CMSA Connecticut Chapter 2014 IPPS Rule

Transcription

1 CMSA Connecticut Chapter 2014 IPPS Rule

2 EAST PENNSYLVANIA ACMA MARCH 1, 2014 THE 2014 IPPS: WHAT YOU NEED TO KNOW ABOUT THE 2 MIDNIGHT RULE June 7, 2014 STEVEN J. MEYERSON, M.D. Senior Vice President Regulations and Education Group AccretivePAS Clinical Solutions smeyerson@accretivehealth.com

3 THE TRADITIONAL 24-HOUR BENCHMARK FOR ADMISSION Physicians should use a 24-hour period as a benchmark, i.e., they should order admission for patients who are expected to need hospital care for 24 hours or more, and treat other patients on an outpatient basis. Admissions are not covered or non-covered solely on the basis of the length of time the patient actually spends in the hospital. Medicare Benefit Policy Manual, Pub 100-2, Chapter 1, Section 10 Admit if expected LOS is 24 hrs. from time of admission order. Clock now starts at first midnight. LOS was not reason for payment or for denial not anymore.

4 PHYSICIAN S DECISION TO ADMIT AS INPATIENT The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors: the patient s medical history and the severity of the signs and symptoms [SI] which impact the medical needs of the patient and influence the expected LOS and the medical predictability of something adverse happening to the patient. Medicare Benefit Policy Manual Chapter 1, Section 10

5 HOW IS OBSERVATION DEFINED BY MEDICARE? Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short- term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Section 20.6, Chapter 6 of the Medicare Benefit Policy Manual (Pub ) Observation has served as an extension of the ED visit.

6 CMS: USE OF OBSERVATION HAS INCREASED In recent years, the number of cases of Medicare beneficiaries receiving observation services for more than 48 hours, while still small, has increased from approximately 3 percent in 2006 to approximately 8 percent in This trend concerns us because of the potential financial impact on Medicare beneficiaries in only rare and exceptional cases do reasonable and necessary outpatient observation services in the hospital span more than 48 hours IPPS Final Rule (CMS-1599-F)

7 OBSERVATION LOS HAS INCREASED 2006 < 12 hrs. - 17% hrs. - 43% 24 to 48 hrs. 37% > 48 hrs. - 3% CMS, 72 F.R , (Nov. 27, 2007) 2008 > 48 hrs. nearly 6% CMS letter to the American Hospital Association, July 7, > 48 hrs. 8% 12% # of obs claims 22%; ALOS hrs MedPAC report to Congress, Sept. 13, > 48 hrs. 3 8% 2014 IPPS Final Rule: CMS-1599-F

8 MEDICARE REQUIRES HOSPITAL TO SCREEN OF ADMISSIONS screening criteria must be used by the UM staff to screen admissions The criteria used should screen both severity of illness (condition) and intensity of service (treatment). Cases that fail the criteria should be referred to physicians for review. Medicare Hospital Payment Monitoring Program (HPMP) Workbook (2008)

9 CoPs REQUIRE REVIEW OF ADMISSION (c) Standard: Scope and frequency of review. (1) The UR plan must provide for review for Medicare and Medicaid patients with respect to the medical necessity of (i) Admissions to the institution; (ii) The duration of stays; and (iii) Professional services furnished, including drugs and biologicals. Medicare Conditions of Participation, 42CFR

10 MEDICARE EXPECTS REVIEWERS TO USE A SCREENING TOOL The reviewer shall use a screening tool [InterQual, Milliman] as part of their medical review of acute IPPS [Inpatient Prospective Payment System, i.e., acute care hospital] and LTCH [long term care hospital] claims. CMS does not require that you use a specific criteria set. In all cases, in addition to screening instruments, the reviewer applies his/her own clinical judgment to make a medical review determination based on the documentation in the medical record. Medicare Program Integrity Manual, Chapter 6, Section 6.5.1

11 IMPATIENT vs OBSERVATION CASE MANAGEMENT SCREENING InterQual and Milliman/MCG: Admission review often a two step process: First level review by case manager against objective clinical admission screening criteria Secondary review by physician to judge medical necessity for admission for those cases that fail to pass admission screening Secondary review by physicians using clinical judgment and applying Medicare regulations, including the 2 midnight LOS expectation

12 CURRENT APPLICATION OF SCREENING CRITERIA One school of thought: They re no longer needed. I disagree. Identify patients more likely to meet new admission criteria. (No longer a near-guarantee) Target for review if admitted despite failing criteria. Screen for unnecessary hospitalization using observation criteria. Help estimate LOS for admission and for discharge planning. Continued stay and discharge criteria for decision to admit from observation Refer to criteria in appeals.

13 THE 2014 IPPS FINAL RULE Federal Register / Vol. 78, No. 160 / Monday, August 19, 2013 / Rules and Regulations Section XI (pp ) Final Rule Home Page: Payment/AcuteInpatientPPS/FY2014-IPPS-Final-Rule-Home-Page.html

14 INPATIENT REDEFINED USING LOS: THE TWO MIDNIGHT BENCHMARK stakeholders suggested that we redefine inpatient using parameters other than the current requirements of medical necessity and a physician order, such as using the beneficiary s length of stay at the hospital. IPPS Final Rule CMS-1599-F, Federal Register, p The 2-midnight benchmark provides that hospital stays expected to last less than 2 midnights are generally inappropriate for inpatient hospital admission and Part A payment absent rare and unusual circumstances IPPS Final Rule CMS-1599-F, Federal Register, p

