Emergency Department Directors Academy Phase II Spring 2018 Course name: Workshop: Billing/Coding/Observation 5/3/2018, 12:45:00 PM - 2:15:00 PM, TH-41 DESCRIPTION: Billing and Coding for Observation services is a complex area fraught with regulatory intrigue and uncertainty. We will work to clarify the known and unknowns and go through the rules, regulations, best practices, and benchmarks to facilitate your Observation unit s financial success. OBJECTIVES: Outline the basic factors driving Emergency Department Observation revenue Analyze best practices for appropriate Observation charge capture Explore methods for applying simple solutions to your local ED Observation program Describe strategies for appropriate use of Observation services FACULTY: Michael A Granovsky, MD, FACEP BIO: Dr. Granovsky is the President of LogixHealth, a national ED coding and billing company. Following completion of his Emergency Medicine residency Dr. Granovsky went on to found Greater Washington Emergency Physicians. Dr. Granovsky then attained a coding certification, followed by an ED specialty certification in coding. Dr. Granovsky is the Director of the American College of Emergency Physicians (ACEP) Coding and Reimbursement course, and leads the education efforts of ACEP's National Coding and Nomenclature Advisory Committee. Dr. Granovsky also serves as editor for both ED Coding Alert and the American Academy of Professional Coders (AAPC) ED Specialty Coding Certification Exam. A nationally recognized expert in Emergency Medicine coding and reimbursement, Dr. Granovsky is a regularly featured speaker at multiple state ACEP Coding and Reimbursement Conferences, ACEP's Scientific Assembly and the ED Directors Course. DISCLOSURE: (*) Ownership Interest (stocks, stock options, or other ownership interest excluding diversified mutual funds) : President, LogixHealth
Observation Workshop EDDA 2 2018 Michael A. Granovsky, MD CPC FACEP President of LogixHealth
Why Is Obs Important Now? CMS Recovery Audit Contractors (RACs) focusing on inpatient DRG payments vs. Observation status Hospitals under pressure to cut costs Global contracts/acos/directly insuring communities ED groups ideally suited to run efficient units with short lengths of stay The masters of the throughput mindset!
DRG Economics Medicare pays a fixed amount for inpatient care Typically a large amount Much more than the observation payment Recent study calculated use of Obs instead of inpatient reduce CMS cost dramatically Average cost savings per patient = $1,572 Annual savings calculated: $3.1 Billion
RAC Stats RACs collected more than $2 billion from hospitals in 2017 AHA's RACTrac Survey 51% of hospitals allocated at least $40,000 in 2017 for RAC-related defense costs 32 percent > $100,000 in defense costs 6 percent > $400,000 SHORT-STAY DENIALS: Largest Area of Investigation 62% of short-stay denials were because the care was reported as Inpatient vs Obs
Top RAC DRG Targets and Denials TIA 6% (DRG 69) Chest pain 8% (DRG 313) Syncope 16% (DRG 312) COPD (uncomplicated) 5% (DRG 312) Pulmonary edema 4% (DRG 189) RAC review of one-day stays: 78% of claims denied because the care was reported as Inpatient vs Obs
Your Hospital s DRG Profile The Pepper Report Complex Medicare Report Supplies hospital data related to potentially improper DRG payments Number of discharges per DRG Payments per DRG Length of stay per DRG Highlights hospital LOS < 1 calendar day RAC focus for DRG take backs
RAC Impact and Hospital Response Hospitals pressured to avoid short-stay inpatient admissions Increased use of observation status Initially, a billing change now a delivery model change Now have opportunities for cost efficiency Accelerated throughput yields cost savings Requires throughput focused providers: Doctors, Nurses, Mid Levels, Support Staff!
