Increasing Federal Regulations Impact on Care or Documentation of Care Emily A. Boohaker, MD December 9, 2008

1. Increasing Federal RegulationsImpact on CareorDocumentation of Care?Emily A. Boohaker, MDDecember 9, 2008

2. Objectives Review recent Medicare regulations Medicare Severity DRG (MS-DRG) Present on Admission (POA) Hospital Acquired Conditions (HACs) Recovery Audit Contractors (RACs) Medicare Administrative Contractors (MACs) Describe the impact on hospital reimbursement and hospital/physician profiling Illustrate the role of compliant documentation

3. Disclaimer CLINICAL PERSPECTIVE Not a Coder Not a Financial Guru What works at UAB may not work at other institutions Clinical Documentation Specialists Query Process UAB uses a consultant company for education and data trackingUAB uses a consultant company for education and data tracking

5. All a function of docuemtationAll a function of docuemtation

6. Momentum for Changes Institute of Medicine Report Healthcare errors Medicare Prescription Drug, Improvement and Modernization Act of 2003 Reducing costs/improving pt care Deficit Reduction Act of 2005 Hospital Acquired Conditions Value Based Purchasing Active purchaser of higher value healthcare services MPDI got it all going with regards to reducing costs and improving pt care that has resulted in the many of the changes we will be discussing today VBP focuses on quality and efficiency DRA deals witl HACS and the Institue of Miedicn report to err is human moved things along and further gave infrastructure. CMS is using VBP tools to promote increased quality and efficency of caretherefore avoid unnecessary costs. Reduce advers events and improvept safety Make performace results transparent comprehensible, empoweres consumers to make value based decisions, encourages hospitals and clinicians to improve QOC. CMS applicatrion of VBP tools such as HAC is transforming mcare from a passive payor to an active purchaser of higher value health care sevices (f rom fed register). MPDI got it all going with regards to reducing costs and improving pt care that has resulted in the many of the changes we will be discussing today VBP focuses on quality and efficiency DRA deals witl HACS and the Institue of Miedicn report to err is human moved things along and further gave infrastructure. CMS is using VBP tools to promote increased quality and efficency of caretherefore avoid unnecessary costs. Reduce advers events and improvept safety Make performace results transparent comprehensible, empoweres consumers to make value based decisions, encourages hospitals and clinicians to improve QOC. CMS applicatrion of VBP tools such as HAC is transforming mcare from a passive payor to an active purchaser of higher value health care sevices (f rom fed register).

7. Diagnostic Related GroupsDRGs Groupings of diagnoses similar clinically and in resource utilization DRG assigned a Relative Weight (RW) Hospital Reimbursement Severity of Illness (SOI) Resource Utilization Relative weight is a reflection of these three thingsRelative weight is a reflection of these three things

8. The Blended Rate Rate for reimbursement for individual hospitals based on Region of country Teaching vs non-teaching (phasing out) Proportion of uncompensated care Bed size Medicare Blended Rate Ranges from $3,000 to $10,000 UAB blended rate $6887 Make sure and state the this is determined by medicareMake sure and state the this is determined by medicare

9. Medicare Hospital Reimbursement Made Simple Physician documents all relevant diagnoses and procedures Coder selects appropriate DRG UTI = DRG 690 DRG defines RW DRG 690 has RW = .7581 RW drives reimbursement RW x blended rate = Payment .7581 x $6887 = $5221

10. Medicare-Severity DRGs(MS-DRGs)

11. Final CMS Rule 2008 Based on CMS updated analysis of a severity DRG system from the mid-1990s, CMS adopted MS-DRGs Better recognize severity of illness Better demonstrate ability to explain differences in patient cost CC: Co-morbid condition or complication MCC: Major co-morbid condition or complication Often treat but do not document diagnoses

13. Medicare-Severity DRGs (DRG Example Table) NEED TO DELETTHE MDC AND TYPe and add column for payment and los.NEED TO DELETTHE MDC AND TYPe and add column for payment and los.

