Finding your lost revenue and keeping it

1

CAHs have similar services = same as OPPS

hospitals

CAHs have different claim submission rules

for outpt to inpt but documentation of

billable services are the same.

CAHs are paid differently than the OPPS

hospital, but the rule for billable services are

the same.

EXCEPTION: J codes/pharmacy are only

required for LCD/NCD drugs; G codes for

OBS. CAHS are paid by billed charges/outpt.

2

Does the order match the service that

matches the billed item/UB- the 3 step! (charge/chart audit)

Hot spots for audit:

Wastage – SDV vs MDV; SDV wastage must be

documented to bill. No ability to bill wastage with MDV.

JW modifier is NOW required, Jan 2017.(CMS pub 100-04 Chpt 17,

section 40) Nursing, pharmacy, RT, imaging, anesthesia = hot!

Original order changed after receipt.. Did

referring physician’s order change in the record?

Protocol – must be ordered pt specific(OB, LAB, Imaging, RT, pharmacy, others?

3

4

Lost Charges/Revenue

Daily Charge Reconciliation

Cost of Late Charges

And easy chart/charge audit

ideas to identify

documentation challenges and

charge alignment

Recovery – house wide – up to 4-6 hrs

Nursing services in ancillary areas

Drug Administration – Observation

OB –HBC scheduled visits, delivery

rates/levels, labor levels, unplanned

Hospital based clinics – E&M visits

Blood transfusion – house wide

Scheduled procedures done in the ER

OR – Implantables & invoice reconciliation

OR – unscheduled, interrupted/7x modifer

Ancillary – reduced/52 modifier 5

6

Department Benchmark UB04 audits: Compare 10 UB-04/billing documents against the

itemized statement– Outpt areas 1st (Obs, ER, Surgery,

Hospital based clinics/IV therapy/Chemo)

Look for potential lost charges (ER: sutures but no

procedure)

Look for billing combinations that were missed:

250/pharmacy –how was it given? IV Infusion, injection

Look for non-billable items present: Medicare outpt self

administered medications/pt pays; routine supplies

Look for descriptions that won’t pass the ‘Mom’ test

Look for charges that are not uniform across the facility

7

Not ‘new revenue’ but lost revenue

Question: “What services are we currently

not billing for or costs that we are not

covering?”

Brainstorm with department heads, compile

a master list and start looking – primarily

outpatient but limited inpt.

8

Nursing is not good at charge capture..so…

Aggressively look for ways to move ownership

with nursing still responsible for charting,

not charging: Lab – Blood Transfusions/36430. Auto have Blood

products/P + 36430 bill together. (Safety net: billing edit

to reject any claims without both 390 and 391 present.)

Charge Capture Analyst – identifies charges, completes

charge ticket and logs all lost charges due to missing

documentation. Nursing’s partnership is to ensure the

start and stop times of each bag are present. CCA ‘s

partnership is charge capture. WORKS!

9

Daily Dept-Specific Audits:

Compare scheduled/resulted/completed

patients against charges generated. (2 day

lag)

Manual schedules or automated

Registrations with no charges. Why?

Ensure each patient activity is accounted for.

10

Focus on high stress/severity of illness areas

Focus on labor intensive processes

Ask all depts to look for potential lost revenue Code Blue – how is nursing assuring charges made it

to the bill? Drugs? Supplies? 92950/Cardiac Arrest? Procedures done?

“Sticky” for supplies – nursing has them on their clothing. Who do they belong to? How many go down on the sheets?

Patient complaints – once research, corrected claim –but is research done to determine who the charge really does belong to?

Drug adm – nursing floating outside the care area. Who is completing the charge ticket?

OB – look at the aspects of outpt : ER to OB; scheduled visits; post inptdischarge/lactation HBC visit, delivery rates

Scheduled visits in the ER – bill as a HBC visit

Drop in pts for after care as an outpt – bill as a HBC visit (suture removal, follow up care)

All Drug Adm and Blood –outpt housewide

Physician orders, medically necessary services, E&M leveling for all HBC visits, incident to the physician

11

12

Rework – to the individual dept, to PFS and the pt –as they get corrected bills/EOBs

Reprocessing the claim, lost productivity

Lost Revenue with limited accountability

Decreased patient satisfaction

Track and trend repeat late activity, dept specific

Do dept heads know what a late charge is?