15 INPATIENT REDEFINED USING LOS: THE TWO MIDNIGHT BENCHMARK In the proposed rule, we stated that the judgment of the physician and the physician s order for inpatient admission should be based on the expectation of care surpassing 2 midnights IPPS Final Rule CMS-1599-F, Federal Register, p

16 So one midnight = out? Two midnights = in? How a hospital should not respond to the two midnight rule.

17 THE CALENDAR AND A CRAYON APPROACH

18 THE CALENDAR AND A CRAYON APPROACH Get yourself a calendar.

19 THE CALENDAR AND A CRAYON APPROACH Get some crayons. +

20 THE CALENDAR AND A CRAYON APPROACH + X X Cross off 2 nights in the hospital.

21 THE CALENDAR AND A CRAYON APPROACH and voila! + = Inpatient? X X

22 THE CALENDAR AND A CRAYON APPROACH NOT SO FAST! + = Inpatient? X X

23 THE CALENDAR AND A CRAYON APPROACH Meeting the 2 midnight benchmark does not, in itself, render a beneficiary an inpatient or serve to qualify them for payment under Part A. X X + = Inpatient? January 30, 2014 CMS Subregulatory Guidance

24 MEDICAL NECESSITY FOR ADMISSION= NEED TO TREAT IN HOSPITAL FOR 2 MNs Physician s decision: Now to treat in hospital vs. send home: In our existing guidance, we stated that the decision to admit a patient as an inpatient is a complex medical decision based on many factors, including the risk of an adverse event during the period considered for hospitalization, and an assessment of the services that the beneficiary will need during the hospital stay. The crux of the medical decision is the choice to keep the beneficiary at the hospital in order to receive services or reduce risk, or discharge the beneficiary home because they may be safely treated through intermittent outpatient visits or some other care. IPPS Final Rule CMS-1599-F, Federal Register, p

25 REASONS FOR TWO MIDNIGHT EXPECTATION MUST BE DOCUMENTED The factors that lead a physician to admit a particular beneficiary based on the physician s clinical expectation are significant clinical considerations and must be clearly and completely documented in the medical record The physician has ample opportunity to explain in detail why the expectation of the need for care spanning at least 2 midnights was appropriate in the context of that beneficiary s acute condition. IPPS Final Rule CMS-1599-F, Federal Register, p

26 LESS THAN 2 MIDNIGHTS = OUTPATIENT Similarly, we proposed that review contractors would generally determine that hospital services spanning less than 2 midnights should have been provided on an outpatient basis, unless there is clear documentation in the medical record supporting the physician s order and expectation that the beneficiary would require care spanning more than 2 midnights or the beneficiary is receiving a service or procedure designated by CMS as inpatientonly IPPS Final Rule CMS-1599-F, Federal Register, p

27 THE BENCHMARK INCLUDES OUTPATIENT TIME Medicare s review contractors would consider all time after the initiation of care at the hospital in applying the benchmark that hospital inpatient admissions are generally reasonable and necessary for beneficiaries who are expected to require more than 1 Medicare utilization day (defined by encounters crossing 2 midnights ) in the hospital receiving medically necessary services. IPPS Final Rule CMS-1599-F, Federal Register, p

28 THE BENCHMARK OF THE SECOND MIDNIGHT The two midnight benchmark for admission if the beneficiary has already passed 1 midnight as an outpatient observation patient or in routine recovery following outpatient surgery, the physician should consider the 2 midnight benchmark met if he or she expects the beneficiary to require an additional midnight in the hospital. IPPS Final Rule CMS-1599-F, Federal Register, p Benchmark admission: Part A billing is vulnerable to audit unless 2 midnights in hospital following admission order. Medical necessity for second night must be documented. Risk of being accused of delays and gaming.

29 APPROACHING THE BENCHMARK OF THE SECOND MIDNIGHT The decision to admit becomes easier as the time approaches the second midnight, and beneficiaries in necessary hospitalizations should not pass a second midnight prior to the admission order being written. IPPS Final Rule CMS-1599-F, Federal Register, p

30 DOCUMENTATION REQUIRED TO SUPPORT ADMISSION So inpatient admission requires medical necessity plus two midnight expectation based on complex medical judgment. In the proposed rule, we stated that the judgment of the physician and the physician s order for inpatient admission should be based on the expectation of care surpassing 2 midnights, with both the expectation of time and the determination of the underlying need for medical care at the hospital 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. IPPS Final Rule CMS-1599-F, Federal Register, p

31 CONFOUNDING FACTORS Some confounding issues that can prolong stay: Services unavailable Weekends, holidays Staffing Equipment down The need for outside specialized diagnostics Local issues Throughput (TATs) Traditional LOS (Example: NSTEMI) Availability of consultants Patient safety (What is an unsafe discharge?) Patient and family delays Convenience

32 WEEKEND DELAY = DELAY IN PROVISION OF CARE / FINANCIAL DECISION / CONVENIENCE Q5: If a Part A claim is selected for medical review and it is determined that the beneficiary remained in the hospital for 2 or more midnights but was expected to be discharged before 2 midnights absent a delay in the provision of care, such as when a certain test or procedure is not available on the weekend, will this claim be considered appropriate for payment under Medicare Part A as inpatient under the new 2 midnight benchmark? A5: hospital care that is custodial, rendered for social purposes or reasons of convenience, and is not required for the diagnosis or treatment of illness or injury, should be excluded from Part A payment contractors will exclude extensive delays in the provision of medically necessary services from the 2 midnight benchmark. FREQUENTLY ASKED QUESTIONS 2 Midnight Inpatient Admission Guidance &Patient Status Reviews for Admissions on or after October 1, 2013

33 ICU OR TELEMETRY INPATIENT Use of telemetry and admission to ICU do not qualify for inpatient status. FREQUENTLY ASKED QUESTIONS 2 Midnight Inpatient Admission Guidance &Patient Status Reviews for Admissions on or after October 1, 2013 Telemetry can be provided in outpatient units. Many types of ICUs ICU may be used just for monitoring. Small hospitals: ICU may be only location with telemetry. Location or level of care not a factor in admission.

