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Briefings on HIPAA, November 2016

HIPAA enforcement

Small breaches could become a big problem

In a year of high-profile, multimillion dollar settlements for large HIPAA breaches, OCR raised the stakes in a big way?by taking a harder line on small breaches. OCR announced plans to crack down on smaller breaches?those affecting fewer than 500 individuals?in August. Although all breaches must be reported to OCR, generally only breaches affecting 500 or more individuals are regularly investigated, while small breaches are investigated only as resources permit. OCR instructed its regional offices to increase investigations of small breaches to discover the root causes. Identifying common root causes will help the agency better measure HIPAA compliance throughout the industry and address industrywide compliance gaps, OCR said. Regional offices may obtain corrective action if an investigation of a smaller breach reveals noncompliance.

Regional offices were instructed to take several factors into consideration when investigating smaller breaches and determining potential corrective action. These are:

  • The size of the breach
  • Whether a single entity reports multiple small breaches with a similar root cause
  • Whether the breach involves theft or improper disposal of PHI or hacking

 

A closer look

OCR has come under fire for its handling of small breaches. In late 2015, a joint Pro Publica/NPR investigation analyzed federal data on HIPAA complaints and requested documents from OCR, including letters sent to entities that were the subject of HIPAA complaints (www.propublica.org/article/few-consequences-for-health-privacy-law-repeat-offenders). The investigation identified the top serial HIPAA violators, including the Department of Veterans Affairs and CVS. OCR generally responded to these complaints by sending letters reminding the entity of its obligation to protect patient privacy and follow HIPAA, and warned that if OCR received another complaint it may take more serious action. However, OCR rarely took any further or more serious action.

One reason could be that many of these breaches affect fewer than 500 individuals. Both large and small breaches must be reported through OCR’s web portal (www.hhs.gov/hipaa/for-professionals/breach-notification/breach-reporting/index.html) but there are different deadlines for reporting each and, previously, they were not equally prioritized by OCR.

But that asymmetric enforcement policy left many frustrated and means that OCR may be missing data vital to creating an overall picture of HIPAA compliance and effectiveness. An NPR report released in conjunction with Pro Publica’s investigation revealed the lasting and personal harm done by small breaches (www.npr.org/sections/health-shots/2015/12/10/459091273/small-violations-of-medical-privacy-can-hurt-patients-and-corrode-trust).

Massive breaches caused by hackers will put patients at risk for medical and financial identity theft, but, considering the amount of personal data stored by entities across all industries and the sheer number of data breaches, it’s difficult to tie a specific breach to identity theft (see the July and August issues of BOH for more information on breaches and medical identity theft). Small breaches, however, often expose PHI to people in the community the patient lives and works in, leaving the patient at risk for far more personal harm.

But OCR hasn’t ignored all small breaches. In July, the agency reached a $ 650,000 HIPAA settlement with Catholic Health Care Services of the Archdiocese of Philadelphia (CHCS), a business associate (BA), for a 2014 breach affecting 412 individuals after an unencrypted mobile device was stolen (www.medicarecompliancewatch.com/news-analysis/business-associate-agrees-650000-hipaa-fine).

The agency’s strong action may have been spurred by CHCS’ long-standing organizationwide HIPAA noncompliance. CHCS hadn’t conducted a risk analysis since September 23, 2013, the compliance date of the Security Rule for BAs, and therefore had no risk management plan. CHCS also lacked any policies regarding the removal of mobile devices from its facility. OCR suggested that, due to CHCS’ widespread neglect of basic security measures, the fine could have been even higher and only a consideration of the role CHCS plays in delivering care to at-risk populations, including the elderly, disabled individuals, and individuals living with HIV/AIDS, tempered its decision.

Getting perspective

Implementing OCR’s directive may be a tall order for resource-strapped regional offices and it’s difficult to predict what the outcome will be, Kate Borten, CISSP, CISM, HCISSP, founder of The Marblehead Group in Marblehead, Massachusetts, says.

"I’m not sure it’s actually going to make a huge difference, but I think, from the beginning, those of us who were watching HIPAA enforcement were concerned that, while HHS had good intentions, they just didn’t have the resources," she says.

