Compliance Officer Strategies: Assessing Your Risk Lori Purcell, RHIA, CCS Shannon Church, LCSW, CHC Cindy Sanders RHIT, CCS
The solution to the "problem" of compliance is to see compliance as a solution. Dean Edward D. Miller Hopkins Medical News winter 2000
Focus on Risk Areas Perhaps the single biggest risk area for hospitals is the preparation and submission of claims or other requests for payment from the Federal health care programs.
Find Claim Errors Hospitals must disclose and return any overpayments that result from mistaken or erroneous claims.
Review Documentation Practices Hospitals should review their outpatient documentation practices to ensure that claims are based on complete medical records and that the medical records support the levels of service claimed.
Develop Auditing and Monitoring Plan Effective auditing and monitoring plans will help hospitals avoid the submission of incorrect claims to federal health care program payors.
Focus on Risk Areas Injections and Infusions New codes 2005 and 2006 with several program transmittals addressing codes Therapy Services CMS update of policy manual, claims processing manual Observation Audit reports on OIG website
Auditing Process Select record sample Complete medical record, UB-92 claim and remittance advice Utilize audit tool Document findings If overpayment exists, refund Medicare Identify and correct the root cause of billing errors Annual review or ongoing focused review of problem areas
Injections, Infusions and Chemotherapy
Injections Charge per injection 90772 Intramuscular 90773 Intra-arterial C8952 Intravenous 90471/90472 Vaccine administration C8952 includes infusions 15 minutes or less Use 36550 for declotting by thrombolytic agent of implanted vascular access device or catheter Do not use 96523, port flush, with any injection or infusion codes
Infusions Use C8950 for the first hour (at least 16 minutes must be documented to qualify) Use C8951 for each additional hour C8950 and C8951 report the duration of the infusion, regardless of the number of drugs infused Charge 1 unit of C8950 for each encounter, not each drug infused Infusion must be therapeutic, not saline lock, heplock or to-keep-open (TKO) rate
Infusions Do not charge infusion when integral to a procedure, such as blood transfusion, contrast administration, surgery or moderate sedation For more than one encounter on the same date, repeat C8950 with modifier 59 Do not use modifier 59 when infusion is stopped and started again during the same encounter For more than one site, report two units of the first hour infusion code without modifier 59
Infusions Providers may receive payment for patients whose infusion began before they arrived at the facility Documentation must include the time infusion began and the time infusion ended Do not use C8951 unless at least 31 minutes of next hour applies Use 92977 for intravenous infusion of thrombolytics
Chemotherapy Use a combination of CPT codes and HCPCS codes Medications or infusions administered independently or sequentially as supportive management of chemotherapy administration, should be separately reported with C8950 and C8951 Chemotherapy includes Parenteral administration of non-radionuclide antineoplastic drugs Anti-neoplastic agents provided for treatment of non-cancer diagnoses Substances such as monoclonal antibody agents and other biologic response modifiers
Services Included in Injections, Infusions and Chemotherapy Use of local anesthesia IV start Access to indwelling IV, subcutaneous catheter or port Flush at conclusion of infusion Standard tubing, syringes, and supplies
Pharmacy Hospitals must report all appropriate HCPCS codes and charges for separately payable drugs Drugs are to be billed in multiples of the dosage specified in the HCPCS code, rounded up if necessary CMS requests that hospitals voluntarily report the HCPCS codes and charges for drugs that are packaged
Resources CMS Pub 100-04, Claims Processing Manual, Chapter 4, Section 230 Billing and Payment for Drugs and Drug Administration CMS Pub 100-04, CR 4258, January 2006 Update: Change to Coding and Payment for Drug Administration
Auditing and Monitoring Lincoln Medical Center External review recommended additional monitoring Began with audit of 10 records per quarter Auditing performed by ER nurse Records were selected randomly Utilized audit tool
3 rd Quarter 2005 Audit included 10 patients admitted from ER to observation (OBS) 5 records with errors 3 injections ordered in OBS none were charged 2 injections ordered 1 charged IV push ordered once in ER, 5 times in OBS 1 charged in ER, 0 charged in OBS IV started in ER no infusion treatment minutes marked on ER charge sheet; 4 IV push given in ER not charged Pneumovax medicine charged no IM admin fee
Action Plan Rebilling of claims with modifier 59 when appropriate Nursing staff education Quarterly findings presented to nursing ER Nurse Manager now reviews accounts daily for charge capture
Action Plan Continuous monitoring resulted in improvement in error rate Case management reviews observations for injections/infusions
Injection & Infusion Exercises
Therapy Services
Chargemaster Review Are modifiers GN, GO and GP used only with the list of applicable therapy services? Review list of HCPCS codes considered therapy services Modifiers GN, GO and GP should never be used with codes that are not on the list of applicable therapy services For example, respiratory therapy services, or nutrition therapy services
Plan of Care Review Is there an order for therapy services? Is the date on the order prior to the start of therapy services? An order provides evidence of both the need for care and that the patient is under the care of a physician Certification requirements are met when the physician certifies the plan of care If the signed order includes a plan of care, no further certification of the plan is required
Plan of Care Review Is there a plan of care established before treatment is begun? Is the plan of care signed and dated by the person who established the plan? The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits It is appropriate that treatment begins when a plan is established The time spent in evaluation does not also count as treatment time
Plan of Care Review Does the plan of care include: Diagnoses Long term treatment goals Type, amount, duration and frequency of therapy services
Plan of Care Review Plan of Care Review Was the plan of care certified by the physician within the first 30 day interval of care? Certifications are required for each 30 day interval of treatment and are timely when the certification occurs before or during the interval Certifications are acceptable without justification for 30 days after they are due Delayed certifications should include any evidence the provider or supplier considers necessary to justify the delay Is there a recertification of the plan of care every 30 days?