13

The Medicare Reimbursement Manual defines Routine Services in 2202.6 on page 22-7:

“Inpatient routine services in a hospital or skilled nursing facility generally are those services included by the provider in a daily service charge—

sometimes referred to as the “room and board” charge. Routine services are composed of two broad components: (1) general routine services, and (2) special care units (SCU’s), including coronary care units (CCU’s) and intensive care units (ICU’s). Included in routine services are the regular room, dietary and nursing

services, minor medical and surgical supplies, medical social services, psychiatric social services, and the use of certain equipment and facilities for which a separate

charge is not customarily made.

“In recognition of the extraordinary care furnished to intensive care, coronary care, and other special care hospital inpatients, the costs of routine services

furnished in these units are separately determined. If the unit does not meet the definition of a special care unit (see § 2202.7), then the cost of such service cannot

be included in a separate cost center, but must be included in the general routine service cost center. “ (See § 2203.1 for further discussion of routine services in an

SNF.)

Top At Risk Issues for Pt

Inpatient Status Audits

14

• 2 MN rule is alive and well

• AND we are looking ‘back to the future’ with an enhanced definition of ‘rare and unusual.’

• Still use the physician’s documentation of ‘why an inpt’ but if the provider cannot estimate 2 MN /Presumption –then declare an inpt with rationale for ‘severity of the condition/intensity of the care’ that will require in hospital care. HUGE AUDIT RISK!

• No change to SNF; no Short stay DRG

• Effective 1-1-16/back to the future of ‘rare and unusual’ documentation to support inpt without 2 MN/presumption.

• SEPT 2016 – QIOs are back auditing!

Effective 10-1-15 –changes in auditing short stay P&E – 0 and 1 MN stays

QIO (level 2 appeal) review 10-25 charts; denies or approves

Calls hospital to set up review

QIO tells MAC to recoup denied claim

# of denials determines referral to RAC (but not before 1-16 DOS)

MAC sends overpayment letter with appeal rights.

Then Appeal levels begin:

MAC/level 1; QIO/level 2; ALJ/level 3…

Preferred as some physician involvement at the QIO

RACs are not involved until a referral occurs – patterns of denials

Per Lavanta/QIO – 3 failed audits = referral to the RAC for auditing. (Per RI hospital, 3-16)

15

Each payer has their own set of ‘criteria’

for coverage. (United, Blues, Part C Medicare,

PEPPER/Traditional Medicare is targeting 1 day surgical, 2

day Surgical, same day medical, and same day surgery,

etc.)

Each payer has their own standards for

appeals

Each payer determines if the

documentation supports the service that

was billed.

Documentation to tell a strong pt story –but be

aware of the enhanced payer battles..Education 2016 16

Education 2016 17

ALL PAYERS

Admit to inpatient

Diagnosis

Reason for

Admit/Plan for why

an inpt (dx or

multiple dx).

**Traditional Medicare

only- Pt needs 2

MNs/Presumption or an

additional MN/Benchmark

to resolve the condition.

(Hint: Pre-created ques in the CPOE

order set = excellent)

MEDICARE ONLY

“Clarify” that the LOS is an

estimated 2 MN/Presumption

“Clarify’ that after the 1st

outpt MN, a 2nd ‘in hospital’

MN is required/Benchmark

After 1-1-15, provider still

outlines why the 2 MN, what is

the plan that will take 2 MN. No

longer ‘certify’ but still needs to

clarify the order/signed prior to

discharge and rationale for the 2

MN. (Do certify 20 day

mark/outlier)

Critical Access Hospital – must

still certify initial 96 hrs and

again, at the 96 hr mark.Education 2016 18

Does the physician clearly state: Why an inpt? What is the plan that will take 2 MN/Medicare? For non-

Medicare – why can’t the pt be treated safely as an outpt.

(Same issues as Medicare-just no 2 MN declaration)

Medicare/only-If the pt needs a 2nd MN after 1 MN as an

outpt – what is occurring with the pt’s condition that will

‘push the pt’ to stay a 2nd MN? Convert to inpt and

include: Why?