34 MECHANICAL VENTILATION: AN EXCEPTION THAT ISN T REALLY ONE CMS notes that newly initiated mechanical ventilation is rarely provided in hospital stays less than 2 midnights, and that it embodies similar characteristics as those procedures included in Medicare s inpatient only list. While CMS believes a physician will generally expect beneficiaries with newly initiated mechanical ventilation to require 2 or more midnights of hospital care, if the physician expects that the beneficiary will only require 1 midnight of hospital care, inpatient admission and Part A payment is nonetheless generally appropriate. CMS Frequently Asked Questions (12/13/13) NOTE: This exception is not intended to apply to anticipated intubations related to minor surgical procedures or other treatment.

35 ONE MIDNIGHT INPATIENT STAYS If an unforeseen circumstance results in a shorter beneficiary stay than the physician s reasonable expectation of at least 2 midnights, the patient may be considered to be appropriately treated on an inpatient basis and hospital inpatient payment may be made under Medicare Part A. Such circumstances must be documented in the medical record... Examples include death, transfer to another hospital, departure against medical advice, clinical improvement, and election of hospice care in lieu of continued treatment in the hospital. CMS: Reviewing Hospital Claims for Patient Status: Admissions On or After October 1, 2013 (Updated 2/24/14) Document unexpectedly rapid recovery OR If invalid admission, use Condition Code 44 to convert to OP if patient still in hospital. Rebill Part B if already discharged. Must use UR process for both.

36 ONE MIDNIGHT INPATIENT STAY: TERMINAL PATIENT Principal diagnosis is the terminal condition. Diagnosis code V66.7: Terminally ill patient receiving palliative care. May begin with aggressive treatment and change to palliative care. Terms such as comfort care, end-of-life care, and hospice care are all synonymous with palliative care. These, or similar terms, need to be written in the record to support the use of code V66.7. The physician should be queried if the treatment record seems to indicate that palliative care is being given but the documentation is unclear. The care provided must be aimed only at relieving pain and discomfort for the palliative care code to be applicable. Coding Clinic, First Quarter 1998, Vol. 15, No. 1

37 MEDICAL NECESSITY FOR OBSERVATION: POTENTIAL AUDIT TARGET If, based on the physician's evaluation of complex medical factors and applicable risk, the beneficiary may be safely and appropriately discharged, then the beneficiary should be discharged, and hospital payment is not appropriate on either an inpatient or outpatient basis. FREQUENTLY ASKED QUESTIONS 2 Midnight Inpatient Admission Guidance &Patient Status Reviews for Admissions on or after October 1, 2013

38 THE PRESUMPTION OF MEDICAL NECESSITY: INPATIENT TWO MIDNIGHTS = REDUCED AUDIT RISK inpatient hospital claims with lengths of stay greater than 2 midnights after the 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 in an attempt to qualify for the 2- midnight presumption IPPS Final Rule CMS-1599-F, Federal Register, p

39 THE PRESUMPTION OF MEDICAL NECESSITY CMS will instruct the Medicare Administrative Contractors (MACs) and Recovery Auditors that, absent evidence of systematic gaming or abuse, they are not to review claims spanning 2 or more midnights after admission for a determination of whether the inpatient hospital admission and patient status was appropriate. CMS Subregulatory Guidance, January 30, 2014

40 2 MIDNIGHT STAYS STILL SUBJECT TO REVIEW Two midnight stays can still be reviewed despite presumption of medical necessity: Review contractors will also continue to assess claims in which the beneficiary span of care after admission crosses 2 midnights: To ensure the services provided were medically necessary; To ensure that the stay at the hospital was medically necessary; To validate provider coding and documentation as reflective of the medical evidence IPPS Final Rule CMS-1599-F, Federal Register, p

41 RAC REVIEW FOR GAMING BUT NOT OF ADMISSION DECISION AFTER 2 IP NIGHTS Review contractors will identify gaming by reviewing stays spanning 2 or more midnights after formal inpatient admission for the purpose of monitoring and responding to patterns of incorrect DRG assignments, inappropriate or systematic delays, and lack of medical necessity for services at the hospital, but not for the purpose of routinely denying Part A payment on the basis that the services should have been provided at the hospital on an outpatient basis. FREQUENTLY ASKED QUESTIONS 2 Midnight Inpatient Admission Guidance &Patient Status Reviews for Admissions on or after October 1, 2013

42 ABUSE OF PRESUMPTION LOSS OF PROTECTION If a hospital is found to be abusing this 2-midnight presumption for nonmedically necessary inpatient hospital admissions and payment (in other words, the hospital is systematically prolonging the provision of care to surpass the 2- midnight timeframe), CMS review contractors would disregard the 2- midnight presumption when conducting review of that hospital. IPPS Final Rule CMS-1599-F, Federal Register, p Penalty for gaming: Loss of relative protection of presumption for all admissions. No mention of due process or appeal rights.

