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    Slide 1:Managing CMI Begins in the Emergency Department

    HFMA Kentucky Chapter Annual Winter Educational Institute January 15, 2010 Melinda Tully, MSN, CCDS SVP Clinical Services and Education J. A. Thomas & Associates 1

    Slide 2:U.S. Healthcare in Crisis


    Slide 3:Key Points for Discussion

    CMS continues to promote and expand Value Based Purchasing for FY 2010 MS-DRGs require accurate documentation and coding for severity and the highest allowable DRG relative weight Recovery Audit Contractor (RAC) findings compel a change in ED strategies to mitigate losses A new trend in hospitals - a documentation specialist in the ED How can hospitals bring greater focus on clinical documentation into the ED? How can ED documentation help correct your Case Mix Index and quality reporting? 3

    Slide 4:The ED Impact on Financial Results

    Ever-increasing patient volumes in the ED strain staff and facility capacity Growing proportion of 50% or more inpatients admitted through the ED Non-reimbursement of hospital-acquired conditions that are not documented present on admission (POA) Medicares Recovery Audit Commission (RAC) activities and burden on hospitals Quality core measures suggesting P4P (pay for performance) Patient safety indicator documentation Medical necessity denials 4

    5 6

    Slide 7:POA Preparedness in the ED


    8 9

    Slide 10:The Washington Times May 13, 2009

    The Medicare hospital trust fund will exhaust its reserves in 2017, rendering it insolvent two years earlier than the trustees predicted last year. Its unfunded obligation is $13.4 trillion, $1 trillion higher than last year's estimate. That amount would have to be deposited in an interest-earning account today in order for Medicare's hospital trust fund to be able to pay all its scheduled benefits over the next 75 years. Medicare's total unfunded obligations, including its programs that use general revenues to pay for doctors' fees and prescription drugs, have reached $37.8 trillion. 10

    Slide 11:The Congressional Focus Maintaining Medicare Viability

    Enforcement Actions re Fraudulent Billing [8:1 ROI] Recovery of Erroneously Paid Claims [10:1 ROI] The RAC Audits Value Based Purchasing (VBP) Value-based Purchasing is the key mechanism for transforming Medicare from a passive payer to an active purchaser of quality 11

    Slide 12:MedPAC

    The Medicare Payment Advisory Commission (MedPAC) is an independent congressional agency established by the Balanced Budget Act of 1997 (P.L. 10533) to advise the U.S. Congress on issues affecting the Medicare program. 12


    Slide 14:VBP Program Goals

    Improve clinical quality Reduce adverse events and improve patient safety Encourage patient-centered care Avoid unnecessary costs in the delivery of care Stimulate investments in effective structural components or systems Make performance results transparent and comprehensible To empower consumers to make value-based decisions about their health care To encourage hospitals and clinicians to improve quality of care 14

    Slide 15:VBP Programs

    Hospital Quality Initiative: Inpatient & Outpatient Pay for Reporting Hospital VBP Plan & Report to Congress Hospital-Acquired Conditions & Present on Admission Indicator Reporting Physician Quality Reporting Initiative Physician Resource Use Reporting Physician VBP Plan & Report to Congress Home Health Care Pay for Reporting ESRD Pay for Performance Medicaid 15

    Slide 16:VBP Demonstrations and Pilots

    Premier Hospital Quality Incentive Demonstration Physician Group Practice Demonstration Medicare Care Management Performance Demonstration Nursing Home Value-Based Purchasing Demonstration Home Health Pay for Performance Demonstration 16

    Slide 17:Value Based Purchasing

    The emergency department may be the point of entry to the hospital for 50% of admissions The ED is where the documentation of critical clinical information and medical necessity begins Complete, accurate clinical documentation of the care delivered is paramount in supporting the quality and safety of inpatient care 17

    Slide 18:The Future of VBP

    The current administration is committed to VBP Decreasing Readmission Rates is a Medicare area of focus PQRI incentives will increase and may become mandatory (or penalty for non-participation) Hospital Core Measures are here to stay and expanding Adding to POA/HAC List annually Episodes of Care/Hospital-Physician Payment Bundling Alignment of Hospital/Physician Priorities Documentation will be key in any scenario! 18


