Clinical Documentation Improvement Programs and Physician Advisors: Working Together to Improve Effectiveness October 12, 2009 Betty B. Bibbins, MD, CHC, FACOG, C-CDI, C CDI, CPEHR, CPHIT President & Chief Medical Officer DocuComp LLC Agenda Present an overview of the goals of mission of Clinical Documentation Improvement (CDI) Programs Discuss the importance of clinical documentation to Physician Practices within the Inpatient and Office Settings Discuss and overview of Compliance requirements by CMS regarding the documentation of Severity-of-Illness and Medical Necessity within the medical record Discussion of how CDI can proactively prepare physician practices for Recovery Audit Contractors (RAC) and Medicare Administrative Contractor (MAC) audits. Improving effectiveness of CDI Programs with support of Physician Advisors.
Documentation and Coding What really counts? Specificity in Documentation Bridging the gap between clinical & ICD-9 classification language
Where Non-Specificity May Be Detrimental Words that can Make or Break You Acute Chronic Acute on Chronic No further specification CHF Blood loss anemia Heart disease Kidney disease History of cancer, COPD, bronchitis, etc.. The Name of the Game Capture allclinical conditions managed, treated, worked-up, monitored with appropriate specificity in documentation and medical necessity. Uniform Hospital Discharge Date Set item #11Bdefines other diagnoses as follows: All conditions that : Coexist at the time of admission, That develop subsequently, or That affect the treatment received and/or length of stay.
Other Diagnoses For reporting purposes, the definition for other diagnoses is interpreted as additional conditions that affect patient care in terms of requiring: Clinical evaluation Therapeutic treatment Diagnostic procedures Extended length of hospital stay Increased nursing care and/or monitoring General Principles of Inpatient & Outpatient Medical Record Documentation The medical record should be complete and legible. The documentation of each patient encounter should include: Reason for the encounter and relevant history, physical examination findings and prior diagnostic test results; Assessment, clinical impression or diagnosis;
General Principles (cont) Plan for care; and Date and legible identity of the physician. The rationale for ordering diagnostic and other ancillary services should be explicitly documented. Past and present diagnoses should be accessible to the treating and/or consulting physician. General Principles (cont) The patient s progress, response to and changes in treatment, and revision of diagnosis should be documented. The CPT and ICD-9-CM codes reported on the physician s 1500 Claim Form, the facility s UB-04 Claim Form, or any electronic billing statement should be supported by the documentation in the medical record.
Win Win Situation? YES! Observation Documentation
Observation Status- The Skinny Outpatient observation status (OOS) is for: 1. Evaluating a patient for possible inpatient admission; 2. Treating patients expected to be stabilized and released in 24 hours; 3. Extended recovery following a complication of an outpatient procedure (abnormal postoperative bleeding, poor pain control, intractable vomiting, delayed recovery from anesthesia). Documentation must explicitly support the reason for observation Pitfalls of Observation It is NOT Substitute for an inpatient admission. For medically stable patients who need diagnostic testing or outpatient procedures. For patients who need therapeutic procedures (e.g., blood transfusion, chemotherapy, dialysis) that are routinely provided in an outpatient setting.
Pitfalls of Observation It is NOT (cont) For patients awaiting nursing home placement. To be used as a convenience to the patient, his or her family, the hospital, or the attending physician. For routine prep or recovery prior to or following diagnostic or surgical services. A routine "stop" between the emergency department and an inpatient admission. Outpatient Observation Status Serves a Specific Purpose!
Observation Particulars A physician's order must be written prior to initiation of observation services, as documented by a dated and timed order in the patient's medical record. An order may not be back-dated. Examples of Observation Status Altered mental status Anemia Asthma Atypical chest pain Back pain Headache, unknown etiology Hypertension Kidney stones, renal colic Nausea Key Point Clinical Documentation Improvement Specialists review these cases after 24 hours for documentation assessment and query/clarification - if necessary UR - Case Management/CDI Collaboration
Condition Code 44 Know the Reasons to Report Condition Code 44 the RACsdo! In some instances, a physician may order an inpatient admission, but upon subsequent review, staff members determine that the inpatient level of care does not meet the hospital s admission criteria. The National Uniform Billing Committee issued Condition Code 44 to identify cases when this scenario occurs and hospitals must change the patient s status from inpatient to outpatient.
Condition Code 44 How is a patient identified on a hospital claim when the inpatient admission has been changed to outpatient? Facilities use Condition Code 44 on the UB-04 claim form to identify these patients. It is for use on outpatient claims only, when the physician ordered inpatient services, but upon internal utilization reviewperformed beforethe claim was originally submitted, the hospital determined that the services did not meet its inpatient criteria. Condition Code 44 (cont) The patient must still be in the hospital when the status change is made. The Attending Physician must CONCUR with the change in status and this must be documented in the chart.