43 OUTPATIENT NIGHTS DON T COUNT TOWARD SNF COVERAGE SNF coverage is affected because a hospital s observation services are considered outpatient rather than inpatient services, and section 1861(i) of the Act requires a qualifying 3-day inpatient hospital stay for Part A SNF coverage. IPPS Final Rule CMS-1599-F, Federal Register, p A hospital midnight as an outpatient counts toward the 2 midnight benchmark for admission but does not count toward the 3 day stay for SNF.

44 WHEN DOES THE CLOCK START IN THE ED? Waiting time prior to initiation of care doesn t count. the starting point for the 2 midnight timeframe for medical review purposes will be when the beneficiary starts receiving services following arrival at the hospital excludes wait times prior to the initiation of care, and therefore triaging activities (such as vital signs before the initiation of medically necessary services responsive to the beneficiary's clinical presentation) must be excluded. A beneficiary sitting in the ED waiting room at midnight while awaiting the start of treatment would not be considered to have passed the first midnight, but a beneficiary receiving services in the ED at midnight would meet the first midnight of the benchmark. CMS Frequently Asked Questions, 10/1/2013

45 WHEN DOES THE CLOCK START IN THE ED? if the emergency department patient arrives at the triage desk, and is triaged after care that is responsive to the beneficiary s needs is established and begun, not including the simple triage time but care that begins in response to the needs of the patient. From that time forward, all that time that is contiguous within the outpatient setting will be included in the time of the two midnights for the purposes of the benchmark. CMS Special Open Door Forum, December 19, 2013

46 TRANSFERS AND THE BENCHMARK The initial hospital should continue to apply the 2- midnight benchmark based on the expected length of stay of the beneficiary for hospital care within their facility. MLN Connects National Provider Call; Feb 27, 2014

47 TRANSFERS AND THE BENCHMARK Pre-transfer time and care provided to the beneficiary at the initial hospital may be taken into account to determine whether the 2- midnight benchmark was met. Start clock for transfers begins when the care begins in the initial hospital. Excessive wait times or time spent in the hospital for nonmedically necessary services must be excluded. Records may be requested from the transferring hospital to support the medical necessity of the services provided and to verify when the beneficiary began receiving care. MLN Connects National Provider Call: Feb 27, 2014

48 TRANSFERS AND THE BENCHMARK For the purpose of determining whether the 2-midnight benchmark was met, the Medicare review contractor shall 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 time spent in the hospital for non-medically necessary services shall be excluded. Medicare review contractors may request records from the transferring hospital to support the medical necessity of the services provided and to verify when the beneficiary began receiving care to ensure compliance and deter gaming or abuse. CMS: Medical Review of Inpatient Hospital Claims (2/24/14)

49 USE OBSERVATION IF NEXT DAY TRANSFER EXPECTED If Hospital A expects to transfer the patient to Hospital B and that transfer is planned to take place before 2 midnights passes in Hospital A, that patient should be kept as an outpatient. This is regardless of whether Hospital A expects that the total length of stay (Hospital A + Hospital B) to last for 2 or more midnights. If it later becomes clear that the patient will not be transferred before 2 midnights in Hospital A, then Hospital A may admit the patient at that time, based on the expectation that the patient will require hospital care for 2 or more midnights in Hospital A. Jennifer Dupee RN, JD, MSN, MBA Nurse Consultant, Provider Compliance Group Office of Financial Management Centers for Medicare & Medicaid Services Personal correspondence, 2/27/14

50 INPATIENT TRANSFERS ADMIT AS INPATIENT ON ARRIVAL Q: Sometimes the patient has a non-stemi in the community Hospital and stays for three days. They come over to us and we do a cath...sometimes these patients come over with nitroglycerin drips or with other drips and sometimes we have a negative cath and we send them home the same day. Do I bring them in as an outpatient, or do I bring them in as an inpatient? CMS: If you admitted a patient at Hospital A, for purposes of rule out and they have spent beyond two midnights at the other hospital, it's an inpatient to inpatient transfer. Okay? We would expect you to bill that as a DRG in both places. MLN Connects National Provider Call; Feb 27, 2014

51 TRADITIONAL MEDICARE MANUALS: ADMISSION ORDER REQUIRED A patient of an acute care hospital is considered an inpatient upon issuance of written doctor s orders to that effect. Medicare Claims Processing Manual (MCPM) (Pub ), Chapter 3, Section (K)

52 IPPS: ADMISSION ORDER REQUIRED FOR INPATIENTS a physician order is required for all inpatient hospital admissions, regardless of the length of stay. the order must be present in the medical record and supported by the physician admission and progress notes IPPS Final Rule CMS-1599-F, Federal Register, p The physician order must be furnished at or before the time of the inpatient admission. IPPS Final Rule CMS-1599-F, Federal Register, p

53 IPPS: ADMISSION ORDER REQUIRED FOR PAYMENT For purposes of payment under Medicare Part A, an individual is considered an inpatient of a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner IPPS Final Rule CMS-1599-F, Federal Register, p

54 WHEN DOES ADMISSION BEGIN? What is meant by formal admission? "I think formal admission, by a dictionary definition, means that the hospital has taken some steps to intake the patient and begin treatment. The order must be completed by a qualified physician or practitioner and inpatient time begins when that order is made. MLN Connects National Provider Call Feb. 27, 2014

55 QUALIFICATIONS OF ADMITTING PRACTITIONER The order must be furnished by a physician or other practitioner ( ordering practitioner ) who is: (a) licensed by the state to admit inpatients to hospitals, (b) granted privileges by the hospital to admit inpatients to that specific facility, and (c) knowledgeable about the patient s hospital course, medical plan of care, and current condition at the time of admission. CMS Subregulatory Guidance, January 30,