Optimizing Observation Revenue Maximize RVUs/patient Physician documentation Coding methodology Optimize RVUs/day Appropriate patient selection Refine the profit margin Census and staffing Facility revenue considerations
2018 Obs CPT & CMS Observation care is a well-defined set of specific, clinically appropriate services, that are furnished while a decision is being made regarding whether patients will require further treatment as hospital inpatients. CMS Transmittal 1745, 290.1 - Obs Services Overview Such services are covered only when provided by order of a physician The following codes are used to report encounters by the supervising physician and performance of periodic reassessments CPT 2018 page 13
General Documentation Requirements Timed/dated order to place in observation status A short treatment plan regarding the goals of observation Clinically appropriate progress notes Asthma different than chest pain A discharge summary reviewing the course in observation, findings, and plan
Professional Observation CPT Codes Same day admit and discharge CPT Codes: 99234 Low severity Low-complexity MDM 99235 Moderate severity Moderate-complexity MDM 99236 High severity High-complexity MDM
CMS 8 Hour Rule Medicare requires 8 hours of Obs. on the same calendar date to bill 99234-99236 CPT does not define a time threshold If the Obs. stay spans 2 calendar days, no time constraints for CMS or CPT payers RAC Issue A00010002013:
Professional Observation CPT Codes Admit and discharge more than one calendar day: Initial Day CPT codes: 99218 Low severity Low-complexity MDM 99219 Moderate severity Moderate-complexity MDM 99220 High severity High-complexity MDM
Professional Observation CPT Codes Discharge day CPT Code: 99217- Discharge Day Includes final exam, discussion of observation stay, follow-up instructions, and documentation Used with codes from the initial observation day codes series (99218/99219/99220)
Coding Scenarios Observation Services Observation Level of Care Care All on the Same Day Care Covers Two Calendar Days 1 99234 99218 + 99217 2 99235 99219 + 99217 3 99236 99220 + 99217
Audience QA A high complexity patient is placed in Observation Status at 9 am and discharged home later that day at 8 PM. What physician code(s) would be assigned 99285 99220 99236 99291 **99236
Audience QA A high complexity patient is placed in Observation Status at 9 pm and discharged home the next day at 8 AM. What physician code(s) would be assigned 99285 99220 + 99217 99236 99291 **99220 + 99217
Physician Documentation All but the lowest level Obs require very significant Hx and PE documentation Comprehensive Hx and PE: 99219/99220 & 99235/99236 HPI: 4 elements PFSHx: 3 areas (Requires Family Hx) ROS: 10 systems PE: 8 organ systems Obs services typically require a family history Beware overuse of macros for ROS and PE
CMS PFSHx Observation Requirement CMS requires that comprehensive observation histories have 3 of 3 PFSH elements rather than the 2 of 3 requirement for ED E/M codes Medicare 1995 DGs page 6 May utilize the nurse s notes but beware Rarely document a Family Hx A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient.
Summary Documentation Requirements Level HPI ROS PFSHx PE 99234 4 2 1 5 99235 4 10 3 8 99236 4 10 3 8 Complete and Appropriate Documentation Beware Macro Over use
Audience QA A chest pain Obs patient coded 99236 requires which of the following? 4 HPI 10 Review of Systems Past Medical and Social History Family History **All of the above
Audience Coding Vignette 53 y.o. male with CP placed in Observation at 9 am and discharged at 7pm. What code set would we consider? 99234-99236 Documentation includes 4 HPI, 10 ROS, Past/Family/Social Hx/ 8 PE organ systems Assuming high complexity what code would be applied? 99236 What if the Family Hx is omitted? 99234
2018 RVU Values for Observation Services Same Day Obs Total RVU Over Midnight Obs Total RVU ED E/M Service Total RVU 99234 3.77 99217 2.07 99284 3.32 99235 4.79 99218 2.83 99285 4.89 99236 6.18 99219 3.85 99220 5.27 99217 + 99220 = 7.34 RVUs Total
2018 Cost Of Hx and PE Downcodes 2 downcodes: 99236 99234 Loose 4.82 RVUs. $173.52 39% $500.00 $400.00 Obs Revenue $442.96 $357.20 $300.00 $271.44 $200.00 $100.00 $0.00 99236 x2 1 Downcode 2 Downcodes
Audience QA List the below codes in order of highest to lowest RVUs 99285 99220 + 99217 99236 99284 RVUs lowest-highest 99284 99285 99236 **99220 + 99217 **2.41 RVUs > 99285
Obs Coding Methodology Most ED run Observation units see higher acuity patients Chest pain or clinically equivalent complexity is very common ED Observation E/M distribution influenced by pre-selected complexity
Clinical Benchmarks of Patient Complexity No AMA CPT Appendix C Obs code vignettes CMS RUC data base vignettes 99234: 19 y.o. pregnant patient (9 weeks gestation) presents to the ED with vomiting X 2 days. The patient is admitted for observation and discharged later on the same day. 99235: 48-year-old presents with an asthma exacerbation in moderate distress. 99236: 52-year-old patient comes to the ED because of chest pain.