Rules for using Condition Code 44: The entireepisode of care must be treated as if the inpatient episode never occurred and the billing can only be outpatient. Failure to bill properly can result in audit recoupmentsfor both the physician and the hospital! Take these steps to ensure Compliance with Condition Code 44: A Utilization Review (UR) committee (i.e., two or more practitioners) must carry out the determination if admission criteria has been met, once the question of appropriateness of inpatient admission has been raised by CDI/UR/Case Mgt. At least two members of the committee must be doctors of medicine or osteopathy. The following individuals do not have the authority to change a patient s status from inpatient to outpatient: Case managers. Other types of utilization management staff members who are not licensed practitioners permitted by the state to admit patients to a hospital. Doctors of medicine or osteopathy who do not have the authority to change a patient s status from inpatient to outpatient.
Compliance with Condition Code 44 (cont): The UR committee must consult with the practitioner(s) responsible for the patient s care and allow them to present their views beforemaking a determination. It may also be appropriate to include the practitioner who admitted the patient if this is a different person. In the end, these physicians must agree with the decision to append condition code 44, and this agreement should be documentedin the patient s medical record. Two members of the UR committee must determine whether an admission or continued stay is medically necessary. One member of the UR committee may make this decision only when the practitioner(s) responsible for the patient s care either concurs with the determination or fails to present his or her views when afforded the opportunity to do so. Compliance with Condition Code 44 (cont): When the UR committee determines that the admission is not medically necessary, it must give written notification within two days of the determination to the hospital, the patient, and the practitioner responsible for the patient s care. The UR committee must make the change in patient status from inpatient to outpatient prior to discharge or release, and before the hospital submits the claim to Medicare. Review of the medical record for inpatient admission criteria may be performed before, during, or after hospital admission. In Summary Considering the CMS explanations that include comparing and monitoring one day admissions to outpatient status, it strongly suggests that the conversion to OOS may be an appropriate equivalent conversion when the term outpatient is used If appropriate documentation is written within the medical record. With the increased scrutiny in today s regulatory environment being given to one day admissions UR and CDS personnel need to be diligent in reviewingphysician documentation regarding appropriate inpatient criteria to support the admitting diagnosis.
Medical Necessity Medical Necessity- The Precedent Observation services also must be reasonable and necessary to be covered by Medicare. Only in rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours.
Medical Necessity- The Legal Language Medical Necessity Defined- Medicare Words Title XVIII Social Security Act Section 1862 (a)(1)(a): No Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Medical Necessity Governs Inpatient vs. Outpatient Designation Clinical Documentation Medical Necessity Symptom vs. Diagnosis Clinical Documentation Improvement Specialists
Clinical Documentation Improvement Specialists Role Work with the physician to obtain explicit medical record documentation: Medical Decision Making Medical Record Documentation Appropriate Severity-of-Illness Captured Medical Necessity Proper Hospital Reimbursement Win - Win Situation Order Status It Is All In The Words The order for outpatient versus inpatient status -Words do Matter! Inpatient Admission- Admit as Inpatient. Observation- Place in Observation Strive for (tentative) diagnosis to be included in order. Symptoms should be linked to a provisional diagnosis.
Government Agencies Government Agencies Comprehensive Error Rate Testing (CERT) Hospital Payment Monitoring Program (HPMP) Medicare Administrative Contractors (MAC) Recovery Audit Contractors (RAC)
The CERT Program The CMS established two programs to monitor and report the accuracy of Medicare FFS payments: 1. The Comprehensive Error Rate Testing (CERT)program 2. The Hospital Payment Monitoring Program (HPMP). The national error rate is calculated using a combination of data from the CERT contractor and HPMP with each component representing about 60% and 40% of the total Medicare FFS dollars paid, respectively. MAC Program Through implementation of Medicare Contracting Reform, CMS has integrated the administration of Medicare Parts A and B for the fee-for-service benefit to new entities called Medicare Administrative Contractors (MACs). This operational integration centralizes information once held separately, creating a platform for advances in the delivery of comprehensive care to Medicare beneficiaries. CMS consolidates administration of Part A and Part Binto integrated MACs, the following improvements to services for beneficiaries and providers can be expected: Improved Beneficiary Services Most beneficiaries will now have their claims processed by onlyone contractor, reducing the number of separate explanation of benefits statements a beneficiary will receive and need to organize. A/B MACshave develop an integrated and consistent approach to medical coverage across its service area, which benefits both beneficiaries and providers.
Design of the Recovery Audit Contractor (RAC) Program RAC Demonstration Program For the 3-year demonstration required by the Medicare Prescription Drug Improvement, and Modernization Act (MMA), the Centers for Medicare & Medicaid Services (CMS) contracted with RACs to: -Detect Medicare improper payments (including both underpayments and overpayments); and -Correct Medicare improper payments (i.e., repay money to a provider who was underpaid or collect money from a provider who was overpaid). - Paid on a contingency fee for identifying and correcting improper payments. -Were chosen based upon their proven track record in contractingwith other private third party payers in a similar arrangement. RAC Demonstration Recoupments 8% Overpayments by Error Type $391.3 Million Medically Unnecessary 17% 40% $331.8 Million Incorrectly Coded $160.2 Million Other 35% $74.3 Million No/Insufficient Documentation
Physicians Advisors The Role of the Physician Advisor Regarding Clinical Documentation Improvement & Medical Necessity Educator with the Medical Staff Negotiator with the Medical Staff Liaison between 3rd Party Payers and the Medical Staff in communicating efficient and costeffective medical practice Supporting the Documentation Improvement & Utilization Review functions
Areas of Physician Advisor Expertise Clinical Documentation Improvement Review Medical Necessity Review Continued Stay Review / One Day Stay Review Clinical and Regulatory Guideline Compliance Hospital Reimbursement, and Quality Helps to assist in education of CDI, UR and medical staff members on the above topics regularly. Physician Advisor CDI and UR reviewers are responsible for identifying and referring cases requiring physician review. Physician Advisors must be considered members of the CDI & UR review teams, working in tandem with 1 st line reviewers and with peer Attending Physicians to ensure the best possible outcomes. At strong consideration regarding any Physician Advisor is his or her ability to make a complete commitment, unencumbered by ongoing obligations to a peer group with which he or she shares a need for mutual professional support.