Timing of Initial Certification Certification requires a dated signature The provider should obtain certification as soon as possible after the plan of care is established As soon as possible means as soon as the plan is obtained, or before the end of the first interval beginning at the initial therapy treatment Since payment may be denied if a physician does not certify the plan, the therapist should forward the plan to the physician as soon as it is established
Plan of Care Review Plan of Care Review Were any significant changes to the plan of care certified? While the physician/npp may change a plan of treatment established by the therapist providing such services, the therapist may not significantly alter a plan of treatment established or certified by a physician/npp without their documented written or verbal approval. Procedures and modalities are not goals, but are the means by which long and short term goals are obtained Changes to procedures and modalities do not require physician signature when they represent adjustments to the plan that result from a normal progression in the patient s diseases or condition
Documentation/Coding Review Are all services represented with HCPCS codes included in the plan of care? For each HCPCS code reported, is there a progress note in the record documenting the service on the date billed?
Documentation/Coding Review For timed modalities, is there documentation of time recorded in the medical record? Does the total time reflected in the medical record for timed modalities equal the number of units for timed modalities on the date the visit was provided?
Time Documentation For any single CPT code, providers bill a single 15-minute unit for treatment greater than or equal to 8 minutes and less than 23 minutes Time intervals for larger numbers of units are as follows: 3 units - 38 minutes to < 53 minutes 4 units - 53 minutes to < 68 minutes 5 units - 68 minutes to < 83 minutes If more than one CPT code is billed during a calendar day, then the total number of units that can be billed is constrained by
Resources Transmittal 515, Pub 100-04, April 1, 2005 Benefit Policy Manual, Pub 100-02, Chapter 15, Sections 220 and 230 Regarding Therapy Services Claims Process Manual, Pub 100-04, Chapter 5, Part B Outpatient Rehabilitation and CORF/OPT Services
Coding Compliance Lincoln Medical Center Due to off-site therapy services, coders relied on face sheet diagnosis Coding performed from incomplete documentation Denials received from payers Therapists used status post as a reason for therapy
Action Plan Education to therapists Need for complete information, including symptoms, such as pain, joint stiffness Consistent monitoring and auditing revealed inadequate documentation and manual process to obtain diagnosis for coding Decision made to include the Therapy Care Plan which lists all the problems/ symptoms Coders continue to require the presence of the Care Plan prior to coding
DIAGNOSIS: S/P ACDF C4-5 & C5-6
. PRIMARY DIAGNOSIS Pertinent Medical D.X.) /P ACDF C4-5 & C5-6 10. TREATMENT DIAGNOSIS Neck pain & LBP 20: INITIAL ASSESSMENT (History, medical complications, level of function at start of Care Reason for referral) 81 4/0 female with complaint cervical and lumbar pain. Pt had 2 spurs removed in the cervical region. Pt had immediate improvement following surgery but in the past 4 days has developed numbness in legs and fingers. Pain radiating into neck.