56 REQUIREMENTS FOR ORDERING PRACTITIONER Who is knowledgeable enough to admit? Admitting physician of record (the attending ) Hospitalist Primary care physician Surgeon (major procedure) ED or clinic practitioners other practitioners qualified to admit inpatients and actively treating the beneficiary at the point of the inpatient admission decision CMS Subregulatory Guidance, January 30,

57 VERBAL ORDERS: DISCUSSION AND DIRECTION the [verbal] 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. A transcribed and authenticated order also satisfies the order part of the physician certification as long as the ordering practitioner also meets the requirements for a certifying physician. Example: Admit to inpatient v.o. (or t.o.) Dr. Smith and Admit to inpatient per Dr. Smith CMS Sub-regulation Letter of Sept 5, 2013

58 VERBAL ORDERS: DISCUSSION AND DIRECTION the ordering practitioner directly communicates the inpatient admission order to staff as a verbal (not standing) order, and the ordering practitioner need not separately record the order to admit. Following discussion with and at the direction of the ordering practitioner, a verbal order for inpatient admission may be documented In this case, the staff receiving the verbal order must document the verbal order in the medical record at the time it is received. The order must identify the qualified admitting practitioner, and must be authenticated (countersigned) by the ordering practitioner promptly and prior to discharge. January 30, 2014 CMS Subregulatory Guidance

59 PROXY ADMISSION BY RESIDENTS AND EDPs Residents and ED physicians may admit as proxy for admitting physician if the ordering practitioner approves and accepts responsibility for the admission decision by counter-signing the order prior to discharge. CMS Subregulatory Guidance, January 30,

60 ADMISSION BY RESIDENTS, NPs AND EDPs Certain non-physician practitioners and residents working within their residency program are authorized by the state in which the hospital is located to admit inpatients, and are allowed by hospital by-laws or policies to do the same. Also applies to ED physicians if hospital authorizes bridge orders. Timely countersigned admission order counts toward certification. Hospital Inpatient Admission Order and Certification, January 30, 2014

61 ADMISSION BY RESIDENTS, NPs AND EDPs We would not consider it to be a valid order until it is properly authenticated and countersigned in the medical record by a physician that does have admitting privileges. Inpatient time starts with the verbal order if authenticated. MLN Connects National Provider Call, Feb 27, 2014

62 APPROPRIATE LANGUAGE FOR ADMISSION ORDER While we are not requiring specific language to be used on the inpatient admission order, we believe that it is the interest of the hospital that the admitting practitioner use language that clearly expresses intent to admit the patient as inpatient that will be commonly understood by any individual that could potentially review documentation of the inpatient stay. We do not recommend using language that may have specific meaning individuals that work in the hospital (e.g. admit to 7W ) that will not be commonly understood by others. CMS Hospital Inpatient Admission Order and Certification January 30, 2014

63 PHYSICIAN ADMISSION CERTIFICATION The certification requirement for inpatient services other than psychiatric inpatient services is found in section 1814(a)(3) of the Act IPPS Final Rule CMS-1599-F, Federal Register, p But the certification regulations referred to here are for outlier stays (cost and LOS outliers) not for new admissions. Outlier certification and recertification rules were applied to admissions. Certification has rarely (if ever) been performed in the past and has never been enforced by CMS.

64 PHYSICIAN ADMISSION CERTIFICATION (3) with respect to inpatient hospital services (other than inpatient psychiatric hospital services) which are furnished over a period of time, a physician certifies that such services are required to be given on an inpatient basis for such individual s medical treatment, or that inpatient diagnostic study is medically required and such services are necessary for such purpose, except that (A) such certification shall be furnished only in such cases, with such frequency, and accompanied by such supporting material, appropriate to the cases involved, as may be provided by regulations, and (B) the first such certification required in accordance with clause (A) shall be furnished no later than the 20th day of such period. Social Security Act, 1814(a)(3)

65 IPPS: PHYSICIAN CERTIFICATION Medicare Part A pays for inpatient hospital services (other than inpatient psychiatric facility services) only if a physician certifies and recertifies the following: (1) That the services were provided in accordance with of this chapter.[the 2 midnight benchmark] (2) The reasons for either (i) Hospitalization of the patient for inpatient medical treatment or medically required inpatient diagnostic study; or (ii) Special or unusual services for cost outlier cases... (3) The estimated time the patient will need to remain in the hospital. (4) The plans for posthospital care, if appropriate. 42 CFR Requirements for inpatient services of hospitals other than psychiatric hospitals

66 CERTIFICATION OF OUTLIERS e)timing of certification and recertification: Cases subject to PPS. For cases subject to PPS, certification is required as follows: (1) For day-outlier cases, certification is required no later than one day after the hospital reasonably assumes that the case meets the outlier criteria, established in accordance with (a)(1)(i) of this chapter, or no later than 20 days into the hospital stay, whichever is earlier. The first and subsequent recertifications are required at intervals established by the UR committee (on a case-by-case basis if it so chooses) but not less frequently than every 30 days. (2) For cost-outlier cases, certification is required no later than the date on which the hospital requests cost outlier payment or 20 days into the hospital stay, whichever is earlier. If possible, certification must be made before the hospital incurs costs for which it will seek cost outlier payment. In cost outlier cases, the first and subsequent recertifications are required at intervals established by the UR committee (on a case-by-case basis if it so chooses). 42 CFR Requirements for inpatient services of hospitals other than psychiatric hospitals