CMS Benchmark Data: Patient Complexity Medicare Claims Data Code Total Reporting E Med Reporting % # E Med Patients E Med Distribution 99234 53,624 4.45% 2,386 10.9% 99235 143,673 4.16% 5,977 27.3% 99236 164,691 8.20% 13,504 61.8%
CMS Obs E/M Distribution Medicare E Med Obs Codes Reported 70% 60% 61.8% 50% 40% 30% 27.3% 20% 10% 0% 10.9% 99234 99235 99236
Audience Exercise Re: Complexity Benchmark your distribution based on complexity of clinical protocols: Determine if High/Moderate/Low Chest pain High complexity Moderate Asthma TIA Mod. complexity High complexity Syncope High complexity Mild dehydration healthy Low complexity 30
Is it Facility Observation? Variable bed locations: ED, formal Obs unit, 23 hr. short stay area, inpatient bed Variable attending clinician: ED MD or NPP, hospitalist, cardiologist, or PMD Bed location and medical coverage are not the determining factors for Obs billing it is a status not a location The order defines how the service is billed. Direct correlation between variability and inefficiency with LOS
Observation Unit Classifications Hospital Settings In Which Observation Services are Provided Setting Description Characteristics Type 1 Protocol driven, closed observation unit, dedicated nursing staff, defined Attendings Highest level of evidence for favorable outcomes Care typically directed by ED Type 2 Discretionary care, observation unit Care directed by a variety of specialists Unit typically based in ED Type 3 Protocol driven, bed in any location Often called a virtual observation unit Type 4 Discretionary care, bed in any location Most common practice Unstructured care Poor alignment of resources with patients needs. Scatter beds Ross et al; Health Affairs
Cost Savings of Dedicated Units Cost Savings in Type 1 Units 27% - 42% Critical Pathways Cardiology Greater efficiency; protocol driven care, dedicated staff yield shorter length of stay Observation Services, Patients, and Top Twelve Conditions Across Three Study Groups Emory/Grady, 2010 Georgia, 2010 US, 2009-10 ED Visits 185,901 4,194,602 133,957,000 Observation Visits Number 7,199 101,593 1,392,000 Length-of-Stay Average (hours) 17.2 27.6 22.3 Visits >24 hours 10.4% 44.4% 29.0% Visits >36 hours 0.1 24.7 14.9 Ross et al; Health Affairs
Macro Economic Considerations Cost reduction $1,500 - $2,000 per case Brigham Health Affairs data $1,572 / case Emory TIA $2,062 / case Indirect Cost reduction: Risk reduction re-admissions, medical legal (i.e. missed MI) Smart top line revenue growth back filled admissions Baugh options modeling data presented MCEP - $2,908 / case
Audience Case Study Community Hospital 40K ED with a 22% admission rate How many patients daily potentially qualify for Obs? 40,000 per year /365 days = 110 patients per day 110 X.22 = 24 daily admissions 30% qualified for Obs Average of 7 Obs patients per day Chest pain, syncope, cellulitis, pyelo, allergic reaction, Asthma, dehydration,
Audience Case Study Community Hospital What were the cost savings? 10 bed unit. occupied 28 days a month With overnight stays 2,555 patients treated Prior LOS for cohort 25 hours LOS 15 hours Staffing bed hours saved? 2,555 X (25-15) 25,555 bed hours! Days of LOS eliminated? 25,555/24 hours per day = 1,064 day decrease in LOS
How Many Patients? Varies by department acuity and your Obs protocols How wide you cast the net Basic benchmarks Typically 5% - 10% for many groups 1 out of 3 admissions Chest pain most common typically a third Most groups have a 10% - 20% failure rate Converted to inpatient