DIAGNOSIS: R Knee OA, R TKA
. PRIMARY DIAGNOSIS Pertinent Medical D.X.) Knee OA, s/p TKA R 10. TREATMENT DIAGNOSIS Decreased ROM, weakness 20: INITIAL ASSESSMENT (History, medical complications, level of function at start of Care Reason for referral) Knee extension is limited and will need to be addressed primarily
DIAGNOSIS: L Knee medial meniscus tear, s/p meniscectomy
. PRIMARY DIAGNOSIS Pertinent Medical D.X.) Knee med meniscectomy 10. TREATMENT DIAGNOSIS Severe hamstring tightness, moderate edema and antalgic gait
Therapy Exercises
Observation
Observation Services Services reasonable and necessary to evaluate an outpatient s condition or determine the need for a possible admission to the hospital as an inpatient Generally, a person is considered a hospital inpatient if formally admitted as an inpatient with the expectation that he or she will remain at least overnight The purpose of observation is to determine the need for further treatment or for inpatient admission Most observation services do not exceed 1 day
Billing for Observation Services Use G0378 for all observation services Units equal hours Use G0379 for direct admits to observation (revenue code 762, 1 unit) Medicare determines whether the claim meets criteria for the observation APC
Not Covered As Observation Services which exceed 48 hours unless the intermediary grants an exception You must give the beneficiary an ABN if you submit claims for observation services greater than 48 hours Services provided for the convenience of the patient, family, or physician Services which are covered under another Part A or B service Routine postoperative monitoring (4-6 hours) Therapeutic services such as chemotherapy
Not Covered as Observation Standing orders for observation following outpatient surgery Services which were ordered as inpatient services but billed as outpatient Inpatient care, such as complex surgery, clearly requiring an overnight stay
Inpatient Admission Changed to Outpatient Pub 100-04 Transmittal 299 September 20, 2004 Use condition code 44 For use on outpatient claims only, when the physician ordered inpatient services, but upon internal review performed before the claim was initially submitted, the hospital determined the services did not meet its inpatient criteria
All the following conditions must be met: Change is made prior to discharge or release, while the beneficiary is still a patient of the hospital Hospital has not submitted a claim to Medicare for the inpatient admission Physician concurs with the utilization review committee s decision Physician s concurrence with the decision is documented in the patient s medical record Inpatient Admission Changed to Outpatient
Documentation of Time Time begins at the clock time appearing on the nurse s observation admission note Time ends when all clinical or medical interventions have been completed, including any necessary follow-up care furnished by hospital staff and physicians that may take place after a physician has ordered that the patient be released or admitted as an inpatient Expectation is that medically necessary observation services were being provided to the patient up until the time of discharge Does not include the time patient remains after the treatment is finished
Observation Audit/Review Hancock Medical Center Observation Multidisciplinary process Problem-prone process Department assignments Process-specific monitoring Payer-specific guidelines
Review Policies & Procedures Information Systems Admission/Registration Coding Billing Nursing Case Management Medical Staff Payer-specific guidelines
Audit Focus Calculation of observation time Information System to calculate hours Routine review reveals errors Qualify/quantify extent of the errors Medicare observation criteria Medical necessity Documentation Coding and reimbursement Observation audit tool
Observation Audit Results Hours reported incorrectly Over 48 hours One service unit Billed correctly/clean claim Routine post-op monitoring Not medically necessary Ordered prior to surgery 38% 28% 10% 13% 4% 4% 3%
Observation Issues Identified Admission process interfaced with calculation of observation time Operating system required additional table maintenance Auto-calculation reset to exclude ER visit time if indicated by payer or type of stay Claims corrected and re-filed
Additional Medicare Issues Additional Medicare Issues Stays that exceeded 48 hours Advance Beneficiary Notice (ABN) process not followed Diagnostic testing turnaround time Case management on weekends Post-surgical stays exceeded 4-6 hours of routine recovery Documentation lacked medical necessity Planned overnight stays implied Required diagnostic testing Medical staff education
Observation Exercise A patient reports to your hospital on a Saturday afternoon with dizziness and nausea. Your facility admits him overnight and discharges him on Sunday. The final diagnosis is dehydration. On Monday, the case manager reviews the record and determines the case does not meet medical necessity for inpatient admission.
Medicare Observation Time Frames 1 st Quarter 2005 50% 35.94% 12.50% 1.56%
Day of Week Placed in Observation Patients with LOS > 24 hours Medicare Observations - 1st Quarter 2005 15% 30% 20% 20 Patients had a LOS of > 24 hours. 65% of those patients were admitted on Thurs, Fri, or Sat and would have reached the 24-48 hour mark when Case Management was not available to facilitate T discharge planning or obtain orders to convert the patient to a full admission. 10% 10% 10% 5%
Medical Necessity and Length of Stay Medicare Observation 2005 Could Have D/C'd Earlier Could NOT Have D/C'd Earlier 73% 65% 69% 50% 50% 44% 35% 27%
Observation Exercise What are the problems? Who is involved? What are some potential solutions?
Contact Information Lori Purcell QHR 615-371-4850 Lori_Purcell@QHR.com Cindy Sanders Lincoln Medical Center 931-438-7369 lmcmr@lchealthsystem.com Shannon Church Hancock Medical Center 228-467-8699 hmccomp@bellsouth.net