    First, do no harm second, do no pay for harm 19

    Slide 20:Selected HACs for Implementation

    Foreign object retained after surgery Air embolism Blood incompatibility Pressure ulcers Stages III & IV Falls Fracture; Dislocation; Intracranial; injury; Crushing injury; Burn; Electric shock Deep vein thrombosis (DVT)/pulmonary embolism (PE) Total knee replacement Hip replacement Vascular catheter-associated infection Manifestations of poor inpatient glycemic control Hypoglycemic coma; Diabetic ketoacidosis; Nonkeototic hyperosmolar coma; Secondary diabetes with ketoacidosis; Secondary diabetes with hyperosmolarity Catheter-associated urinary tract infection Surgical site infection Mediastinitis after CABG Certain orthopedic procedures Spine; Neck; Shoulder; Elbow Bariatric surgery for obesity Laparascopic gastric bypass; Gastroenterostomy; Laparoscopic gastric restrictive surgery 20

    Slide 21:The HAC Problem

    The IOM estimated in 1999 that as many as 98,000 Americans die each year as a result of medical errors Total national costs of these errors estimated at $17-29 billion IOM: To Err is Human: Building a Safer Health System, November 1999. Available at: 21

    Slide 22:The HAC Problem

    In 2000, CDC estimated that hospital-acquired infections add nearly $5 billion to U.S. health care costs annually Centers for Disease Control and Prevention: Press Release, March 2000. Available at: A 2007 study found that, in 2002, 1.7 million hospital-acquired infections were associated with 99,000 deaths Klevens et al. Estimating Health Care-Associated Infections and Deaths in U.S. Hospitals, 2002. Public Health Reports. March-April 2007. Volume 122. 22

    Slide 23:Statutory Authority: DRA Section 5001(c)

    Beginning October 1, 2007, IPPS hospitals were required to submit data on their claims for payment indicating whether diagnoses were present on admission (POA) Beginning October 1, 2008, CMS cannot assign a case to a higher DRG based on the occurrence of one of the selected conditions, if that condition was acquired during the hospitalization 23


    Slide 25:A Choice in Clinical Documentation

    ORIF hip, Stage 4 Sacral Decubitus Ulcer ORIF hip, Stage 4 Sacral Decubitus, POA 25

    Slide 26:HAC 2010

    The list of selected HAC categories is dependent upon CMS list of diagnoses designated as CC/MCCs. As changes and/or new diagnosis codes are finalized to the list of CC/MCCs, these changes need to be reflected in the list of selected HAC categories In the FY 2010 the addition of ICD-9-CM codes 813.46 (Torus fracture of ulna) and 813.47 (Torus fracture of radius and ulna) were added to the HAC codes, both codes are CCs These new codes more precisely define the previously selected HAC category of falls and trauma CMS did not add any new HAC categories for FY 2010 CMS has not released any aggregated POA or HAC data to the public 26

    Slide 27:Positioning for Value Based Purchasing

    What data is currently available? What is Medicares plan? How Can You Respond Proactively? 27


    Slide 29:AHRQ Quality Indicators

    The AHRQ Quality Indicators are now being used for applications beyond quality improvement Some organizations have used the AHRQ Quality Indicators to produce web based, comparative reports on hospital quality, such as the Texas Heath Care Information Council and the Niagara Coalition. Other organizations have incorporated selected AHRQ QIs into pay for performance demonstration projects or similar programs, such as the Centers for Medicare and Medicaid Services (CMS) and Anthem Blue Cross Blue Shield of Virginia where hospitals would be financially rewarded for performance. 29

    Slide 30:Aggregate Medical Staff Profiles


    31 32

    Slide 33:Reported Medicare Data



    Slide 35:Premier Hospital Quality Incentive Demonstration


    Slide 36:RAC AND THE ED

    Managing CMI Begins in the Emergency Department 36

    Getting RACd 37

    Slide 38:Improper Payments

    Medical Necessity: Largest proportion of take-backs (40%) were related to medical necessity Improper Coding: Responsible for 35% of take-backs Other deficiencies in physician documentation: Responsible for 9% of take-backs 84% of Take-backs Related to Physician Documentation 38


    Slide 40:RAC Return on Investment

    From its inception through March 27, 2008, the RAC demonstration cost only 20 cents for each dollar collected. [5:1 ROI] RAC contingency fees were $187.2 million over the life of the demonstration. 40

    Slide 41:2 Types of Reviews

    Automatic Review A computerized analysis of claims and coding practices. An example of the type of errors identified might be where the provider billed for two units of physical therapy evaluation (a non-time-based procedure may be billed only once). Complex Medical Review Auditing personnel study the actual medical record or other documentation. Such a review could, for example, lead to a denial of payment for admission to an inpatient hospital as not medically necessary. 41

