3/17/2015

Getting Your Physicians to Think in Ink Ralph Wuebker, MD, MBA, Chief Medical Officer

Objectives:

– Get Physician Buy In, Why status matters – Documentation best practices and common errors – Key documentation points for the 2 midnight rule – Documentation example

Why is Getting Patient Status Correct Such an Important Issue?

Overuse of Inpatient

Overuse of Observation

• Focus of Recovery Audit Contractors

• Length of stay artificially elevated

• Potential False Claims issue if no complaint process is in place

• Mortality data artificially elevated

• Potential recoupment of reimbursements during audit and loss of opportunity for appropriate OBS APC and ancillary charge payment

• Qualified stay impact on patient’s skilled care benefit • Unexpected patient financial responsibility (self-administered medication charges, inflated co-payments)

It’s about getting it right!

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Patient Deductible and Copays – Inpatient (Part A) 2015: • Day 1-60: $1260 inpatient deductible • Day 61-90: $315/day • Day 91-151: $630/day – Outpatient (Part B): • $147 per year deductible • 20% coinsurance for all covered outpatient services • 100% of non covered outpatient services

Source: CMS-8056-N, Medicare Program; CY 2015 Inpatient Hospital Deductible and Hospital and Extended Care Services Coinsurance Amounts

National Exposure •

NBC Nightly News/MSNBC March 2014: – –

http://www.nbcnews.com/watch/nightly-news/why-going-under-observation-can-cost-you-170444355554 http://www.nbcnews.com/watch/nightly-news/critical-advice-all-medicare-patients-should-hear170260035926

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FierceHealthcare, July 15, 2013

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JAMA: July 8, 2013 - Invited Commentary: Observation Status for Hospitalized Patients/Hospitalized but Not Admitted Kaiser News May 3, 2013

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Money August 2012; “This could Hurt—a lot” pg. 70 NYTIMES: In the Hospital, but Not Really a Patient; June 22, 2012 USA Today April 17, 2012

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Washington Post 2010: Patients held for observation can face steep drug bills

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http://www.fiercehealthfinance.com/story/study-hospitals-lose-money-observation-care/2013-0715?utm_medium=nl&utm_source=internal

http://www.kaiserhealthnews.org/Stories/2013/May/03/lawsuit-challenges-observation-rules-inMedicare.aspx

http://www.usatoday.com/money/industries/health/drugs/story/2012-04-30/drugs-can-be-expensive-inobservation-care/54646378/1

CMS Transmittal 541 •

Effective: 09-08-14

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The auditors have the discretion to deny other “related” claims submitted before or after the claim in question – Limited to surgical claims

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For services where the patient’s history and physical (H&P), physician progress notes or other hospital record documentation does not support the medical necessity for performing the procedure, post-payment recoupment will occur for the surgeon’s Part B service.

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The MAC, Recovery Auditor, and ZPIC are not required to request additional documentation for the “related” claims before issuing a denial for the “related” claims.

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Contactors shall process appeals of the “related” claim(s) separately.

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[Section Break Slide – Insert Section Title] Documentation Tips for Medical Necessity

What the Auditors Expect

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What Typically is Provided

“Foreign Body Removed #!” Name Protected, MD

Physician Documentation Uses Before: • E&M level validation • Communication with physician partners and consultants • Reminder notes for self use • Possible use by nurses

Now: • Audit defense • Billing justification • Malpractice defense • Quality of Care Measurement • Government investigations

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Common Documentation Problem Areas •

Limited or no physician documented info (consult, ED note or H & P) o Only information available is a list of symptoms/ lab work o No documentation until several hours after “admission”

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No plan of care or clear impression in the H & P o Common with mid-level providers, medical students and residents

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OP note/H & P for procedures that do not address/include any risk from past medical history o Frequently occurs from using office notes as history and physical

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Lack of discharge summary for a readmission review and no mention of stability on discharge/return to baseline in the discharge note

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Prolonged stays frequently do not include the current progress note or orders to indicate why the patient requires continued acute care

Common Documentation Problem Areas •

Using a symptom rather than a diagnosis for the impression or assessment ─ N/D/V vs. bowel obstruction ─ SOB, chest pain, headache, back pain ─ Listing the diagnosis as an intractable symptom (vertigo, abdominal pain, vomiting) without noting the potential diagnosis

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Using a lab value or treatment plan with no diagnosis

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Documentation for medical necessity is different than for billing level or coding

General Documentation Takeaways •

5 key pieces of documentation to support medical necessity for Inpatient admissions under Medicare: – Medical history – Current medical needs – Severity of signs and symptoms – Facilities available for adequate care – Predictability of an adverse outcome

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Key Words

SUSPECTS

What is your suspicion of what is going on, i.e. impression?

CONCERNS

What are your concerns of the situation?