14. Medicare-Severity DRGs MCC and CC Specificity of documentation can make a difference. Shows how specific the documentation has to be. Shows how difficult it is to get the specificity to get cc mcc as that is what will drive DRG Specificity of documentation can make a difference. Shows how specific the documentation has to be. Shows how difficult it is to get the specificity to get cc mcc as that is what will drive DRG

15. From the Federal Register �We highly encourage physicians and hospitals to work together to use the most specific codes that describe their patient�s conditions. Such an effort will not only result in more accurate payment by Medicare but will provide better information on the incidence of this disease in the Medicare patient population.� From the compliance stand point, this is from the fed register which says it is okayFrom the compliance stand point, this is from the fed register which says it is okay

16. From the Federal Register �We do not believe there is anything inappropriate, unethical or otherwise wrong with hospitals taking full advantage of coding opportunities to maximize Medicare payment that is supported by documentation in the medical record. We encourage hospitals to engage in complete and accurate coding.� Nothing wrong with making sure that documentation is as accurate as possible and that terminonlogy mathces the coding rules by querying the physicians. Sue will talk about how we approached querying providers at UABNothing wrong with making sure that documentation is as accurate as possible and that terminonlogy mathces the coding rules by querying the physicians. Sue will talk about how we approached querying providers at UAB

17. Example 1 68 yo with h/o DM, COPD presents with altered mental status. Family states over the past several days he has become more �sleepy� and is having chills. PE: Ill appearing, diaphoretic. T = 102, BP 127/80, HR = 102, RR = 24, tachycardic, supra-pubic tenderness Labs: WBC = 13k, 90% segs, CBS = 200, UA positive

18. Example 1(continued) Admitting Diagnoses UTI Urosepsis Altered Mental Status Diabetes Mellitus Hospital Course IV antibiotics started Urine Culture: E. Coli; Blood cultures: negative Mental status returned to baseline Discharged home after 5 days

19. Example 1(continued) What is the principal diagnosis warranting this admission? Is there another diagnosis that more accurately describes the severity of illness and the additional resources used to manage this patient? Sepsis from a urinary source

20. Sepsis SIRS: 2 or more of the following T > 100.4 or < 96.8 HR > 90 RR > 20 or PaCO2 < 32 WBC > 12k or < 4k or > 10% bands Sepsis: SIRS due to suspected or confirmed infection (do not need positive blood cultures) Severe sepsis: Sepsis associated with organ dysfunction, hypoperfusion or hypotension Septic shock: Sepsis induced hypotension despite adequate fluid resuscitation along with presence of perfusion abnormalities American Journal of Medicine (2007) 120, 1012-1022

21. MS-DRGs Example 1 ARespF with mcc does not affect DRG. ARespF with mcc does not affect DRG.

22. Example 2 30 yo s/p renal transplant, h/o leukopenia with disseminated Zoster, presents with fever and sore on tongue. PE: No acute distress, T = 100.8, BP = 135/82, HR = 120, tongue with pustular lesion Labs: WBC = 1, Hct = 41, BUN/Cr = 28/2.7 (baseline = 10/1.2), CXR neg, culture neg

23. Example 2(continued) Admitting Diagnoses: Neutropenic fever Renal insufficiency Hospital Course: Treated with acyclovir Aggressive IVFs Frequent monitoring of renal function Creatinine returned to baseline Discharged home after 6 days

24. Example 2(continued) Is there a more accurate diagnosis to better describe what is going on with his renal function? Acute Renal Failure

25. MS-DRGs Example 2 Nurse queried for Acute renal FailureNurse queried for Acute renal Failure

26. Severity Matters Public reporting of mortality/morbidity Contract negotiations for the organization Ex: treating UTIs when truly septic Pay for performance for physicians

27. Present on Admission(POA)

28. POA Indicators Initiated in January 08 for Medicare and October 08 for BCBS Identify potentially preventable hospital-acquired conditions vs conditions already present on admission All diagnosis codes must have an indicator