Mgd Care Medicare/PartC/Medicare

Advantage – HIGH AT RISK. What criteria are they

using? Get it in the contract! NOT SUBJECT TO

TRADITIONAL Medicare rules

Commercial Mgd Care or Commercial- who

knows? Makes their own rules for disallowed charges. 19

Managed Medicare Plans/Part C = HUGE

They do not have to adapt Traditional coverage rules.

Treat them like a Commercial Payers – get pre-certs, determine if they are using ‘2 MN’ rule methodology and/or clinical guidelines.

Update contracts to CLEARLY outline the tools used to determine: what is an inpt.

Always use: Physician order with rationale for why? (Sound familiar??)

Big increase in denials…

WHAT IS THE PAYER’S DEFINITON OF AN INPT!

2015 20

Who is the primary payer?

What are their rules for inpt?

Is this payer contracted? What are the pt status

contract terms? If not contracted, then what?

What guidelines is the payer using to support

/determine inpt? Milliman? Interqual? Neither?

Who is the provider who will write the inpt

order?

What if the payer disputes the inpt request?

What are the payer’s rules for resolving a pt

status dispute?

Does UR know ANY of the contract terms? Why

not.. 21

Pt Status – what is their definition of an inpt?

DRG Downgrades – what documentation

standards are required to allow all physician

inclusion of ALL dx the pt has and are

included in the thought process/not always

the actual treatment?

Readmissions - Related means? 30 days

when CMS does not use this standard.

Preventable means? Hint – all must be in the contract! Usually silent.

22

CLEARLY –At the point of

conversion – WHY AN INPT for

a 2nd MN? Then if d/c early –

what unexpected?

2midnight presumption

“Under the 2 midnight

presumption, inpt hospital

claims with lengths of stay

greater than 2 midnights after

formal admission following the

order will be presumed

generally appropriate for Part

A payment and will not be the

focus of medical review efforts

absent evidence of systematic

gaming, abuse or delays in the

provision of care.Pg

Benchmark of 2 midnights

The new Medicare Inpt

“the decision to admit the

beneficiary should be based on

the cumulative time spent at

the hospital beginning with the

initial outpt service. In other

words, if the physician makes

the decision to admit after the

pt arrived at the hospital and

began receiving services, he or

she should consider the time

already spent receiving those

services in estimating the pt’s

total expected LOS. Pg 50956

2015 23

EX) Pt is an outpt and is receiving

observation services at 10pm on

12-1-13 and is still receiving obs

services at 1 min past midnight on

12-2-13 and continues as an outpt

until admission. Pt is admitted as

an inpt on 12-2-13 at 3 am under

the expectation the pt will require

medically necessary hospital

services for an additional

midnight. Pt is discharged on 12-3

at 8am. Total time in the hospital

meets the 2 MN

benchmark..regardless of

Interqual or Milliman criteria.

ER, Observation, outpt surgery =

all included in the 2 MN

Benchmark.

Ex) Pt is an outpt surgical

encounter at 6 pm on 12-21-13 is

still in the outpt encounter at 1

min past midnight on 12-22-13 and

continues as a outpt until

admission. Pt is admitted as an

inpt on 12-22 at 1am under the

expectation that the pt will

required medically necessary

hospital services for an additional

midnight. Pt is discharged on 12-

23-13 at 8am. Total time in the

hospital meets the 2 MN

benchmark..regardless of

Interqual or Milliman criteria.

2015 24

NSETMI: “ According to the 2 MN, the

admission status is determined by the

expectation of care crossing 2 MNs and the

need to be ‘in hospital.’ In our facility, if

the pt comes in under the wire such that he

can have the cath that same day, he will

only cross one MN before discharge,

therefore, is discharged (as an outpt.)

However, if he comes in and crosses a MN

before the cath (stabelizing), the cath is

done the next day and the pt is discharged

the following day (thus care crossing 2 MNs

in hospital ) – then the pt is an inpt.

This is why I have taught the staff to pay

close attention to when a pt started

receiving medical care to determine if the

NSTEMI should be placed as inpt or outpt

obs.

