Coding Implications of Coding Medical Necessity and Core Measures. Medical Necessity. NCHIMA Coding Roundtable Webinar.

Transcription

1 Coding Implications of Coding Medical Necessity and Core Measures NCHIMA Coding Roundtable Webinar February 20, 2013 Kou Yang, RHIA Sharon Easterling, MHA, RHIA, CCS, CDIP, CPHM February 2013 Medical Necessity Presented to the NCHIMA Coding Roundtable by Kou L. Yang, RHIA Medical Necessity Presented to the NCHIMA Coding Roundtable by Kou L. Yang, RHIA 1

2 Key Objectives: Define Medical Necessity Identify key areas in the Revenue Cycle that Medical Necessity edits can be worked Components necessary to quantify Return on Investment Explore options available to work medical necessity Medical Necessity [Services or supplies] that are justified as reasonable, necessary, and/or appropriate, based on evidence based clinical standards of care. FIs, Carriers, and Medicare Administrative Contractors (MACs) are Medicare contractors that develop and / or adopt Local Coverage Determinations (LCD)s. Medicare contractors develop LCDs when there is no National Coverage Determination (NCD) or when there is a need to further define an NCD. Centers for Medicare & Medicaid Services 2

3 NCD NCD NCD Cardiac Rehab Programs 3

4 Sections of an NCD Policy Tracking Information Publication Number Version Number Manual Section Number Effective Date of said Version Title Implementation Date Description Information Claims Processing Instructions Sections of an NCD Policy Transmittal Information Revision History National Coverage Analyses (NCAs) Original consideration for the policy & any additional considerations Additional Information NCD for Cardiac Rehab Programs Claims Processing Instructions TN 1974 (Medicare Claims Processing) Provides specific requirements HCPCs Detail Modifier Detail Diagnosis Detail Providers requirements Contractor requirements Denial Codes Payment guidance 4

5 LCD List LCDs by State LCD MAC Part A / FI / Palmetto GBA (110501, MAC Part A) LCD 61 Records 5

6 LCD Cardiac Rehab (L32872) LCD LCD LCD Sections Document Information LCD Number Title Geographic Jurisdiction Revision effective date CMS National Coverage Policy Coverage Indications Limitations and/or Medical Necessity Coding Information Bill type codes Revenue codes CPT / HCPCs Codes ICD 9 Codes General Information Documentation Requirements Utilization Guidelines 6

7 Medical Necessity Components Physician Order Dated & Signed Identify service being ordered The medical condition requiring the service / signs & symptoms Coverage Indications May detail required services needed to render prior to LCD service being ordered and performed Patient s medical record / results Advance Beneficiary Notice (ABN) New form CMS-R-131 mandatory use date November 1, 2011 Advance Beneficiary (A) (B) Notifiers to include name, address, and telephone number Patient Name (C) Identification Number medical record # (D) (E) (F) (G) Body Items / Services believed to be non-covered Reason Medicare may not pay Medicare does not pay for this test for your condition. Medicare does not pay for this test as often as this (denied as too frequent). Medicare does not pay for experimental or research use tests. Estimated Cost good faith estimate Options 3 options for patient (A) (B) (C) Understand service may be denied but want the procedure and request the claim be submitted to Medicare and beneficiary may appeal Want the procedure but do not submit claim to Medicare and bill patient Do not want the procedure (H) Additional Information (I) Signature (J) Date ABN 7

8 Opportunities in the Revenue Cycle that Medical Necessity can be assessed Services Ordered Services Performed Charges Entered Claim Coded Claim Processed thru Claims Editing Claim Submitted to A/B MAC Revenue Cycle Opportunity for Medical Necessity Point of service ordered Point of charge entry Point of coding Claims edit Point of Service Order & Charge Entry Options Manual process would involve identifying commonly adjusted and denied services for medical necessity and familiarize physician and staff of covered indications Automated process would involve investing in a resource(s) that is capable of flagging for services that do not meet medical necessity. Benefits Minimizes medical necessity adjustments Access to physician Retain revenue Decrease A/R days Challenges Limited staffing resources Limited funds to invest for screening software Limited time resources Implemement new processses 8

9 Point of Coding Options Have Coders resolve Medical Necessity All charges have to be entered into the system and carried over to the Coding software. This in turn will flag any services / charges subject to policies for review for covered indications. The Coding software will have to include a medical necessity screening tool which may be available at additional expenses. Benefits of implementing screening process Minimize medical necessity adjustments Decrease A/R days Documentation available Retain Revenue Challenges Productivity based Not all charges are entered by point of Coding Expense attached to screening software not available Claims Edit Options The claims management tool will have the software available to screen for Medical Necessity Benefits of the claims management tool screening edits out Provides an opportunity to review documentation and add onto the claim to avoid adjustments Minimize adjustments due to medical necessity Retain revenue Challenges Determining where and who will be processing and resolving the edits Expenses associated Documentation availability Claims Edit Challenges (continued ) Medical diagnosis documented does not support the service(s) rendered in accordance to the policy 9