29. General POA Reporting Requirements Indicator is required for all claims involving Medicare and BCBS inpatient admissions to general acute care hospitals Defined as present at the time the order for inpatient admission occurs Includes conditions that develop during an outpatient encounter in: Emergency department Observation Outpatient Surgery Issues related to inconsistent, missing, conflicting, or unclear documentation must be resolved by the provider

30. CMS POA Indicator Reporting Options and Definitions Y N U W 1 Diagnosis was present at time of inpatient admission Diagnosis was not present at time of inpatient admission Documentation insufficient to determine if condition was present Clinically undetermined by provider Unreported/not used. Exempt from POA reporting Don�t like to use U�s and should not have too many W� as well. If U for HAC won�t get reimbursed (considered a yes?)Don�t like to use U�s and should not have too many W� as well. If U for HAC won�t get reimbursed (considered a yes?)

32. POA Example 78 yo with CHF presents from Spain Rehab with acute dyspnea/hypoxemia. MET activated Afebrile, BP 90/50, RR 20, HR 70 O2 sat = 80% Using accessory muscles, chest crackles, lower extremity edema

33. POAExample (continued) Admitting Diagnoses CHF PTE HAP On day 3 attending documents hypoxemic respiratory failure Coder after discharge assigns respiratory failure with an �N� indicator

34. POA Example (continued) Was respiratory failure present on admission? YES �clarify as late entry in chart Add as a late entry okay to do but you need to write Late Entry and make sure you date and sign it.Add as a late entry okay to do but you need to write Late Entry and make sure you date and sign it.

35. Hospital-Acquired Conditions(HACs)

36. HACs: Scope of the Problem IOM Report To Err Is Human: Building a Safer Health System HACs are leading cause of M&M in US 98,000 Americans die annually due to medical errors National costs of these errors estimated at $17-$29 billion CDC Report Estimated that HACs add nearly $5 billion to US health care costs annually IOM: To Err is Human: Building a Safer Health System, November 1999 (http://www. iom.edu) Centers for Disease Control and Prevention: Press Release, March 2000 (http://www.cdc.gov)

37. HACs Section 5001(c) of the DRA required the Secretary to identify those conditions that Are high cost or high volume or both, Result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, Could reasonably have been prevented through the application of evidence-based guidelines Resonable preventable does not mean always preventable. AS you recall presence of a cc or MCC as a 2ondary diagnosis on a claim may generate a higher payment. Resonable preventable does not mean always preventable. AS you recall presence of a cc or MCC as a 2ondary diagnosis on a claim may generate a higher payment.

38. HACs Conditions not payable after 10/01/08 Air embolism Blood incompatibility Object left in during surgery Catheter-associated UTIs Vascular catheter-associated infections Pressure ulcers (stage 3 and 4) Mediastinitis after CABG Hospital-acquired injuries: fractures, dislocations, burns, crushing or intracranial injuries

39. Additional HACs Surgical site infections following certain elective procedures including certain orthopedic surgeries, and bariatric surgery for obesity Certain manifestations of poor blood glucose control DVT or PE following total knee and hip replacement procedures

40. BCBS HACs Conditions not payable after 01/01/09 All Medicare HACs PLUS 11 more from the National Quality Forum Surgical events Product or device events Care Management events Environmental events

41. Documentation of HACs HACs that are usually well documented Blood incompatibility Air embolism Object left in during surgery Mediastinitis after CABG Hospital-acquired injuries DVTs or PEs after certain orthopedic surgeries HA injuries�falls/fractures dislocations intracranial injuries burns electrical shcokHA injuries�falls/fractures dislocations intracranial injuries burns electrical shcok

42. HACs that may require additional documentation by provider Catheter-associated urinary tract infections Vascular catheter-associated infections Pressure ulcers (site and stage) Surgical site infections after gastric bypass Documentation of HACs Not always tied to gether in the documentationNot always tied to gether in the documentation