In our facility, therefore some NSTEMI are

inpts (because the care crossed 2 MNs based

upon their time of presentation) and some

are observation –(unplanned event needing

beyond routine recovery /de) – because they

had their cath on the same day of

presentation..did not cross 2 MN.”

RAC RELIEF Debbie Jones, MD 2-19-16

RARE AND UNUSUAL: “I think the

‘exception’ to the 2 MN rule for ‘rare and

unusual’ circumstances is a land mine

waiting for a hospital to step on. As I have

pointed out before, how can a hospital

make a case that inpt care is required based

on clinical presentation when CMS/Medicare

says inpt and outpt care is distinguished only

by LOS? The only exception CMS has

acknowledged so far is unplanned

mechanical ventilation and they said its

because these cases usually required more

than 2 MNs.

Complete this sentence without implying

that there’s a difference between inpt and

outpt care: “This pt required inpt care

regardless of the anticipated LOS

because….” I say it can’t be done. That is

why CMS won’t give an example. There isn’t

one and they won’t admit their mistake

either.

If the pt needs ‘inpt care’, it’s going to be a

patient who needs more than 2 MNs. If less

than 2 MNs, why didn’t you order obs?”

RAC RELIEF Dr Steven Myerson 2-20-16

Education 2016 25

2 MN presumption: ALWAYS ensure there is a clinical plan for why the

pt needs 2 MN at the first point of contact. The plan is key!

Ensure the ER provider and the Hospitalists or attending AGREE on the plan..

Handoffs need evaluated to ensure consistency. UR and PA involved.

The care is then documented – with nursing and the provider – documenting the

course of treatment/progression of care as it relates to the plan.

SURPRISE: Clearly document the patient’s unexpected recovery; unexpected

transfer out; unexpected response to treatment. Then, a beautiful inpt.

2 MN benchmark: ALWAYS ensure there is a clinical plan for why a 2nd MN was

medically appropriate/in hospital care after an outpt 1st MN. The plan is the key !

The hospitalists/attending and UR need to communicate closely as the 2nd MN

approaches… DO NOT WAIT UNTIL the am of the 3rd day.

CAREFUL not to convert early on the 2nd day and then discharge same day…no 2nd

MN. What was the plan? Was it met early?

Note: Order takes effect when written. EX) Day 3 am, doctor converted to inpt.

10 mins later, discharged. How was the plan met in 10 mins?

26

After the 1st MN as an outpt – anywhere – or the

first MN in another facility and transferred in –

“The decision to admit becomes easier as the

time approaches the 2nd MN, and the

beneficaries in necessary hospitalization should

NOT pass a 2nd MN prior to the admission order

being written.’ (IPPS Final rule, pg 50946)

Never, ever, ever, ever have a 2nd medically

appropriate MN in outpt..convert, discharge or

free…

2015 27

If the beneficiary has already

passed the 1 midnight as an

outpt, the physician should

consider the 2nd midnight

benchmark met if he or she

expects the beneficiary to

require an additional midnight

in the hospital. (MN must be

documented and done)

Note: presumption = 2

midnights AFTER obs. 1

midnight after 1 midnight OBS

= at risk for inpt audit but still

an inpt.

Pg 50946

..the judgment of the physician

and the physician’ s order for inpt

admission should be based on the

expectation of care surpassing the

2 midnights with BOTH the

expectation of time and the

underlying need for medical care

supported by complex medical

factors such as history and

comorbidities, the severity of

signs and symptoms , current

medical needs and the risk of an

adverse event. Pg 50944

2015 28

It never has and never will mean – “meeting clinical

guidelines” (Interqual or Milliman)

It has always meant – the physician’s documentation to

support inpt level of care in the admit order or admit

note.

SO –if UR says: Pt does not meet Criteria – this means:

Doctor cannot certify/attest to a medically appropriate 2

midnight stay – right?

11/1/2013 Section 3, E. Note: “It is not necessary for a

beneficiary to meet an inpatient "level of care" by

screening tool, in order for Part A payment to be

appropriate“

Hint: 1st test: Can attest/certify estimated LOS of 2

midnights? THEN check clinical guidelines to help clarify

any medical qualifiers… but the physician’s order with

ROA – trumps criteria.RAC 2014 29

Transfer update: During MedLearn call

(2-26-14) CMS updated: receiving

hospital CAN count time at a sending

hospital toward their own 2 MN

benchmark.