67 RECERTIFICATION (f)recertification requirement fulfilled by utilization review. (1) At the hospital's option, extended stay review by its UR committee may take the place of the second and subsequent physician recertifications required for cases not subject to PPS and for PPS day-outlier cases. (2) A utilization review that is used to fulfill the recertification requirement is considered timely if performed no later than the seventh day after the day the physician recertification would have been required. The next physician recertification would need to be made no later than the 30th day following such review; if review by the UR committee took the place of this physician recertification, the review could be performed as late as the seventh day following the 30th day. 42 CFR Requirements for inpatient services of hospitals other than psychiatric hospitals

68 IPPS: PHYSICIAN CERTIFICATION Physician Certification of Admission Certification begins with the order for inpatient admission. IPPS Final Rule CMS-1599-F, Federal Register, p

69 PHYSICIAN CERTIFICATION - PRIOR TO DISCHARGE For all hospital inpatient admissions, the certification must be completed, signed, and documented in the medical record prior to discharge. IPPS Final Rule CMS-1599-F, Federal Register, p

70 PHYSICIAN CERTIFICATION 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. Except as provided for delayed certifications, there must be a separate signed statement for each certification or recertification. CMS Sub-regulation Letter of Sept. 5, 2013

71 PHYSICIAN CERTIFICATION Example 4 - Physician Attestation Statements without Supporting Medical Record Documentation: The physician s order contained a checkbox with pre-printed text stating The beneficiary is expected to require 2 or more midnights of hospital care. The physician s plan of care, however, stated that the beneficiary was to have diagnostics performed post-operatively, with a plan to discharge in the morning if stable. The beneficiary was discharged the following day as planned, after a 1-midnight stay. Upon review of the claim, the MAC denied Medicare Part A payment because the medical record failed to support an expectation of a 2-midnight stay when the order was written. MAC Probe and Educate review results letter

72 SAMPLE PHYSICIAN CERTIFICATION FORM (1) (IF YOU CHOOSE TO USE ONE)

73 SAMPLE PHYSICIAN CERTIFICATION FORM (2) (IF YOU CHOOSE TO USE ONE)

74 WHEN PHYSICIAN CERTIFICATION FOUND IN MEDICAL RECORD (NO FORM) If all the required information is included in progress notes, the physician's statement could indicate that the individual's medical record contains the information required and that hospital inpatient services are or continue to be medically necessary. January 30, 2014 CMS Subregulatory Guidance

75 PHYSICIAN CERTIFICATION IN MEDICAL RECORD In the absence of specific certification forms or certification statements, CMS and its contractors will look for the following medical record elements in order to meet the initial inpatient certification requirements. a. Authentication of the practitioner order: The physician certifies that the inpatient services were ordered in accordance with the Medicare regulations governing the order. Hospital inpatient services are reasonable and necessary and appropriately provided as inpatient services in accordance with the 2 midnight benchmark. CMS Sub-regulation Letter of Sept. 5, 2013

76 PHYSICIAN CERTIFICATION WHO CAN SIGN a. Authentication of the practitioner order: Certification can be signed by 1. MD or DO 2. Dentist 3. Podiatrist 4. If none of the above, certification must be signed by a member of the medical staff who has reviewed the case and who also enters into the record a complete certification statement that specifically contains all of the content elements discussed above. CMS Sub-regulation Letter of Sept. 5, 2013

77 PHYSICIAN CERTIFICATION Reason for inpatient services documentation of an admitting diagnosis could fulfill this part of the certification requirement. Estimated time requirement The physician certifies the estimated time in the hospital the beneficiary requires (if the certification is completed prior to discharge) or the actual time in the hospital (if the certification is completed at discharge). January 30, 2014 CMS Subregulatory Guidance

78 PHYSICIAN CERTIFICATION The post hospital care plan ( if appropriate ) will be met either by physician notes or by discharge planning instructions. (See Sept. 5 CMS Guidance) CAH 96 hour expectation requirement the physician must certify that the beneficiary may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH January 30, 2014 CMS Subregulatory Guidance

79 ESTIMATION OF LENGTH OF STAY c. The estimated (or actual) time the beneficiary requires or required in the hospital: The physician certifies the estimated time in the hospital the beneficiary requires (if the certification is completed prior to discharge) or the actual time in the hospital (if the certification is completed at discharge). Estimated or actual length of stay is most commonly reflected in the progress notes where the practitioner discusses the assessment and plan. For the purposes of meeting the requirement for certification, expected or actual length of stay may be documented in the order or a separate certification or recertification form, but it is also acceptable if discussed in the progress notes[,] assessment and plan or as part of routine discharge planning. CMS Subregulation Jan 30, 2014

80 DOCUMENTATION OF EXPECTED LENGTH OF STAY CMS reminds providers that attestation statements indicating the beneficiary s hospital stay is expected to span 2 or more midnights are not required under the inpatient admissions policy, nor are they adequate by themselves to support the expectation of a 2-midnight stay. Rather, the expectation must be supported by the entirety of the medical record. Medicare Inpatient Hospital Probe and Educate Status Update February 24, 2014

81 DOCUMENTATION OF EXPECTED LENGTH OF STAY Physicians need not include a separate attestation of the expected length of stay; rather, this information may be inferred from the physician s standard medical documentation, such as his or her plan of care, treatment orders, and physician s notes. Reviewing Hospital Claims for Patient Status: Admissions On or After October 1, 2013 (Last Updated: 02/24/14)

82 DOCUMENTATION OF EXPECTED LENGTH OF STAY Just spoke with our MAC Medical Director who told that they are not looking for any specific certification form, and their review nurses are instructed to infer the intent from anywhere in the record. Physician Advisor, Sonoma Co. Posted on rac-relief.com, 4/29/14