43. If this is the only complication or co-morbid condition driving the MS-DRG to a higher level For compliant coding must include the condition on the bill Medicare will reimburse at the lower MS-DRG If this is not the only complication or co-morbid condition driving the MS-DRG to a higher level For compliant coding must include the condition on the bill Medicare will reimburse at the higher MS-DRG Medicare HAC Payment Must have the code on there. Many pts that have these HACs have other comorbid conditions that will drive to the DRG so just because you have an HAC does not always mean that you will lose reimbursemetn however this is publicly reported data and will have negative impacts in other ways. From handout CMS pays for cc/mcc for HACs coded as a Y and W. CMS does not pay for cc/mcc for hacs coded as N or UMust have the code on there. Many pts that have these HACs have other comorbid conditions that will drive to the DRG so just because you have an HAC does not always mean that you will lose reimbursemetn however this is publicly reported data and will have negative impacts in other ways. From handout CMS pays for cc/mcc for HACs coded as a Y and W. CMS does not pay for cc/mcc for hacs coded as N or U

44. HAC: Example 1 MS-DRG 281 Acute MI, discharged alive with a CC; only CC is UTI RW = 1.2213 ($8411) Query for catheter-related UTI Lose CC RW = 0.8696 ($5989) Table of strokeTable of stroke

45. HAC: Example 2 83 yo transferred from OSH for LLE ulcer/cellulitis, CHF, DVT, etc After 5 days pt acutely decompensates/febrile/sob Possible HAP, cellulitis, possible sepsis from line infection-will change Cath tip showed 40 CFU Candida parapsilosis Blood cultures negative Did this pt have a hospital acquired vascular cath associated infection? Transferred after being in the osh for 6 weeks at family request. When decompensated required intubation. This was only documentation of the line sepsis so coders have to cod it since no further documentation it was ruled out. Pt was not treated for thisTransferred after being in the osh for 6 weeks at family request. When decompensated required intubation. This was only documentation of the line sepsis so coders have to cod it since no further documentation it was ruled out. Pt was not treated for this

46. HAC: Example 2 Attending queried Late entry in to chart �patient had negative blood cultures from that day, so he did not meet the CDC definition of line associated bacteremia or fungemia.�

47. How do you get paid if the condition is HAC? For compliant coding must include the condition on the bill Was it preventable? BCBS HAC Payment Up to hospital to determine if preventable. There are no clear cut guide lines yet for BCBS (READ HANDOUT)Up to hospital to determine if preventable. There are no clear cut guide lines yet for BCBS (READ HANDOUT)

48. Recovery Audit Contractors(RACs)

49. RAC Background Medicare Modernization Act of 2003 CMS to use RACs to identify and recoup over and under payments Tax Relief and Health Care Act of 2006 RAC Program permanent Expansion to all 50 states no later than 2010 MMA 2003 requires Rac demonstration and the tax relief act makes it permanent and expansion nationwide by 2010. CMS has a moretorim to place RACS on hold as two of the bidders are protesting so it will not start in Alabma is August as anticipated because of protest of two of biddersthat were not selectedMMA 2003 requires Rac demonstration and the tax relief act makes it permanent and expansion nationwide by 2010. CMS has a moretorim to place RACS on hold as two of the bidders are protesting so it will not start in Alabma is August as anticipated because of protest of two of biddersthat were not selected

50. Overpayments Collected by Provider Type Through 3/27/08Most over payments were collected from inpt hospital services for med necessity and coding Look at page 7 of RAC: latest focusThrough 3/27/08Most over payments were collected from inpt hospital services for med necessity and coding Look at page 7 of RAC: latest focus

51. Overpayments Collected by Error Type

52. Claim Review Process Automated Reviews Look for �low hanging fruit� Use data mining techniques Mainly outpatient hospital claims Multiple units billed Missing modifiers that would impact payments Payment for discontinued HCPCS/CPT codes

53. Claim Review Process Medical Record Audits Hospitals have 45 days to comply Missing records automatic denials Request 100 records/45 days for UAB RAC has 60 days to review chart and issue either a denial or an �all clear� letter to the provider Providers must follow Medicare appeal rules to dispute a RAC adjustment About 800 charts per yearAbout 800 charts per year

