAHKS, June 2012 publication. Created acheck list to assist surgeons with the required documentation elements.Suggestions: Surgery scheduling joins the UR prevention team. Education on new checklist requirementIn the medical record /surgical H&P. Validate it is present prior to procedure. UR works with theSurgeon; surgery works with the surgeon. Alternative idea: Include the physician’s notes with theHospitals. Alert: Many HIM depts would not submit these as they may not be identified as part of thelegal medical record. Also some state limitations. Explore HIPAA privacy issues for non‐hospitalrecords for treatment, payment or operations.RAC 2014 49Palmetto, Pre Payment AuditingBegan early 2012(Site: CA site. Prior to Feb, 2012 – never had a prepayment audit request. Had 12 in 1st request.)DRGs focus: 871Septicemia/Sepsis 641Misc disorders of nutrition 690Kidney / UTI 470Joint replacement Probe 227/inpt implant with defib w/o cath or CC or MCC.Aver 42,298. Rebill – ancillary only (11-12)J15/CGS:DRG 308-310, post payment Cardiac Arrythmia audit (KY and Ohio).123 claims. 55 denied. Due to ‘moderate error rate of 36.4%, continued complexauditing will occur.RAC 2014Cahaba – Pre-Auditing of the below DRGs. t Ischemia)(Chronic Obstructive Pulmonary Disease w CC)(Simple Pneumonia & Pleurisy w/o CC/MCC)(Percutaneous Cardiovascular Procedure w Drug-Eluting Stent w/oMCC)(Circulatory Disorders Except AMI, w Cardiac Cath w/o MCC)(Chest Pain)(Esophagitis, Gastroenteritis & Misc Digestive Disorders /o MCC)(Medical Back Problems w/o MCC)(Nutritional & Misc Metabolic Disorders w/o MC

RAC 2014 7 PRG Schultz - out as a RAC subcontractor. Not enough money!! YEAHOO CMS announces RAC 'pause" (2-19-14) Feb 21- last day may issue an ADR Feb 28th -last day MAC may issue a prepayment ADR for the RAC demo project June 1st -the alst day a RAC may send denied claims to the MAC to recoup payment. 5 changes to the RAC