    Slide 42:Example of a Medical Necessity Complex Review Audit

    CLAIM FACTS The beneficiary presents to the emergency room with shortness of breath. EKG is normal. Chest x-ray rules out pneumonia. The hospital admits the beneficiary for a one-day hospital stay. Medical record reviews indicates no reason why the services could not have been performed on an outpatient basis. The entire inpatient claim is denied. Error Type: Medically Unnecessary 42

    Slide 43:An Excerpt From the RAC Report


    Slide 44: Sepsis and UTI and Urosepsis

    44 Secondary dx ESRD Secondary dx - ESRD F2010 RW LOS

    Slide 45:Overview of RAC Process

    Majority of RAC take-backs resulted from poorly documented medical necessity of short stay admissions, which occur most frequently through the ED RACs are directed to follow CMS guidelines and the QIO manual when performing audits Manuals state that review of physician intent is necessary when determining medical necessity InterQual criteria do not address physician intent and are, alone, an insufficient screen for medical necessity 45

    Slide 46:CMS: RACs not to conduct medical necessity reviews until 2010

    The Centers for Medicare & Medicaid Services does not expect its Medicare recovery audit contractors to conduct complex reviews for medical necessity of hospital services until 2010, agency officials recently told AHA. For this type of review, a RAC auditor retroactively reviews a Medicare claim to determine if services provided to a beneficiary were medically necessary as defined by Medicare guidelines in effect at the time of service. During CMS three-year RAC demonstration, 40% of all claims denials were for medical necessity. 46

    Slide 47:RAC Issues Approved for Region B

    Hospital Inpatient: Automated Reviews Hospital to Hospital Transfer Identified MS-DRG inpatient claims improperly reported as a discharge to home rather than as a transfer to another hospital resulting in an overpayment to the transferring hospital. When a transferring inpatient prospective payment system (IPPS) hospital indicates to Medicare that the patient is being discharged to home, the transferring hospital receives a full MS-DRG payment. In these cases, the transferring hospital should have received a per diem payment rate when transferring a patient to another acute-care facility. An overpayment exists when both hospitals (the transferring hospital and the final discharging hospital) receive full MS-DRG payments. CSW during Inpatient Hospital CSW during Inpatient Hospital: Clinical Social Workers services (CSW) rendered during an Inpatient Hospital stay are not separately payable under Medicare Part B. These services are included in the facilitys Prospective Payment System (PPS). CSW providers are expected to seek reimbursement from the facility. 47

    Slide 48:RAC Issues Approved for Region B

    Hospital Outpatient: Automated Reviews PreAdmission Testing Diagnostic services (including clinical diagnostic laboratory tests) provided to a beneficiary by the admitting hospital, or by an entity wholly owned or wholly operated by the admitting hospital (or by another entity under arrangements with the admitting hospital), within 3 days prior to and including the date of the beneficiarys admission are deemed to be inpatient services and included in the inpatient payment. Separately Paid Ambulance Service during Inpatient Hospitalization Review Ambulance transports provided by Hospital-Based Ambulance Providers and Suppliers to beneficiaries who are in an inpatient stay are the responsibility of the inpatient hospital provider with the exception of transports on the day of admission, day of discharge and during a leave of absence from the inpatient facility. Bronchoscopy Services Bronchoscopy Services - should be billed with a maximum of (1) unit per patient per date of service (outpatient hospital/physician) Once in a Lifetime Procedures Once in a Lifetime Procedures Specified procedures that can only be performed once in a lifetime per beneficiary. Untimed Codes Untimed Codes CPT codes (excluding modifiers KX, and 59) where the procedure is not defined by a specific timeframe (untimed codes), the provider should enter a one (1) in the units billed column per date of service. 48

    Slide 49:RAC Issues Approved for Region B

    Hospital Outpatient: Automated Reviews; Infusions, transfusions, injections Intravenous Infusion Chemotherapy and Non-chemotherapy - Excessive Units Reported The physician is to report only one initial service code unless protocol requires that two separate IV sites must be used. If more than one initial service code is billed per day, the carrier shall deny the second initial service code, unless the patient has to come back for a separately identifiable service on the same day or has two IV lines per protocol. Blood Transfusions Blood Transfusions should be billed with a maximum of (1) unit per patient per date of service (outpatient/physician) IV-Hydration IV-Hydration- should be billed with a maximum number of units (1) per patient per date of service Neulasta Neulasta (HCPCS code J2505) Claims submitted with the total number of milligrams instead 1 unit per 6mg. Claims for J2505 should be submitted so that the units billed represent the number of multiples of 6mg administered, not the total number of mgs. Oxaliplatin Oxaliplatin represents 0.5 mg per unit and should be billed 1 unit every 0.5 mg administered per patient per DOS 49