83 REASONABLE AND NECESSARY RULE Medical necessity is not going away. Satisfying the requirements regarding the physician order and certification alone does not guarantee Medicare payment. Rather, in order for payment to be provided under Medicare Part A, the care must also be reasonable and necessary the instruction for reviewers to account for all documentation in the medical record, in addition to the actual order for inpatient admission, is consistent with statutory instruction and our prior policy IPPS Final Rule CMS-1599-F, Federal Register, p

84 CERTIFICATION OF PSYCHIATRIC ADMISSIONS Physician Certification of Psychiatric Admission The requirement for certification and recertification of inpatient psychiatric services as a condition of payment are found in section 1814(a)(2) of the Act and 42 CFR We did not propose to exclude any hospitals from our proposed clarification of the requirement for the physician order and physician certification for Part A payment of hospital inpatient services. IPPS Final Rule CMS-1599-F, Federal Register, p

85 CERTIFICATION OF INPATIENT REHAB FACILITY ADMISSIONS Physician Certification of IRF Admission IRF requirements at also must be met in order for the IRF to be paid for hospital inpatient services under Medicare Part A. However, due to the aforementioned inherent differences in the operation of and beneficiary admission to IRFs, such providers are excluded from the 2-midnight admission guidelines and medical review instruction, as provided under XI.C.3. of the preamble of this final rule. IPPS Final Rule CMS-1599-F, Federal Register, p

86 RECERTIFICATION OF ADMISSION Waiting for CMS to define recertification of admission. The only regulation on recertification pertains to outliers.

87 WHAT ABOUT SURGERY AND PROCEDURES? Inpatient only surgery exempt from 2 MN rule (but not from certification) [A] physician should order admission if the beneficiary requires a procedure specified as inpatientonly services designated by CMS as inpatient only which are appropriate for inpatient admission without regard to duration of care IPPS Final Rule CMS-1599-F, Federal Register, p

88 ADMISSION ORDER REQUIRED PRIOR TO INPATIENT ONLY PROCEDURES CMS will not pay for inpatient-only procedures that are provided to a patient in the outpatient setting on the date of the patient s inpatient admission or during the 3 calendar days (or 1 calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission. Medicare Claims Processing Manual, Pub , Transmittal 2234, Change Request 7443 May 27, 2011

89 NON-INPATIENT ONLY PROCEDURES: INAPPROPRIATE FOR INPATIENT Non inpatient only surgery and procedures [W]hen a patient enters a hospital for a surgical procedure not specified by Medicare as inpatient only a diagnostic test, or any other treatment, and the physician expects to keep the patient in the hospital for only a limited period of time that does not cross 2 midnights, the services are generally inappropriate for inpatient admission IPPS Final Rule CMS-1599-F, Federal Register, p

90 NON-INPATIENT ONLY PROCEDURES: INITIATE AS OUTPATIENT CMS reminds providers that instances in which the typical expected length of stay for a procedure is less than 2 midnights should be initiated as outpatient. If it later becomes clear that the beneficiary will require 2 or more midnights of hospital care due to a complication or other factor, the physician can order the inpatient admission at that time. Medicare Inpatient Hospital Probe and Educate Status Update February 24, 2014

91 PRE-BILL REVIEW OF NON-INPATIENT PROCEDURES REGISTERED AS INPATIENT Pre-op admission: Was reason for expectation of 2 midnights appropriate and documented? Post-op admission: Was there a post-procedure complication that would require a 2 midnight stay? If stay was medically necessary 2 MNs, bill Part A. If stay was 0-1 MN, review admission documentation: If wrong choice, use Condition Code 44 (if still in hospital) or rebill Part B (if already discharged).

92 Two AHA Law Suits Filed April 14, 2014 re 2014 IPPS Supported by 4 large hospital systems. Alleges 2 midnight rule is arbitrary and capricious. Challenges CMS authority to define inpatient as a patient that spends 2 nights in the hospital. Challenges applying timely filing to Part B rebilling CMS allows rebilling but timely filing makes it impossible. Challenges legality of requiring signed admission order for Part A billing. Prohibited by Congress. Challenges the 0.2% DRG reduction as unfounded. Demands refunds of payment denials based on rule. AHA doesn t suggest what should take the place of the current rule except reverting to the old rule.

93 Q & A Contact info: Steven J. Meyerson, M.D. SVP, AccretivePAS 231 S LaSalle St, Ste 1600 Chicago, IL smeyerson@accretivehealth.com Cell:

94 APPENDIX A 2014 IPPS Work Flow

95 2014 IPPS: 2 MIDNIGHT WORK FLOW

96 DAY #1: STARTING IN THE ED Inpatient (no review) Inpatient (after review) Observation

97 DAY #2: UNEXPECTED RECOVERY AND DISCHARGE (Includes transfer, death, hospice, and AMA) Inpatient (no review)

98 DAY #2: INPATIENT OR OBSERVATION? ADMIT? Inpatient Inpatient Observation

99 DAY #3 AND BEYOND Admitted Day #2 Inpatient on admission

100 POST DISCHARGE: PREBILL PART A REVIEW

101 APPENDIX B Sample Cases

102 CASE EXAMPLE v yr old female scheduled for lap chol y for stones and chronic pain. COPD, Type II DM, OA knees. PCP clears patient. Surgeon reads medical clearance and schedules and performed as outpatient on Monday. Post-op wheezing in RR, nebs ordered q 6 hr. Orders observation post op. Tuesday still wheezing and coughing, dyspneic, CXR neg, PCP wants to keep for one day for nebs and monitoring. Referred for PA Review PA recommends, Admit as inpatient (1 MN + 1 MN = 2 MN = meets benchmark)

