Cahaba GBA’s 2014 Medicare Expo

August 6-7, 2014 – Chattanooga, TN

Two Midnight Rule

Presented by: Cole Williams, RN, BSN

Disclaimer

This resource is not a legal document. The presentation was prepared as a tool to assist providers and was current at the time of creation.

Responsibility for correct claims submission lies with the

provider of services. Reproduction of this material for profit is prohibited;

providers are encouraged to share this education with staff.

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Topics

• Medical Review • Comprehensive Error Rate Testing (CERT) • Two Midnight Rule • Resources

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Preventing Improper Payments

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The Affordable Care Act of 2010

• Proposals to protect the Medicare Trust Fund • Authority to recover overpayments

Social Security Act

• Sections 1833(e), 1842(a)(2)(B), and 1862(a)(1)(A)

Centers for Medicare and Medicaid Services (CMS)

• Protect the Medicare Trust Fund • Identify inappropriate payments • Take corrective actions

Payment Accuracy: www.paymentaccuracy.gov/about-improper-payments

Medical Review Goal

Reduce payment errors by identifying and addressing billing errors related to coverage and coding of services

Data Driven

o Indentify vulnerabilities o Identify questionable billing patterns o Prevent and/or address provider errors o Reduce paid claims error rate o Publish Local Coverage Determinations (LCD)

Medical Review and Education - Overview: www.cms.gov/Medical-Review/ Program Integrity Manual - Pub. 100-08 - Medical Review Program:

www.cms.gov/manuals/downloads/pim83c03.pdf

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Comprehensive Error Rate Testing (CERT)

Documentation Contractor

Reviews Medical Records

Requests Medical Records

Protect, Measure, Assess, Evaluate CERT

Review Contractor

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Part A Review-All States: February 2014

Service Error Rate Denial Rationale Action Required

Al , GA, TN-Short Term Hospitals- Condition Code 07

33.60%

High Dollar Amount

Per Pub 100-04, Ch. 11 Medicare Claims Processing Manual (Processing Hospice Claims) § 50 Billing and Payment for Services Unrelated to Terminal Illness.

Services related to a hospice terminal diagnosis provided during a hospice period are included in the hospice payment and are not paid separately.

Condition code 07 should be used for any Medicare covered services not related to the treatment of condition for which hospice was elected.

Fiscal Year 2014 Inpatient Rule

2014 Hospital Inpatient Prospective Payment System (IPPS)

• Update for 2014 Medicare payment policies for inpatient stays • General Acute Care • Long Term Care Hospitals (LTACHs) • Inpatient Psychiatric Hospitals • Critical Access Hospitals (CAHs)

• Goal is to improve value and quality in hospital payments

• Provides clarification about when a patient should be admitted to the hospital

• Addresses concerns regarding extended Medicare Beneficiary stays in the hospital outpatient department

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Two Midnight Rule

Medicare Part A payment will be presumed appropriate if:

• Physician expects the patient’s treatment to require hospital stay exceeding a two midnight benchmark or requires a procedure on the inpatient only list

• Admits patient based on that expectation

• Formal physician order is required to begin inpatient status

• Physician Certification

• Clear Documentation supporting medical necessity of admission and expectation

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Two Midnight Rule Any stay less than 2 midnights after inpatient order:

• Allows physician to consider all time patient has spent in the hospital as outpatient in guiding their two midnight expectation • Observation • Emergency Room • Operating Room • Other Treatment Area

• Applies to admissions with dates of service on or after October 1, 2013

CMS Issues FY 2014 Inpatient Payment Rule http://www.cahabagba.com/news/cms-issues-fy-2014-inpatient-payment-rule/

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Two Midnight Rule Inpatient Order Requirements

• Required for inpatient coverage and Part A payment • Inpatient status begin when order is written • Must specify admission to inpatient status • No retroactive orders allowed

Who may write the order?