Audience Case Study 50,000 visit ED 22% admit rate How many potential Obs cases First how many admissions? 50,000 / 365= 137 patients per day 137 X 22%= 30 admissions How many Obs patients? 30 admissions X.3 = 10 Obs patient per day
Who Should Be In Obs? Which Obs patients will an ED group be successful with? Select patients with diagnoses that have clinical protocols Expedite throughput Achieve decreased length of stay Reach a successful clinical endpoint Prolonged stays drag down RVU efficiency
Patient Selection for Observation Services Selecting correct patients is key to the operational success of an observation unit Select patients with diagnoses that have that have associated clinical protocols Expedite throughput Achieve decreased length of stay Reach a successful clinical endpoint Prolonged stays drag down RVU efficiency
The Spectrum of Complexity Easier Harder Chest pain Abdominal pain Headache Cellulitis Pyelonephritis Asthma Dehydration Renal colic Hypoglycemia Allergic reaction Pharyngitis Closed head injury Vertigo Hematuria Pancreatitis SOB CHF/COPD Back pain* non ambulatory Extremes of age* Mental Health* Substance abuse
Audience Exercise Place in order the desirability for Obs 81 y.o. dizzy 52 y.o. pancreatitis 27 y.o. moderate asthma Chest pain Chest pain 27 y.o. moderate asthma 52 y.o. pancreatitis 81 y.o. dizzy non ambulatory
Observation Protocol Resources ACEP Observation Medicine Section www.acep.org Clinical & Practice Management» Resources» Observation Medicine http://www.acep.org/observationsection/ Brigham, Duke, Hospital of Central CT, Houston Northwest, William Beaumont http://www.bidmc.org/centers-and- Departments/Departments/Emergency- Medicine/Services/Observation-Medicine.aspx#D http://www.obsprotocols.org
Does Protocol Driven Care Create Value and Efficiency?
Length of Stay Improvement Metric In Patient CDU All patients: Length of stay 29.55 hrs 19.04 hrs Stays > 24 hours 42.9% 21.9% Syncope 43.44 hrs 23.00 hrs Society of Hospital Medicine: 2012 RIV Abstract Issue, Volume 7, April 2012 Abstract Supplement
Length of Stay and Cost Metric In Patient CDU Length of Stay 47 hours 29 hours Cost $2420 $1400 Annals of Emergency Medicine: 5 Emergency Departments N = 124 Syncope > 50 y.o. Sun et al; 2013.10.029
Length of Stay, Cost, and Quality Improvement OBS Units/Cost TIA Example Metric CDU In Patient Length of stay 25.6 hrs 61.2 hrs Cost $890 $1,547 Full testing 97% 91% Source: Ross, MA An Emergency Department Diagnostic Protocol for Patients with Transient Ischemic Attach: A Randomized Controlled Trial Annals of Emergency Medicine Vol. 50, Issue 2, Pages 109-119
Summary Goals Efficient quality care with decreased length of stay Create hospital bed capacity Obs service line that adds value to the Hospital Short LOS with great care is the paradigm
Patient Selection: Smart Bed Use A Driver of Financial Success
RVU Modelling: LOS and Bed Use CHF 3 day stay Htn, Creat. 2.3 & BS 385 Monday placed in CDU Tuesday slow diuresis BS, K+ abnormal, BP Home late Wednesday Alternative bed use Day 1- Chest pain patient 15 hour LOS Day 2 pyelonephritis Stays overnight Dc d in the AM Day 3 Chest pain 15 hour LOS
Audience Code & RVU Exercise CHF 3 day stay Mon- Wed Monday high complexity first Obs day 99220 5.27 RVUs Tuesday 99225 2.07 RVUs Wed discharge 99217 2.07 RVUs Alternate Use Monday Chest Pain 99236 6.18 RVUs Tuesday Morning Pyelo 99220 5.27 RVUs Wednesday Morning Pyelo DC 99217 2.07 RVUs Wednesday Chest pain 99236 6.18 RVUs