10 Return on Investment To show return on investment on developing a process to minimize medical necessity adjustments Quantify adjustments due to medical necessity Gross Total Charges Reimbursement Total Charge Take a sample of those adjusted and identify where the opportunity exists. Coding Omission (Documentation had supporting indication but not reported) Ordered for an un-covered sign or symptom Documentation not available Return on Investment Quantify those adjustments for comparison Total Gross Charges Reimbursement Total Quantify expenses Coding Software Medical Necessity Software FTE CEUs Benefits Inter-department expenses Return on Investment Once final numbers have been identified and ROI is promising Solicit the support of Senior Leadership 10

11 Options for working edits post charge entry Direct accounts back to Coding Direct accounts back to ordering department Centralize efforts by developing a team to work edits Outsource Adjust without review Options for working edits post charge entry Direct accounts back to Coding & Develop a process to communicate the potential recoveries and ensure it supports tracking Spreadsheets Share Files Benefits of Coding working the edits Familiar with the documentation, locating in the documentation the covered indications Provides Coders the information and insight of post Code processes Provides accountability Challenges Limited in FTE and Time Resources Options for working edits post charge entry Direct accounts back to Ordering Department Develop a process to communicate the accounts that edit out for medical necessity and ensure it supports tracking Spreadsheets Share Files Benefits Provides Accountability Provides Feedback Documentation availability Challenges Staff (charge entry staff) Time resource 11

12 Options for working edits post charge entry Develop a team RHIA, RHIT, CCS, CPC Require a screening tool Access internal systems Documentation Claims management Department specific software (Radiology / lab software) Imperative to have Senior Leadership support Develop good rapport with departments Benefit of this is decreasing adjustments and the process will be centralized to one team Challenge would be the expense necessary to develop and maintain the team FTE CEUs Benefits What can you do? Keep the Physician Orders and make sure that it identifies what service is requested with covered indications, physician s signature, and dated Comprehensive Error Rate Testing Identify the most commonly ordered services, review the applicable policy and provide education to staff Benchmark adjustments ROI ABNs Develop a process to ensure that the documentation is continuous from practice to the facility If available - scan orders, results, medical record to be part of the electronic medical record. Look at possible option to invest in software to identify medical necessity up front References risdiction%2011%20ab%20mac%20and%20hhh%20ma C%20Jurisdiction%20C%20Implementation%20Dates?ope n&cat=events klet_icn pdf 12

13 Core Measures/Quality NCHIMA Sharon Easterling, MHA, RHIA, CCS, CDIP, CPHM 2/20/13 Objectives Review current Core Measures Understand the impact of Coding on Core Measures Obtain steps to become about of the Core Measure Team A National Quality Initiative Mandated by the Center for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC) to monitor specific hospital clinical processes and how well hospitals provide recommended care. 13

14 Uses of Core Measure Data Medicare Pay for Performance/Value Based Purchasing All major payers moving toward using Core Measure results to benchmark & for contract negotiations As of 2013, also the basis for Physician reimbursement Goal of Core Measures High Quality of Care by use of inclusion criteria exclusion criteria with guidelines for acceptable documentation Quality Measure Information Specifications Manual for National Hospital Inpatient Quality Measures Discharges (1Q13) through (4Q13) cifications_manual_for_national_hos pital_inpatient_quality_measures.as px 14

15 The Specifications Manual for National Hospital Quality Measures The Joint Commission Inpatient Outpatient The Specifications Manual for National Hospital Quality Measures Acute Myocardial Infarction (AMI) Heart Failure (HF) Pneumonia (PN) Hospital Venous Thromboembolism (VTE) Stroke (STK) The Specifications Manual for National Hospital Quality Measures Children s Asthma Care (CAC) Surgical Care Improvement Project (SCIP) Hospital Outpatient Measures (HOP) Perinatal Care (PC) Hospital-Based Inpatient Psychiatric Services (HBIPS) 15

16 The Specifications Manual for National Hospital Quality Measures Emergency Department (ED) Immunization (IMM) Tobacco Treatment (TOB) Substance Use (SUB) The Specifications Manual for National Hospital Quality Measures Readmission and Mortality Measures Age > or = to day measures Utilize medicare claims data AMI, CHF, Pneumonia What is done with the Data? Data is transmitted on all measures you select via a vendor software based on the Specifications Manual for that criteria set Internal External 16

17 What is done with the Data? Oryx implemented in 1997 Hospitals are required to collect and transmit data to The Joint Commission for a minimum of four core measure sets or a combination of applicable core measure sets and non-core measures What is done with the Data? Data is publicly reported The Joint Commission website at Quality Check CMS 17