• Physician or other practitioner o Licensed by State to admit patients oGranted admitting privileges in the hospital o Knowledgeable about the hospital course, medical plan

of care, and current condition at the time of admission oNon-Physician practitioner would still need co-

signature if incident to ordering physician

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Two Midnight Rule Non-Physician Practitioners/Residents

• No admitting privileges

o May under state laws or hospital by laws write initial orders to initiate inpatient admission

o Order must be documented following collaboration with ordering physician

Must identify the qualified physician Qualified physician must co-sign order before discharge Authenticated order by qualified physician will satisfy order part of

the physician certification as long as he/she meets requirements for a certifying physician

• Example: • Admit to inpatient per Dr. Smith • Admit to inpatient v.o./t.o. Dr. Smith

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Two Midnight Rule

Physician Certification

• Condition of payment

o Required for Part A payment under section 1814(a) of the Social Security Act

o Indicates that inpatient services were medically necessary

• Content

o Authentication of physician order o Reason for inpatient services o Estimated time required in hospital o Plan for post-hospital care if appropriate

Physician Order and Certification Requirements http://cms.gov/center/provider-type/hospital-center.html

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Two Midnight Rule Physician Certification (cont)

• Authorization to sign certification

o A physician who is a doctor of medicine or osteopathy o A dentist in the circumstances specified in 42 CFR 424.13(d) o A doctor of podiatric medicine if his or her certification is

consistent with the functions he or she is authorized to perform under State law

All of which are responsible for case or by another physician with knowledge of the case and is authorized by the responsible physician or hospital’s medical staff

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Medical Record Documentation • All entries in the medical record must be complete in order to:

o Justify admission o Justify continued hospitalization o Support the diagnosis o Describe the patient’s progress o Describe the patient’s response to medications; and medical intervention

• All entries in the medical record must be legible o Illegible entries in the medical record may be misread or misinterpreted o Misread or misinterpretation could lead to medical errors or other

adverse patient events

• All entries in the medical record must be dated, timed, and signed o By the individual that provided or evaluated the service o Handwritten or electronically

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Two Midnight Rule Reviewing Hospital Claims for Inpatient Status

• General Rule for 0-1 Midnight stays

o Inappropriate for inpatient admission if estimated length is between 0-1 midnight stays regardless of the time the patient arrived or if they used a bed o Exception

o Inpatient only List oUnforeseen Events oRare and Unusual Circumstances

o Medicare Administrative Contractor will deny these inappropriate admissions as directed by CMS unless these exceptions apply.

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Two Midnight Rule

Reviewing Hospital Claims for Inpatient Status

• Short Stay Admissions o Less than two midnights o May be appropriate for Part A payment if unforeseen

circumstances results in a shorter stay than the physician’s reasonably expectation of two midnights Death Transfer to another hospital Discharged against medical advice (AMA) Clinical Improvement Hospice Election

o Rare and unusual circumstances

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Two Midnight Rule Rare and Unusual Circumstances

• Newly Initiated Mechanical Ventilation o Excludes anticipated intubations related to minor surgical

procedures or other treatment

o CMS does recognize that additional rare and unusual circumstances exist that have not been identified

o For suggestions to additional rare and unusual circumstances, please email CMS at IPPSAdmissions@cms.hhs.gov o Subject: “Suggestion exceptions to the two midnight rule”

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Scenario Example • 70 y.o. male enters the emergency room for shortness of

breath on 01/03/2014. Patient is triaged and placed in one of the ED rooms at 11:00 p.m. Shortly after, patient is evaluated by physician at 11:15 p.m. Physician writes the order to admit patient as IP after a chest x-ray determined patient has a dx of pneumonia. MD expects patient to be in the hospital past two midnights. He receives IP services and is discharged on 01/07/2014.

• Since the MD expects patient to receive medical necessary services for at least two midnights based on his condition, then Part A payment for inpatient will be presumed appropriate. (Notice: Patient stayed past two midnights after IP order was written).