That’s not surprising: HHS is a huge department with many major priorities, including CMS. But, given that HHS and OCR work with limited resources, the new focus on small breaches could be a significant sign of things to come, Borten says. The agency likely recognizes that small breaches are a huge unknown: There’s no "Wall of Shame" for small breaches and little in the way of accountable reporting.

"I just have the sense that there’s an enormous volume of under 500 breaches that get reported that we don’t hear much about," she says. "So I think it’s very important that they take this step."

Some organizations may have been inclined to brush off small breaches: 499 patients is still shy of the 500 mark, she points out, and an organization could easily add it to the end of the year small breach report and forget about it. Those organizations are the ones that will be in for the biggest wake-up call. "Hopefully they’ll hear this and they’ll think again," she says.

Large breaches often grab the headlines, and with good reason. But massive incidents like the Anthem breach may not provide the most useful data for either OCR or other covered entities (CE) and BAs. Massive breaches are statistically unlikely, according to a June 2015 report by researchers at the University of New Mexico and the Lawrence Berkeley National Laboratory (www.econinfosec.org/archive/weis2015/papers/WEIS_2015_edwards.pdf).

"Certainly, you could get hit by one of those big ones," Borten says. "But it’s much more likely, far more likely, you’re going to suffer smaller breaches."

Big breaches come with the risk of big settlements. OCR makes a point of publicizing HIPAA breach settlements and putting the dollar signs front and center. This year alone the agency has levied millions of dollars in HIPAA settlements fines for large breaches. But even as HIPAA breach settlement fines are getting bigger, the numbers don’t stack up against the amount of breaches that are reported each year. Many more organizations get away with little more than a strongly worded letter from OCR. A multimillion dollar fine may be significant for most organizations, but the odds are currently in their favor, Rick Kam, CIPP/US, president and co-founder of ID Experts, says.

"The likelihood that an organization will get fined is so low," he says. "They only catch the big ones, but there are millions of others that are losing data everywhere because nobody’s looking at them."

Too often, organizations assume that if the volume of patients affected by a breach is low, the impact is also low, Borten says, and that’s simply not true. Even a breach involving a single individual’s record can have serious consequences.

As physician practices and local hospitals are absorbed into large corporate health systems, executive perspective on small breaches can become even more skewed, Borten cautions. Executive officers overseeing multiple hospitals, clinics, and physician practices may be more interested in overall numbers and the big picture. A clinical summary handed to the wrong patient at a physician office across the state may simply not register and the impact on the patient will be invisible.

But it’s the duty of privacy and security officers to avoid making that same mistake, she says. "They should be wiser than to fall into that thinking. It falls to them to take a case to the senior leadership or the board of directors and make them recognize that it isn’t just the big breaches," she says. "We worry about the little ones, too."

Privacy and security officers should help provide C-suite the perspective to recognize small breaches and give them the proper weight. A small breach can be just as serious as a large one, Borten says. If an employee posts a patient’s PHI on a social media site, for example, the organization could find itself fighting a lawsuit; even if the case is dismissed, direct legal expenses and time and resources spent preparing documents add up fast. And, as the NPR report showed, it’s not only the patient’s reputation in the community that may suffer; an organization can easily earn a reputation as careless and unconcerned with its patients’ well-being after a small breach.

Small breaches, little data

Because small breaches aren’t investigated to the same standards as large breaches, it’s difficult to measure just how HIPAA-compliant most organizations are and what the real HIPAA pain points are. Another problem is the underreporting of small breaches, Borten says. In 2013 when the HIPAA omnibus rule was released, HHS strengthened the language describing what constitutes a reportable breach. However, HHS also commented at the time that it was concerned there was a significant amount of underreporting. Borten says her experience working with CEs and BAs proves HHS was right to be concerned.

"I think there’s a tendency for underreporting to be more common when there are just one or two patients involved," she says.

In the early days of HIPAA breach notification, some may have been under the impression that CEs and BAs were not required to report breaches affecting fewer than 500 individuals at all, she adds. But that’s never been the case. Although large and small breaches are reported to OCR according to different systems and time frames, organizations are required to treat any breach the same regarding notification to patients.