103 CASE EXAMPLE v yr old female scheduled for lap chol y for stones and chronic pain. Severe COPD, Type II DM, CKD stage 4, OA knees, colitis. ASA Class IV PCP states: Last surgery- lap hyst- Pt was in hospital 6 days due to pulmonary problems and brittle diabetes. high risk for surgery; expect slow recovery; need to monitor pulmonary status and kidney function closely; Will need frequent adjustments of insulin; expect > 2 MN stay. Referred for PA Review High risk patient with expected long stay well documented PA: Admit as inpatient pre=op

104 CASE EXAMPLE v yr old female scheduled as outpatient for lap chol y Surgery successful, in RR patient does not wake up, husband recalls same thing during previous surgery, woke up next day after TAH pseudocholinesterase deficiency, needs to stay on vent overnight; patient transferred to ICU for the night. Surgeon expects one night stay. Referred for PA Review PA recommends Observation - only expect one MN Location does not matter. It s length of time in hospital. ICU patients can be outpatient/observation

105 CASE EXAMPLE v yr old male sees cardiologist for chest pain; stress test abnormal; scheduled for elective cath. COPD - on nebs and oxygen at home, Type II DM, ESRD on dialysis, takes 12 medications. Send to PA for Review PA recommends: Schedule as outpatient since moderate risk for complications but no planned intervention. Could admit after procedure if complication occurs.

106 CASE EXAMPLE v 3.0 Outcome The pt does well, no stents- outpatient, send home same day - No referral Outcome Does well, gets stent as outpatient. Doc wants to watch overnight - sent to PA for Review PA recommends outpatient since pt did well Outcome Gets lots of dye with stent, wheezes, needs stat dialysis x 1- send for Review. PA recommends outpatient - only one MN, reassess if patient stays Outcome Gets proximal LAD stent, goes in to VF, ends up on vent in ICU. No referral, obvious inpatient.

107 CASE EXAMPLE v yr old male with COPD, presents Monday at 10 pm with COPD exacerbation. Patient is an ED friendly face with a visit once monthly, usually lasting 1-4 days. Still smokes, even with his oxygen. Tried nebulizer at home without success. In ED, pt given 3 nebs, IV steroids; CXR neg; labs normal; po2 normal. Getting a little better. At 8 am Tuesday ED doc re-evaluates and determines patient cannot go home due to mild exacerbation of COPD.

108 WHAT STATUS DOES PATIENT NEED? Pt presented Monday 10 pm, it is now Tuesday 8 am; Not going home today. May be able to go home tomorrow, Wednesday Monday midnight + Tuesday midnight = 2 midnights Meets benchmark. Admit as inpatient.

109 CASE EXAMPLE v yr old male with COPD, presents Monday at 6 am with COPD exacerbation. Patient is an ED friendly face with a visit once monthly, lasting 1-4 days. Of course he still smokes, even with his oxygen. Tried nebulizer at home without success. In ED given 3 nebs, IV steroids. CXR and labs normal; getting a little better. At 9 am Tuesday ED doc reevaluates and determines patient cannot go home, mild exacerbation. Referred for PA Review (before first midnight).

110 WHAT STATUS DOES PATIENT NEED? Presented Monday 6 am, it is now Monday 9 am, may be able to go home tomorrow, Tuesday Monday midnight = 1 midnight PA recommends: Place in observation

111 CASE EXAMPLE v 5.1 The same 78 yr old male with COPD, presents Monday at 6 am with COPD exacerbation. In ED given 3 nebs, IV steroids; CXR and labs normal. Not getting better At 9 am, ED doc reevaluates and notes severe exacerbation. Referred for PA Review

112 WHAT STATUS DOES PATIENT NEED? Presented Monday 6 am, it is now Monday 9 am, severe exacerbation. Expected stay= 5-7 days. No midnights so far but expect several in hospital. PA recommends: Admit as inpatient. Document severity of illness and reason for expectation 2 MN stay.

113 CASE EXAMPLE v 5.2 The 78 yr old male with COPD presents Monday at 6 am with COPD exacerbation. In ED given 3 nebs, IV steroids. CXR and labs normal Not getting better. At 9 am ED doc re-evaluates and feels patient not able to go home. Calls hospitalist Places in observation. Referred for PA Review PA agrees and recommends observation.

114 CASE EXAMPLE v 5.2 (CONT D) Pt was placed in observation on Monday On Tuesday patient not breaking. O2 sats dropping on oxygen. Reassess: What is the expectation of LOS based on condition, treatment and risk? Referred for PA Review Mon MN (past) + Tues MN (upcoming) = 2 MN PA recommends: Admit as inpatient now and document the reason the patient requires continued hospital care.

115 CASE EXAMPLE v 5.3 (CONT D) Alternatively, on Tuesday hospitalist slammed with admissions, rounds at 8 pm. Patient feels better but too late to go home, so writes discharge in am if stable. Referred for PA Review Mon MN past (medically necessary) + Tues MN upcoming (not medically necessary) = PA recommends, leave as outpatient. Extended observation not medically necessary.

116 CASE EXAMPLE v 5.3 The 78 yr old male with COPD presents Monday at 6 am with severe exacerbation this time. Following the usual treatment, at 9 am the ED doc reevaluates and notes severe exacerbation of COPD. Hospitalist admits as inpatient documents the reason for his expectation of a 2 midnight or longer hospital stay. No PA referral needed.