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Scenario Example • 45 y.o. female went to the emergency room on 1/2/2014

with complaint of chest pain. Hx of HTN, Smoking and Stents. She was triaged and placed in a ED room at 03:00 p.m. Began receiving services. Cardiac enzymes were ordered. Physician wrote an order to admit patient as observation to the unit at 05:00 p.m. Patient is receiving observation services on floor past midnight. The next morning, 1/03/2014, physician evaluates patient and decides to admit her as IP based on results of cardiac panel.

• The patient was in observation status for one midnight. Per CMS guidelines, Physician appropriately assessed her condition the following day and determined she needed IP care, in which he wrote the order for admission. This way, the two midnight benchmark will be met when reviewed if she stays past the 2nd midnight.

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Scenario Example • Patient comes into ED and is observation from 9am to

12 noon. Patient is admitted inpatient and then discharged later that day. The UR reviews and determines that this needs to be a re-bill. How are we supposed to bill when it is the same date of service?

• Under A/B rebilling, you can bill a 121 and 131 with the same date of service. You will need to bill the 121 claim first and let it finish processing. Once it has completed processing, then bill the 131 TOB.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-

MLN/MLNMattersArticles/downloads/MM8445.pdf

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Updates Two Midnight Benchmark for:

• Hospital to Hospital Transfers

• Off Campus Emergency Department

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Updates Three Day Qualifying Stay-SNF

• If patient is receiving medically necessary services: • Appropriate for the patient to remain in hospital

• Bed available at SNF • Not appropriate to hold patient for the sole purpose

of qualifying for 3 day qualifying SNF stay if patient is not receiving medically necessary care

• Bed not available at SNF • It is appropriate for patient to remain in hospital

until bed is available

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Probe Review

Two Midnight Benchmark Review: • For stays less than two midnights after formal inpatient order is

written: o Subject to Medical Review BUT

• Cahaba GBA Medical Reviewers will consider the time the patient spent receiving ER, Outpatient, or Observation services in determining if two midnight benchmark was met o Clock begins when patient begins receiving services

Triage activities such as checking vital signs does not count Waiting period in the ER does not count Must be receiving medically necessary services responsive to

the patient’s clinical presentation

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Probe and Educate

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Patient Status Reviews • Extended until March 31, 2015

• Pre-Payment Review o 10 claims for most hospitals o 25 claims for larger hospitals

• ADR letters will be sent out via mail or electronically in FISS o Edit number 5Pxxx will be listed on the ADR

• Providers will receive a summary letter explaining each denial

• Cahaba GBA will offer 1:1 education and will repeat the probe process if necessary

Probe and Educate Process-Article http://www.cahabagba.com/news/update-probe-educate-process/

Probe and Educate Patient Status Reviews

• Reviews conducted by MAC’s to determine hospital’s compliance with new rule o Focuses on appropriateness of inpatient treatment

versus outpatient treatment

• Hospital’s compliance will be assessed by the following three criteria:

1. Admission order requirements 2. Certification requirements 3. Two midnight benchmark

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Probe and Educate • Updated Guidance-01/30/2014

o Inpatient Probe and Educate Claims oRe-Openings oAppeals

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Probe and Educate

• Common issue with compliance o Documentation of expectation of two midnight stay

oDocumentation related to patient’s illness that caused the physician to expect that inpatient admission

o Remember: Document, Document, Document o “If it is was not documented, then it was not done”

oDenial

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Denials

• Inpatient Admission o Not reasonable and necessary

• Part B Billing o Inpatient o Outpatient

o 3 day payment window

• Timely Billing Guidelines o 1 year from date of service 28

Probe and Educate

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Please Take Our Survey

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Resource

• Centers for Medicare and Medicaid Services: Inpatient Hospital Review

http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/InpatientHospitalReviews.html

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Questions

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The Part A Provider Outreach and Education staff would like to thank

you for participating in today’s event.

Provider Contact Center: 1-877-567-7271

Thank You