 

Adding up

Small breaches are likely more typical than large ones, Kam says. Since 2009, roughly 230,000 breaches have been reported to OCR. But only approximately 1,000 have been breaches affecting over 500 individuals and subject to the more stringent investigation procedure. Investigating all HIPAA breaches would be a daunting task for any agency, but by almost exclusively looking at large breaches, OCR left the door open for repeat HIPAA offenders. Small breaches are reported to the agency at the end of the year, but each breach is counted separately, meaning an organization could experience multiple small breaches that add up to well over 500 individuals affected?yet still not be investigated because no single breach hit the 500 mark.

"It turns out that for breaches in healthcare, most of the time, the record count is under 500 records," Kam says. "So you have these organizations that are breaching multiple times and not really correcting the situation because it doesn’t get highlighted or investigated."

OCR’s instructions to its regional offices appear aimed to close that loophole. Along with phase two of the HIPAA audit program, this could be a sign that OCR is getting serious about collecting facts on HIPAA compliance in the real world and improving education and enforcement. The agency might be realizing that it’s time to change if it expects organizations to take HIPAA compliance seriously.

"If you’re seeing the same problem over and over, you’ve got to do something to change," Kam says. "So far, nobody’s listening."

 

Data breaches

The cost of a data breach

Complicated Medicare, Medicaid, and private insurer reimbursement rules can easily throw a hospital for a loop and leave it running dangerously low on revenue. An organization’s leaders know they must work better and smarter and make strategic investments that will pay off in savings, while privacy and security officers may sometimes struggle to make the connection between their concerns and those of leadership.

But sound information security programs act as a kind of insurance: money spent up front to protect against an even greater financial loss down the road. Getting that message across can be challenging, but may transform the way an organization approaches information security.

Getting the numbers

Prevention is better than a cure, but privacy and security officers will be expected to back up conventional wisdom with hard numbers. So just how much does a data breach cost on average? The answer depends on the industry, according to the Ponemon Institute’s 2016 Cost of Data Breach Study: Global Analysis (www-03.ibm.com/security/data-breach). The study, sponsored by IBM Security, tracks and analyzes data breach costs and mitigation factors in industries around the world. The average per record cost of a data breach is $ 158 in the U.S., but in the healthcare industry that cost is more than double that at $ 355 per record. That can add up quickly if an organization experiences multiple breaches a year.

Several factors play into the higher costs seen in the healthcare industry, Diana Kelley, executive security advisor at IBM Security, says. Highly regulated industries such as healthcare typically see higher costs for breaches in a combination of fines and administrative costs.

"Whenever there’s a fine coming into play, that could lift up the total cost of recovery post-breach because in addition to all of the work you have to do to eradicate the threat, help your customers, and deal with the cleanup and recovery, you have to pay these fines," she says.

A surprising factor driving breach costs is the cost of breach notification. At more than half a million dollars, the U.S. has higher breach notification costs than any of the other countries in the 2016 Ponemon survey. The U.S. has strong data breach notification laws, Kelley says, and there are both federal and state breach notification laws that organizations must comply with.

What drives that cost? Simply the price of first class postage can quickly add up when breach notification letters must be mailed to hundreds or even thousands of affected patients, Kate Borten, CISSP, CISM, HCISSP, founder of The Marblehead Group in Marblehead, Massachusetts, says. In fact, the rising cost of postage is one way state and federal governments hope to encourage organizations to spend money on prevention rather than remediation.

"The threat of such costs is intended to be a deterrent to lax security and to spur healthcare organizations to do their best to avoid breaches," Borten says. "Some breaches are not avoidable, but many or most are with better, yet still reasonable, security."

Some organizations may only look at fines when calculating how much a breach could cost, but by overlooking the seemingly smaller costs of a breach they may be missing the bigger picture. Breach notification is only one of the smaller individual and indirect costs of a breach that can add up to significant losses. Legal fees, security forensics, and any necessary security replacements or upgrades are only some of the indirect costs. Indirect costs may not be immediately apparent but they hit an organization’s bottom line all the same, Borten says.

"The indirect costs of a breach are probably not well understood by many healthcare organizations, especially smaller organizations that don’t have a good grasp of the Breach Notification Rule and a comprehensive incident response program," she says.