PREDICTABLE RISK

Given the patient’s history and current presentation, what kind of adverse outcomes are likely and what are the chances

DOCUMENTATION NOT CONSISTENT WITH IP ORDER • • •

Custodial Delay Convenience

Examples: – Can go home from ER but the family cannot take care of the patient • “The patient was about to be discharged, but apparently she did/does not have much help at home and she is unable to take care of herself…” – Contradiction of IP order and certification • IP order and “I anticipate 1 midnight in the hospital and hence she will be admitted under observation.” – Here for placement – Home in AM after lab result

[Section Break Slide – Insert Section Title] Physician Documentation for 2 Midnight Rule

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3 Key Requirements for 2 Midnight Rule •

Time the patient is expected to stay in the hospital (2 midnights is guide)

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Order to “admit to inpatient” or “refer for observation/outpatient”

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Documentation of the patient’s medical necessity requiring hospital admission – H and P, progress note and DC summary

[Section Break Slide – Insert Section Title] Time: 2 Midnight Expectation

Expectation of 2 Midnights •

Physician should document if they expect the patient’s hospital care to span more or less than 2 midnights – Treatment time spent in the ED can be counted towards 2 midnights

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Guidelines: – If you believe the patient will be discharged same day or the day following hospitalization, consider ordering Outpatient or Observation – If you believe the patient will NOT be ready for discharge the day after hospitalization, consider ordering Inpatient

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[Section Break Slide – Insert Section Title] Physician Order

Physician Order Clarification •

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Qualifications of the ordering/admitting practitioner: – At some hospitals, practitioners who lack the authority to admit inpatients under either State laws or hospital by‐laws may nonetheless frequently write the sets of admitting orders that define the initial inpatient care of the patient. In these cases, the ordering practitioner need not separately record the order to admit ….. the 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. Verbal orders: – A verbal or telephone inpatient admission order must be authenticated (signed, dated and timed) by the ordering practitioner (or by another practitioner with the required admitting qualifications in his or her own right) in the medical record prior to discharge, unless the hospital or the State requires an earlier timeframe Timing: – The order must be furnished at or before the time of the inpatient admission. Sept 5 CMS Update Memo

Physician Order •

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Qualifications of the ordering/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. The admission decision (order) may not be delegated to another individual who is not authorized by the state to admit patients, or has not been granted admitting privileges by the hospital's medical staff (42 CFR 412.3(b)). However, a medical resident, a physician assistant, nurse practitioner, or other non-physician practitioner may act as a proxy for the ordering practitioner provided they are authorized under state law to admit patients and the requirements outlined below are met……if the ordering practitioner approves and accepts responsibility for the admission decision by countersigning the order prior to discharge. The inpatient admission order cannot be a standing order.

Source: CMS document: Hospital Inpatient Admission Order and Certification, Jan 30, 2014

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Physician Order Guidelines •

Inpatient Cases: should include the words “Admit” and “Inpatient” to be a valid inpatient order

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Observation/Outpatient Cases: Should include the phrase “Refer for Observation Services” or “Outpatient Status” – Avoid using “admit” and “Observation or Outpatient” in the same order. CMS considers this to be contradictory – “Admit to Tower 7” or “Admit to Dr. Smith” are not recommended

Source: CMS document: Hospital Inpatient Admission Order and Certification, Jan 30, 2014; see also, 78 Federal Register 50942 (2014 IPPS Final Rule).

Medical Documentation Keys 7 Key Pieces of Documentation for Medical Necessity • •

Physician Order Past Medical History – Comorbidities

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Severity of Signs and Symptoms – Pertinent positives on physical exam

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Current Medical Needs – Plan of Care and Accompanying Orders

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Facilities available for adequate care

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Predictability of an adverse outcome – Suspected diagnosis and need for hospital services

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Expectation of Length of Stay

Medicare’s Surgical “IP Only List” Medicare's Inpatient Only List should be reviewed at the time the procedure is scheduled – For procedures that are on the Medicare IP only list, • The order for Inpatient must be on the chart PRIOR to the surgery – If the procedure changes during surgery to an Inpatient only case • Ensure the IP order is put on the chart ASAP after the procedure

Source: Medicare Claims Processing Manual, Chapter 4, § 10.12 – Payment Window for Outpatient Services Treated as Inpatient Services; Medicare Claims Processing Manual, Chapter 4, § 180.7 – Inpatient-only Services

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Surgical Guidelines: Inpatient vs. Outpatient For Elective/Scheduled Procedures: –

i.e., procedures scheduled days in advance

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Does not apply to procedures on CMS IP only list

1. Same day discharge (i.e. no overnight stay) is ALWAYS OUTPATIENT 2. 1 midnight/overnight is OP (rarely observation) 3. 2 midnight stay most often is IP, but depends on Medical Necessity – High Risk patient is Inpatient – Low Risk patient is Outpatient

Admission Review – Key Considerations

Physicians Order

Expectation of 2-Midnight Stay

Medical Necessity

Clinical Rational

Medical Necessity Example 1 Chest Pain

• 76 y/o male with central intermittent chest pain for 2 days which lasts about 20 minutes, few episodes • Awoke in the morning with left arm tingling that quickly resolved • Past Hx includes MI, DM2, CABG and prior cardiac stents • PE BP 90/65 HR 105 RR 24 – Tachycardiac with bilateral crackles • EKG besides for Sinus Tach is unchanged and cardiac enzymes nondiagnostic, Cr 1.5, Bld Glc 220 g/dL • Pain is relieved by NTG, then recurs and feels just like his prior MI

THESE FACTS ALONE DO NOT TELL THE STORY

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Documentation is Key: Telling the Chest Pain Story •

The common term "chest pain" does not necessarily refer to cardiac disease and is often misunderstood

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Documentation of your clinical judgment (e.g., cardiac ischemia, recurrent or worsening angina, chest wall pain, non-cardiac, GERD) is important – What is the rationale or factors you considered in your judgment?

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“Atypical chest pain” does not exclude ischemic disease – document suspected cause regardless of typical or “atypical” pattern

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Acute Coronary Syndrome encompasses UA, NSTEMI, or STEMI – UA - rest angina (usually lasting >20min), new onset (