2018 Controlling Bed Flow to Maximize RVUs 25 20 RVU Comparison Over 3 Days 19.70 15 10 5 Chest Pain 5.27 6.18 Pyelo 7.34 2.07 2.07 Chest Pain 6.18 9.41 CHF 3 Day RVUs $338.76 CPx2, Pyelo RVUs $709.20 0 Day 1 Day 2 Day 3 Total
Observation Unit Staffing for Profit 10 bed unit turned 1.3 times daily Blend of moderate and high.5.7 RVUs per case 74 RVUs.$36/RVU.$2,700 daily = $112/hr Cost: salary, benefits, overhead?tough to cover costs Innovative Profit Solutions MD coverage in the morning and evening New admits and discharges 10hrs X $150 = $1500 PA/NP interim coverage 12hrs X $70 = $840 Protocol driven at night Creep up volume to be profitable Expand beyond chest pain to include protocol driven complaints such as Dehydration, Pyelonephritis, Asthma, Cellulitis
2018 Observation Coding Construct Facility observation is a composite APC Requires a qualifying visit and 8 hours of facility time 2015 limited ED visit types qualified Type A 99284/99285/99291 Level 5 Type B ED visit (G0384) An outpatient clinic visit (G0463) 2018 Observation many types of visits potentially qualify 99281-99285 (Type A ) or G0381- G0385 (Type B) 99291 G0463 (hospital outpatient clinic visit) G0379-(direct referral for observation)
2018 Observation Requirements Qualifying Visit 9928x, 99291, outpatient clinic G0463 8 hours reported as units of G0378 (in the units field) There must be a physician order for observation No T status procedure
2018 Observation as a Comprehensive APC CMS has continued to expand the concept of outpatient packaging Comprehensive APCs A C-APC is defined as a classification for the provision of a primary service and all adjunctive services provided to support the delivery of the primary service. We established C-APCs as a category broadly for OPPS payment and implemented 25 C-APCs beginning in CY 2015 Observation APC 8009 retired in 2016-2016 OPPS 124/1221 New observation C- APC 8011 continues for 2018
What s Included in the Observation Comprehensive APC? Everything! (Most: Labs, CT, US, procedures, IVF, Meds) Except (S.I. F, G, H, L and U) Some Brachytherapy services (status indicator U) Pass-through drugs, biologicals and devices (status indicators G or H) Corneal tissue, CRNA services, and hepatitis B vaccinations (status indicator F) Influenza and pneumococcal pneumonia vaccine services (status indicator L) Ambulance services Mammography
2018 Observation Facility Payment
Observation Increased Payments in 2018 What's the Catch? Observation is a Comprehensive APC - mini DRG Bundling: Most Labs, ancillaries, radiology, procedures, hydration/injection/infusion For CY 2018, we did not propose to create any new C-APCs or make any extensive changes to the already established methodology used for C-APCs. There will be 62 C-APCs as of January 1,2018. - OPPS page 43/1133
The Obs Pendulum: Facility Financial Risk/Reward Risks: overuse of observation Financial- lower payment to hospital vs. inpatient $5,142 vs. $1,741 (looking at top 10 diags.) Loss of 3 day qualifying stay for SNF coverage Potential higher out-of-pocket expense for patients Risks: underuse of observation Inappropriate inpatient admissions - RAC target Short inpatient stays: Decrease CMI Hospital payment denials
Conclusions Observation services will be an expanding determinant of our financial success Documentation and correct coding methodology drive the revenue per patient Focused patient selection, throughput and protocols optimize RVUs/day Packaging of services will lead to resource use pressure and efficiency pressure! The ED throughput culture is ideally suited to maximize Observation financial success