Physician Advisor A few general rules should help most Physician Advisors provide the greatest services to your facility: Follow good medical judgment. Follow accepted medical standards. Gather all facts before making a decision. Speak and listen to the Attending Physician. Negotiate a compromise if no other solution is possible. Allow for appeal. Be trained in appropriate Clinical Documentation Improvement and Medical Necessity standards, criteria and guidelines. Physician Advisor Utilization Review is one of the required tasks for Medicare Compliance, but many hospitals may not have a UR Committee that is willing to function in a productive manner. A close lookat what the CMS Conditions of Participation (CoP) say is required, and how to organize your UR Committee to not only comply with the requirements, but make positive changes within the hospital and Medical Staff. An analysis at who should be involved, how to organize information presented to the committee, how to screen utilization within the hospital to gather the low lying fruit, and finally what difference it can make to your organization and to the Medical Staff.
Clinical Documentation Improvement & Physician Advisor Relationships Clinical Documentation serves many purposes For Physicians and Facilities: Adherence to medical practice and standards of care Medical Necessity Quality & Outcome Studies Measures of Efficiency & Effectiveness Medico-Legal Purposes Adherence to Joint Commission Standards and other requirements Submission of Raw Data used for administrative purposes Basis and support of reimbursement for services rendered It Is Not All About the Money
The Real Meaning CDI Work with physicians to document a picture of the patient: List and describe: -Provisional diagnoses and pertinent signs and symptoms. - Degree of clinical uncertainty of patient. - Concern with recognized risk factors. - Known risk of morbidity and mortality. The Real Meaning CDIS Work with physicians to document a picture of the patient: List and describe : Clinical significance of abnormal lab values, radiology results, and other clinical abnormalities Diagnoses for allmeds you are planning on continuing Why continue meds? acute, chronic, stable, mild/moderate/severe Toxicity monitoring?
Physician Advisors as a Support System for CDI Specialists CDI (and UR) personnel initially handle the medical record reviews., with complicated or difficult cases being referred to a Physician Advisor for decisions. As the complexity of cases under review continues to grow and new medical technology is added, there is an increasing demand for fair and well-informed decisions regarding the similarities and differences between the practice of medicine and the documentation of the practice of medicine.. The Physician Advisor must have sound knowledge of: The appropriate length of stay for a given diagnosis or procedure, and Complications that may warrant an addition to the initial length-of-stay assignment. The physician advisor's role, in part, becomes that of final decision-maker in evaluating: Appropriateness of admission, Judging the efficiency of services in terms of level of care and place of service, and Seeking appropriate care alternatives for selected patients. The Combined Role of Clinical Documentation Improvement And Physician Advisor
Questions? Thank You Betty B. Bibbins, MD, CHC, C-CDI, CPEHR, CPHIT President & Chief Medical Officer DocuComp LLC www.docucompllc.com
Condition Code 44: http://www.cms.hhs.gov/contractorlearningresources/downloads/ja0622.pdf http://www.cms.hhs.gov/transmittals/downloads/r299cp.pdf CERT: http://www.cms.hhs.gov/mlnproducts/downloads/certfactsheetv1-3.pdf Outpatient Observationor Inpatient Admission? That is the Question! http://www.hce.org/medicare/hpmp_webex-5-3-07/4.casestudyhandout- HPMP.PPT#256,1,Medicare Why all the controversy over status? http://www.hce.org/medicare/hpmp_webex-5-3-07/3.presentationhandout- HPMP.PPT#258,3 The OIG Work Plan 2009: http://oig.hhs.gov/publications/docs/workplan/2009/work_plan_fy_2009.pdf Fraud Statistics www.oig.hhs.gov Resources Resources (cont) http://www.cms.hhs.gov/cert http://www.cms.hhs.gov/contractorlearningresources/downloads/ja0622.pdf The above link goes to: Related MLN Matters Article #: SE0622 Date Posted: April 4, 2006 Related CR #: 3444 Clarification of Medicare Payment Policy When Inpatient Admission Is Determined Not To Be Medically Necessary, Including the Use of Condition Code 44: Inpatient Admission Changed to Outpatient Developing an in-house physician advisor program - utilization management companies supported by teams of physician advisors, by Grant D. Lawless & Dorothy B. Holt; Physician Executive, May-June, 1991