54. Issues Identified Information on claim did not match the medical record Excisional debridement Respiratory failure Claims with single secondary diagnosis designated as a complication or co-morbidity Discharge status/transfers � claim indicates discharge to home or other facility but medical record indicates beneficiary was discharged to another hospital or home with home care These are the target areas for RAC Reporting of excisioal debridement without adequate mr dcoumenation to meet definition of debridement. Principal diagnosis such as resp failure listed as Principal diagnosis but MR indicates sepsis was the principal dx. With regard to dc status there are target DRGs that require accurate discharge dispositions because the $$ for the episode of care MAY BE split if the pt goes to NH or HH witht the receiving organization Discharge summaries need to accurately reflect where you are sending the pt. These are the target areas for RAC Reporting of excisioal debridement without adequate mr dcoumenation to meet definition of debridement. Principal diagnosis such as resp failure listed as Principal diagnosis but MR indicates sepsis was the principal dx. With regard to dc status there are target DRGs that require accurate discharge dispositions because the $$ for the episode of care MAY BE split if the pt goes to NH or HH witht the receiving organization Discharge summaries need to accurately reflect where you are sending the pt.

55. Issues Identified Medical necessity Inpatient rehab Short stay admissions, including chest pain, back pain, congestive heart failure, and gastroenteritis Admission for scheduled elective procedures Wrong number of units billed Neulasta Speech therapy Transfusions Approximately 3% of ourmedicare population have one day stays for these reasons. If you you find a reason for the chest pain, put that reason down such as msk, GERD etc so they won�t be auditied. Wrong units billed is like grams vs mg, number of procedures per day, blood transfusion billed , neulasta billed one service per mg when the definition of the code is one service per 6 mg vial Med necessity�inpt admission for procedures eleigible for outpt. One day stays that qualify as observation. When our care managers see these they are tying to put them in other categories but this is done retrospecitvely. Need to have a three day stry to qualify for SNF.Approximately 3% of ourmedicare population have one day stays for these reasons. If you you find a reason for the chest pain, put that reason down such as msk, GERD etc so they won�t be auditied. Wrong units billed is like grams vs mg, number of procedures per day, blood transfusion billed , neulasta billed one service per mg when the definition of the code is one service per 6 mg vial Med necessity�inpt admission for procedures eleigible for outpt. One day stays that qualify as observation. When our care managers see these they are tying to put them in other categories but this is done retrospecitvely. Need to have a three day stry to qualify for SNF.

56. Medical Necessity(according to Medicare) CMS determines whether the item or service is �reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.� Two questions Is the therapy/treatment/device/procedure Is the setting in which it is deployed NECESSARY AND APPROPRIATE FOR THE PATIENT IN QUESTION?

57. Medicare Administrative Contractors(MACs)

58. MACs Required by section 911 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA of 2003) CMS is replacing its current claims payment contractors - fiscal intermediaries and carriers - with new contract entities called Medicare Administrative Contractors (MACs) For the first time, MACs will enable the government to match, link and compare both Part A and Part B claims submitted for a specific episode of care. Will integrate No longer just the hospitals problem but also physicians problem. This will get their attention and will be motivation for them to documents appropriately.Will integrate No longer just the hospitals problem but also physicians problem. This will get their attention and will be motivation for them to documents appropriately.

59. MACs Improved Beneficiary Services Claims processed by one contractor Integrated approach to medical coverage Single point of contact Improved Provider Services Single interface for Parts A/B More accurate claims payments Greater consistency in payment decisions Having one contracotr reduces number of separate exlanation of benefits statements a beneficiary will receive. Integrated consistant approach to coverageHaving one contracotr reduces number of separate exlanation of benefits statements a beneficiary will receive. Integrated consistant approach to coverage

60. Conclusions The word game is here to stay Engage each other in the game Documentation must reflect excellent care