Contact Information Michael A. Granovsky, MD CPC FACEP President of LogixHealth www.logixhealth.com mgranovsky@logixhealth.com
Educational Appendix
Documentation Best Practice Document your emergency H&P as usual Beware 3/3 PFSHx Beware overuse of macros Document a separate observation record to include: An order to place in observation or provide observation care with time and date Notation of medical necessity and risk stratification Treatment plan Progress notes for ongoing care Discharge note
Cost: Who Mans the Unit OPPS Regs Direct supervision: during the initiation of observation (immediately available) General Supervision: once the patient is deemed stable (overall control) CMS further stated: the provider could be an MD or NP/PA Original Guidance 2011 OPPS 2017 OPPS Final Rule no changes
The Observation Roll Up When observation status is initiated in the course of an encounter in another site of service (e.g., hospital emergency department) all evaluation and management services provided by the supervising physician in conjunction with initiating the observation status are considered part of the initial observation care when provided on the same date. CPT 2018
Minimum Number of Beds and Volume Minimum size for an early profitable dedicated unit: 6 beds Fixed cost and nursing FTEs Typical Obs LOS 15 hours Max 1.3 bed turns per day. Obs volume is 8 per day ED volume requirement to generate 8 Obs patients: 8% qualify for Obs ED daily census of 100 36,500 patients per year
Optimizing Unit Size for Profit Typical nurse to patient ratio 1:5 Physician coverage 1:12 Basic midsize unit requirements Fixed costs: Bed space, secretary, medication administration Profitability starts to optimize at steady census of 12 daily Adjust your protocols to creep census up 50k ED 137/day 34 admits want 12 for obs 5 chest pain + 2 GU (colic & pyelo) Need 5: syncope/dehydration/abd pain/asthma
The 2 Midnight Rule CMS and members of Congress concerns: Beneficiaries spending long periods of time in Obs without being admitted as inpatients Obs is an outpatient status Concerned beneficiaries may pay more as outpatients If not inpatient then responsible for SNF charges In OIG report, 11% of Obs was > 3 days 80/20 co-insurance under part B Self administered (P.O.) medications not covered Inpatient hospital claims with stays shorter than 2 midnights are generally not appropriate for Part A payment.
Observation Patient Financial Considerations SNF Obs stay no qualifying SNF Medicare coverage Patient may be entirely responsible - $5,000 Typical stay starts at roughly $250 per day Qualifying inpatient stay spanning 3 nights No patient SNF cost sharing for first 20 days After 20 days co-payment is $145 per day 20% co pays add up for longer complex Obs stays Inpatient expense: Part A inpatient deductible $1,288 Self administered meds- uncovered service - gross hospital charges are in play (average bill $528)
ACEP Now Cost Comparison Inpatient vs Observation Baugh, Granovsky ACEP Now March 2016 page 16
How to Calculate The 2 days The final rule clarifies that the benchmark used in determining the expectation of a stay of at least two midnights begins when the beneficiary starts receiving services in the hospital. This would include outpatient care received while the beneficiary is in observation or is receiving services in the emergency department, operating room, or other treatment area.