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19 Core Measure Overview Indicators Acute MI Heart Failure Pneumonia Surgical Care Improvement Program (SCIP) ASA w/in 24 hrs of arrival PCI within 90 minutes of arrival D/C Instructions Blood Culture prior to Antibiotic Administration Antibiotic given within one hour of incision time Removal of Foley Catheter Post-op Day #1 or #2 ASA at discharge Beta Blocker at discharge Evaluation of LV systolic function ACE/ARB at discharge, if LVSD Fibrinolytic within 30 min of arrival Statin prescribed at discharge, if LDL>100 ACEI/ARB for LV systolic dysfunction Blood Culture <24 hrs prior to or 24 hrs after arrival for pts transferred or admitted to ICU Prophylactic Antibiotic selection Peri-op Temp Management Antibiotic d/c w/in 24 hrs of anesthesia end time VTE ordered & given w/in 24 hrs of anesthesia end time Antibiotic Selection ICU/non- ICU Appropriate Hair Removal Beta Blocker in Peri-op period Pneumococcal Pts age 65 & older are screened for Pts age 6-64 years with high risk Vaccine vaccine and receive, if indicated condition-screened for vaccine and 2/19/2013 receive, if indicated 55 Core Measure Overview Influenza Vaccine Indicators Patients 6 months & older-screened for & receive vaccine in season if indicated ED Throughput- Admitted Patients ED Throughput Discharged Patients Hospital Outpatient Surgery Hospital Outpatient AMI/CP ED Arrival Time to ED Departure for Admitted Patients ED Arrival time to ED Departure Time Time to Pain Medication Administration for Long Bone Fracture Antibiotic Selection Median Time to Fibrinolysis Admit Decision Time to ED Departure for admitted pts Door to Diagnostic Evaluation by MD/NP/PA Timing of Antibiotic Prophylaxis Fibrinolytic therapy within 30 minutes Left Without Being Seen Head CT scan results for Stroke (acute ischemic or hemorrhagic) interpreted within 45 minutes of arrival Mean time to EKG ASA at arrival Median time to transfer for Acute Coronary Intervention 2/19/ Code Sets for Criteria Appendix A.1 A.120 ICD-9-CM code Tables ICD-9 codes for selected core measure sets Codes drive whether an indicator is within the criteria set or outside of the criteria set 19

20 Strict Documentation Requirements AMI Moderate or severe aortic stenosis hyperkalemia, angioedema, renal artery stenosis, hypotension, or worsening renal disease Second or third-degree heart block Strict Documentation Requirements AMI AMI ANTEROLATERAL,UNSPEC AMI ANTEROLATERAL, INIT AMI ANTERIOR WALL,UNSPEC AMI ANTERIOR WALL, INIT AMI INFEROLATERAL,UNSPEC AMI INFEROLATERAL, INIT AMI INFEROPOST, UNSPEC AMI INFEROPOST, INITIAL AMI INFERIOR WALL,UNSPEC AMI INFERIOR WALL, INIT AMI LATERAL NEC, UNSPEC AMI LATERAL NEC, INITIAL TRUE POST INFARCT,UNSPEC TRUE POST INFARCT, INIT SUBENDO INFARCT, UNSPEC SUBENDO INFARCT, INITIAL AMI NEC, UNSPECIFIED AMI NEC, INITIAL AMI NOS, UNSPECIFIED AMI NOS, INITIAL What happens when Patient Falls Out? Perform chart review Measures not met Bring to coding 20

21 What happens when Patient Falls Out? Example: Patients presents with chest pain and shortness of breath and fever. Final diagnoses: Pneumonia MI Strict Documentation Requirements CHF q MAL HYPERT HRT DIS W HF BENIGN HYP HT DIS W HF HYP HT DIS NOS W HT FAIL MAL HYP HT/KD I-IV W HF MAL HYP HT/KD STG V W HF BEN HYP HT/KD I-IV W HF BEN HYP HT/KD STG V W HF HYP HT/KD NOS I-IV W HF HYP HT/KD NOS ST V W HF CHF NOS Strict Documentation Requirements CHF LEFT HEART FAILURE SYSTOLIC HRT FAILURE NOS AC SYSTOLIC HRT FAILURE CHR SYSTOLIC HRT FAILURE AC ON CHR SYST HRT FAIL DIASTOLC HRT FAILURE NOS AC DIASTOLIC HRT FAILURE CHR DIASTOLIC HRT FAIL AC ON CHR DIAST HRT FAIL SYST/DIAST HRT FAIL NOS AC SYST/DIASTOL HRT FAIL CHR SYST/DIASTL HRT FAIL AC/CHR SYST/DIA HRT FAIL HEART FAILURE NOS 21

22 Next Steps Volunteer to be on Core Measure Team Assist with EMR in identifying measure sets Participate in review of charts Next Steps Ensure you are capturing diagnoses appropriately Review abstracting Educate coders on how coding drives quality Contact Info Recovery Analytics Sharon Easterling, MHA, RHIA, CCS, CDIP, President/CEO