Q2.2: How should providers calculate

the 2-midnight benchmark when the

beneficiary has been transferred from

another hospital?

A2.2: The receiving hospital is allowed

to take into account the pre-transfer

time and care provided to the

beneficiary at the initial hospital. That

is, the start clock for transfers begins

when the care begins in the initial

hospital. Any excessive wait times or

times spent in the hospital for non-

medically necessary services shall be

excluded from the physician's

admission decision."

Sending hospital – if there is

knowledge that the pt is being

transferred/next day, the pt is

obs as only 1 MN is appropriate in

the sending hospital

Use Occurrence Code Span

72/field to identify the date of

the 1st MN/sending hospital.

Place the date on the Inpt UB

that may only have 1 additional

MN for the receiving hospital.

2 MN Benchmark is now present

on the 1 MN UB from the

receiving hospital.

Reference: SE1117revised

MLNMatters

“Correct provider billing of

admission date and statement

covers period.”2015 30

5PC01 Documentation does not support services

medically reasonable/necessary

5PC02 Insufficient documentation

5PC12 Order missing

5PC13 Order unsigned

5PC15 Certification not present

5PC17 No documentation of 2-midnight expectation

J5

J8

312015

Denial Reason % Denials JH % Denials JL

Documentation did not support two

midnight expectation (did not support

physician certification of inpatient

order)

56% 53%

No Records Received 16% 17%

Documentation did not support

unforeseen circumstances

interrupting stay

4% 3%

No inpatient admission order 9% 15%

Admission order not validated/signed 11% 11%

Other 4% 1%

322015

1st round:

35% denial rate

REASONS:

55% failed to document need

for 2 MN

45% failed admission order

requirements

48% signed after discharge

39% order missing from the record

13 % order not signed

2nd round:

36% denial rate

REASONS: 40% failed to document need

for 2 MN

60% failed admission order

requirements

35% order missing from record

17% order not validated

8% order not signed (as of 2-11-15)

MAC recommendations:Providers document their

decision making process.

Paint a clear, concise

picture of the pt.

2015 33

Begin with the 1st point of contact – ER,

direct or Surgery

Why is the pt not safe to be discharged/ED?

Why is the surgery an inpt if the CPT is not

on the inpt only list? (Medicare only)

What provider laid out a plan for why 2 MN

for a direct admit to the floor? Did the

hospitalist see the pt immediately? Did UR

talk to the ordering provider?

Who is validating status for transfers in? Who

is asking both the sending and the receiving

the 2 MN question? Count 1st in sending.34

35

Day Egusquiza, Pres

Daylee1@mindspring.com

208-423-9036 Free Info Line

www.arsystemsdayegusquiza.com

“Finding HealthCare Solutions… together”

36

At least quarterly, take a small sample and compare orders, against documentation of service, against actual billed service against the UB.

Ensure they all match –consider:

Protocol vulnerabilities

LCD/NDC limitations

Physician orders present

Documentation to match the order

Severity of illness /doctor w/intensity of services/nursing - inpt

Evaluate the impacts of the hybrid medical record

DEVELOP CORRECTIVE ACTION with compliance

37

38

For charge capture to work, each

individual must understand their role in

the process.

Explore observing each area, 24 hr shift

Develop charge capture internal manual –

addressing manual process, order entry,

and other, more unique processes – pods,

HIM, etc.

Develop feedback process for Dept-

specific auditing

39

Using the ongoing department-specific audits, create tracking systems/T-N-T Accuracy of claims

Revenue identified

Lost charges lost no more!

New understanding of ownership

Change of culture

REPORT progress at Dept head meetings

40

Diagramming the process flow for updating, changing, etc. the CDM-including assessment the volume of items for activity

level.

Reviews all new or change items to the CDM with a focus on standardizing like items, looking throughout the organization for other areas providing similar services and educating on

same. (Focus on Routine supplies)

Providing yearly department head education on CDM issues.

Like-Item Pricing audits – as new items are added to specific area.

FOCUS ON PATIENT FRIENDLY and SIMPLIFY!