2-Midnight Rule: Key Definitions 2-Midnight Rule The Benchmark: We are specifying that for those hospital stays in which the physician expects the beneficiary to require care that crosses 2 midnights and admits the beneficiary based upon that expectation, Medicare Part A payment is generally appropriate -2014 IPPS Final Rule 60/2225 The Presumption: 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. -2014 IPPS Final Rule 1726/2225
OIG Concerns: The 2 Midnight Rule Definitions 2 Midnight Rule The Benchmark: We are specifying that for those hospital stays in which the physician expects the beneficiary to require care that crosses 2 midnights and admits the beneficiary based upon that expectation, Medicare Part A payment is generally appropriate. 2014 IPPS Final Rule 60/2225 The Presumption- 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. IPPS Final Rule 1726/2225
Facility Observation: Scenario Patient presents to the ED at 8 AM, observation is ordered at 12 noon and the patient is discharged home at 9 PM, all on the same calendar date Medicare Facility Coding: 99284 or 99285 for ED visit as appropriate G0378, 9 units Any other nursing procedures and ancillary charges
Non-Medicare Facility Observation Commercial payers payment policies vary: Many will accept HCPCS code, G0378 Report only a charge with revenue code 762 Report CPT codes with RC 762 You have to ask the payer Monitor denials
SNF Not Covered If you need skilled nursing facility (SNF) care after you leave the hospital, Medicare Part A will only cover SNF care if you ve had a 3-day minimum, medically necessary, inpatient hospital stay for a related illness or injury. An inpatient hospital stay begins the day the hospital admits you as an inpatient based on a doctor s order and doesn t include the day you re discharged
2018 Part A Deductible Detail The Medicare Part A annual deductible that beneficiaries pay when admitted to the hospital will be $1,340 in 2018, a small increase from $1,261.00 in 2016. The Part A deductible covers beneficiaries' share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. Days 1-60: $0 coinsurance for each benefit period Days 61-90: $329 coinsurance per day of each benefit period Days 91 and beyond: $658 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime) Beyond lifetime reserve days: all costs
3 Midnights Part A SNF Coverage Skilled nursing facility stay Days 1 20: $0 for each benefit period Days 21 100: $167 coinsurance per day of each benefit period Days 101 and beyond: all costs
Changing an Inpatient to Obs Condition Code 44 process is used if a patient is admitted but later found to not meet inpatient criteria The patient may be changed from an inpatient to outpatient Obs: If the decision is supported by the UR committee If the change is made before discharge and no claim has been submitted A physician must concur with the decision and document same in the medical record The patient should be informed Condition code 44 is reported on the UB claim form The Obs hours count starts only after the Obs order is written! Report pre-obs hours/charges under revenue code 760 or 761
Inpatient Order and Certification MD orders admission to inpatient consistent with an expectation of a 2 midnight stay the benchmark Admitting Attending physician, surgeon who has completed a recent major procedure, or physician of the UR Comm who reviews the case No specific procedures or forms are required Countersignature of the inpatient admitting order is allowed Verbal Order of accepting Attending is acceptable
The Notice Act The Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act)requires hospitals to provide written and oral notice, within 36 hours, to patients who are in observation or other outpatient status for more than 24 hours Passed August 2 nd but they forgot to have the MOON go through the paper work reduction process step so delayed
MOON Basics The MOON is a standardized notice to inform beneficiaries (including Medicare health plan enrollees) that they are an outpatient receiving observation services and are not an inpatient of the hospital or (CAH). The MOON is mandated by the Federal Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act), passed on August 6, 2015. The NOTICE Act requires all hospitals and CAHs to provide written and oral notification under specified guidelines..all hospitals and critical access hospitals (CAHs) are required to provide the MOON beginning no later than March 8, 2017.
MOON Process When delivering the MOON, hospitals and CAHs are required to explain the notice and its content, document that an oral explanation was provided and answer all beneficiary questions to the best of their ability. Signature of Patient or Representative: Have the patient or representative sign the notice to indicate that he or she has received it and understands its contents. If a representative s signature is not legible, print the representative s name by the signature. Date/Time: Have the patient or representative place the date and time that he or she signed the notice.
CMS Sample MOON
Contact Information Michael A. Granovsky, MD CPC FACEP President of LogixHealth www.logixhealth.com mgranovsky@logixhealth.com