    The Emergency Department is the Most Important Inpatient Department in the Medical Center 51

    Slide 52: Clinical Integration Specialist (CIS) Emerging Role in the ED

    Begins in the Emergency Department Clinical documentation improvement for severity, compliance and reimbursement POA and HAC conditions reviewed and assessed Core measure review initiated Appropriate admission status established 52

    Slide 53:Clinical Integration Specialist (CIS) Emerging Role in the ED

    To be knowledgeable (based on the CDI model) Clinical knowledge (RNs) Medicare rules & regs Documentation options & impact on severity rating InterQual Criteria & Status Determinations To be efficient/timely Moving documentation support into the ED To provide the ED physician with the necessary information for correct status & to assist in capturing severity of illness through accurate documentation 53

    Slide 54:What Should the ED Physician Expect ?

    Assistance with terminology to capture severity of illness Respiratory Distress ? Acute Respiratory Failure Pneumonia ? Probable Aspiration Pneumonia Assistance with inpatient v. observation status determination Patient assessment for core measures Identification of POA (Present on Admission) conditions 54

    Slide 55:Meeting the Challenge Shifting the Burden

    Hospitals should provide the infrastructure necessary to assist the physician in providing the most accurate, concurrent, compliant documentation of the condition and treatment of each patient, and assignment of the appropriate DRG 55 Risk of poor documentation on chart Clinical risk covering physician Physician risk protect yourself Hospital risk we all go down eventually Shared risk Document non-compliant inevitably comes back to physicianRisk of poor documentation on chart Clinical risk covering physician Physician risk protect yourself Hospital risk we all go down eventually Shared risk Document non-compliant inevitably comes back to physician

    Slide 56:Physician Concerns

    How much time will this take? Goal: Reduce physician time allocated to status determination Goal: Reduce physician time identifying patient safety, POA, or core measure issues What will the physician need to do? Respond to requests for documentation clarification: Example: Dr. Smith: Based on the patients clinical findings on presentation of cyanosis, retraction, use of accessory muscles and laboratory findings (listed) could you please indicate your clinical opinion as to whether this patient presented with ACUTE RESPIRATORY FAILURE, present on admission? 56

    Slide 57:Major Roles and Responsibilities

    Assesses all appropriate admissions for POA documentation of: Pressure ulcers Vascular-catheter associated infections Indwelling urinary catheter associated infections Surgical Site infection (mediastinitis) DVT, Pulmonary embolus Risk for falls Documents assessments in the medical record Initiates core measure review as indicated for specific clinical topics AMI Pneumonia Heart Failure SCIP 57

    Slide 58:Preventing Medical Necessity Admission Denials

    Establish status (inpt/observation) at point of entry Reference most current guidelines (InterQual or Milliman) Create a documentation trail detailing appropriate status determination Provide education and tools to case management Seek physician advisor review when appropriate Consider revenue preservation with accurate status Review CMS Inpatient only list 58

    Slide 59:Impact of CC & MCC Documentation Surgical Patient 9 day LOS

    59 Secondary dx Chronic Systolic Failure Secondary dx Acute Systolic Failure Secondary dx - CHF F2009 RW LOS

    Slide 60:Impact of a Clinical Integration Specialist in the ED

    More accurate clinical documentation resulting in appropriate severity capture, accurate case mix, allowing hospitals and physicians to get credit for the severity of illness of patients treated Case mix indices match true severity and reimbursement less impacted by mis-steps on RAC and POA/HAC requirements 60

    Slide 61:Impact of a CIS in the ED

    The ED documentation and admission disposition is actively managed Enhanced communication between team members by identifying under-documented clinical conditions; Increased awareness of relevant clinical information that may go unidentified by team members not responsible for review of the entire medical record (particularly if electronic); and Admitting doctors get better picture on the details behind why and under what conditions a patient was admitted, leading to better outcomes and core measure adherence Physicians are ranked more accurately when it comes to the quality reporting such as HealthGrades, etc. 61

    Slide 62:O/E Mortality by Quarter University Medical Center Compared to UHC

    Documentation Program 62

    Slide 63:Thank You!

    Melinda Tully MSN, CCDS Senior VP Clinical Services & Education J. A. Thomas & Associates 63