Documentation Updates for Physicians

Transcription

1 Documentation Updates for Physicians CMS IPPS 2014 Final Rule AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product Executive Health Resources, Inc. All rights reserved. 1

2 Agenda Background FY2014 IPPS Compliance Requirements Physician order 2-Midnight Rule Medical Necessity Documentation and Physician Certification Summary 2

3 IPPS Key Requirements/Changes The Time the patient is expected to stay in the hospital (2 midnights is guide) The Order to admit to inpatient or refer for observation/outpatient The Documentation & Certification of medical necessary to support the patient s inpatient admission. 3

4 Time: 2 Midnight Expectation AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product Executive Health Resources, Inc. All rights reserved. 4

5 Benchmark vs. Presumption Benchmark of 2 midnights the decision to admit the beneficiary should be based on the cumulative time spent at the hospital beginning with the initial outpatient service. In other words, if the physician makes the decision to admit after the beneficiary arrived at the hospital and began receiving services, he or she should consider the time already spent receiving those services in estimating the beneficiary s total expected length of stay. Presumption of 2 midnights Page 50946, IPPS Under the 2-midnight presumption, inpatient 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 Page 50949, IPPS 5

6 Exceptions to the 2 Midnight Rule Medicare Inpatient only Surgical List AMA Transfers Death Other Rare exceptions 6

7 Expectation/Certification Physician must document if they expect the patient s hospital care to span more or less than 2 midnights Treatment time spent in the ED can be counted towards 2 midnights Guidelines: If you believe the patient will be discharged same day or the day following hospitalization, consider ordering Outpatient or Observation If you believe the patient will NOT be ready for discharge the day after hospitalization, consider ordering Inpatient 7

8 Physician Orders AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product Executive Health Resources, Inc. All rights reserved. 8

9 Physician Order For payment of hospital inpatient services under Medicare Part A, the order must specify the admitting practitioner s recommendation to admit to inpatient, as an inpatient, for inpatient services, or similar language specifying his or her recommendation for inpatient care Page 50942, IPPS Admit to Tower 7 or Admit to Dr. Smith are not recommended 9

10 Physician must be involved in Order Determination Some commenters commented that their current processes provide for admission to case management or to utilization review rather than specifying inpatient admission. Response: As we discussed above, many public comments from physicians indicated that they believed the physician should be involved in the determination of patient status, and we agree. To reinforce this policy and reduce confusion among hospitals, beneficiaries, and physicians on the differences between outpatient observation and inpatient services, we are providing in this final rule that the order for inpatient admission must specify admission to or as an inpatient. Page 50942, IPPS 10

11 Physician Order Clarification Qualifications of the ordering/admitting practitioner: At some hospitals, practitioners who lack the authority to admit inpatients under either State laws or hospital by laws may nonetheless frequently write the sets of admitting orders that define the initial inpatient care of the patient. In these cases, the ordering practitioner need not separately record the order to admit.. the order must identify the qualified ordering practitioner, and must be authenticated by the ordering practitioner (or by another practitioner with the required admitting qualifications) prior to discharge. Verbal orders: A verbal or telephone inpatient admission order must be authenticated (signed, dated and timed) by the ordering practitioner (or by another practitioner with the required admitting qualifications in his or her own right) in the medical record prior to discharge, unless the hospital or the State requires an earlier timeframe Timing: The order must be furnished at or before the time of the inpatient admission. Sept 5 CMS Update Memo 11

12 Physician Order Guidelines Inpatient Cases: must include the words Admit and Inpatient to be a valid inpatient order Observation/Outpatient Cases: Should include the phrase refer for Observation Services or outpatient status Avoid using admit and Observation or Outpatient in the same order. CMS considers this to be contradictory Admit to Tower 7 or Admit to Dr. Smith are not recommended 12

13 Physician Documentation and Certification Requirements AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product Executive Health Resources, Inc. All rights reserved. 13

14 Certification Requirements CMS requires physician certification of the patient s inpatient admission in the medical record. The certification must include: Order for inpatient admission (as discussed) Diagnosis and rationale for hospitalization/ inpatient medical treatment Documentation of the estimated time the patient will need to remain in the hospital (as discussed) Plans for post-hospital care, if appropriate May be entered on forms, notes, or records that the appropriate individual signs, or on a special separate form. If information is in different places (i.e. progress notes, H+P) [certification] statement should indicate where it may be found Certification must be signed and documented in the medical record prior to the hospital discharge CFR

15 Sept 5 CMS Update: Physician Certification Timing: The certification must be completed, signed, dated and documented in the medical record prior to discharge Authorization to sign the certification: The certification or recertification may be signed only by one of the following: (1) A physician who is a doctor of medicine or osteopathy. (2) A dentist in the circumstances specified in 42 CFR (d). (3) A doctor of podiatric medicine Format: As specified in 42 CFR , no specific procedures or forms are required for certification and recertification statements. The provider may adopt any method that permits verification. The certification and recertification statements may be entered on forms, notes, or records that the appropriate individual signs, or on a special separate form. Sept 5 CMS Update Memo 15

16 Guidelines for Documentation/Certification Excellent patient care should continue to be the top priority. Clearly document and sign the diagnosis, medical rationale, plan of care and anticipated discharge. Sign the admission order and certification (if appropriate) prior to discharge. 16

17 Medical Documentation Takeaways 6 key pieces of documentation for medical necessity Past Medical History Comorbidities Severity of signs and symptoms Pertinent positives on physical exam Current Medical needs Plan of care and orders Facilities available for adequate care Predictability of an adverse outcome Suspected diagnosis and rational Expectation Length of Stay 17

18 Surgical Takeaways Medicare's Inpatient Only List should be reviewed at the time the procedure is scheduled For procedures that are on the Medicare IP only list, the order for Inpatient must be on the chart PRIOR to the surgery If the procedure changes during surgery to an Inpatient only case ensure the IP order is put on the chart ASAP after the procedure 18

19 Summary Changes go into effect October 1, 2013 Order must be written and signed by attending Time Expectation of LOS AND medical necessity drives Inpatient or Outpatient status Certification must be signed by attending physician 19