 

The value of a medical record

Information security may not be a traditionally strong point for some healthcare organizations. Previously, financial and retail organizations were hot targets for hackers after identity and financial information, but healthcare is quickly overtaking those industries. In comparison to the financial industry, healthcare isn’t known for strong security, Borten says.

"One reason is that organizations have been slow to recognize the value of their data. After all, it’s not like money in a bank account or credit card details that can be used for financial identity theft," she says. "Ironically, healthcare data now has a much higher street value than credit card information."

Healthcare organizations are in a unique position because of the amount of data they hold. A retail organization like Target, which experienced a massive data breach in 2013, likely only stores payment card information and mailing addresses, but most healthcare organizations also store insurance information along with sensitive details of an individual’s health. A 2015 survey by the Ponemon Institute and the Medical Identity Fraud Alliance (MIFA), the Fifth Annual Study on Medical Identity Theft, found that more than two million adults were the victim of medical identity theft and fraud in 2014 and according to Ann Patterson, senior vice president and program director of MIFA, that number will only go up.

That prediction may be supported by some of the biggest breaches this year. In July, a hacker offered millions of patient records for sale and posted samples of the records, showing names, contact information, and Social Security numbers, so interested buyers could verify the records. Other incidents this year have seen hackers offering similar teasers. Some of that data is bound to fall into the wrong hands and be used for financial and medical identity theft. Medical identity theft can cost an individual more than $ 13,000 on average, according to the 2015 MIFA/Ponemon survey, but healthcare organizations inevitably wind up absorbing some of the cost in bad debt. (For more on medical identity theft, see the July and August issues of BOH.)

 

Timing and teamwork saves money

The 2016 Ponemon study drew a link between the cost of a data breach and the time and manner in which an organization responds to the breach. The longer it takes an organization to detect a breach, the more it costs?approximately $ 1 million more per incident, the survey shows. The average overall cost of a breach that took a mean time to identify of less than 100 days was $ 3.2 million, while those that took more than 100 days to be identified cost an average of $ 4.38 million. The time it takes an organization to contain a breach also impacts the overall cost, according to the study.

Having a security incident response team in place lowered the costs. An organized, planned team can act quickly to identify, contain, and remediate breaches, key factors in keeping breach costs down, Kelley says. And that can give a clear picture of the actual return on investment for security in terms that the C-suite will easily understand. "If you’re trying to argue for incident response and building out the incident response plan or growing that team, here’s some real dollar value that you could tie to what the return on investment could be," she says.

Participation in threat sharing also showed a clear win for organizations. Threat sharing can give organizations a heads up on the latest and most common threats and help them make smart security investments and strategic threat reduction measures.

"This is becoming very important in healthcare as it is in all industries," Kelley says. "The attackers are very organized and collaborative: they’re sharing data, they’re sharing their tips and tricks with each other so they can get data more effectively."

If information sharing is winning for the bad guys, it can do the same for the good guys, she adds. Cyber threats shift quickly, making real-time or near-real-time information crucial. Organizations can share information on threats, like suspicious websites and server addresses that launch phishing attacks, and tips on shutting them down. But some may hesitate to engage in information sharing out of concern that it may expose sensitive business and security information.

An IBM study released in February looked at the C-suite’s attitudes and actions on cybersecurity (www-03.ibm.com/press/us/en/pressrelease/49100.wss). More than half (53%) of respondents agreed that information sharing between organizations is important for cybersecurity, yet 68% said they were unwilling to do so. It’s not surprising that chief executive officers would be uncomfortable sharing information with rival organizations but it can be done without disclosing sensitive data, Kelley says.

"Nobody wants to give away the keys to the kingdom, and if you’ve been breached you don’t want to show everybody where you went wrong and how you went wrong," she says. "That’s not the kind of information sharing that we need to do to succeed. What we really need to share is what the bad guys are doing."

An organization doesn’t need to discuss its intellectual property, specific security controls, or other corporate secrets. The information an organization should share could be the general content of a phishing email, the IP address it was sent from, and the type of malware attached. This allows cybersecurity researchers and experts to create protections and update anti-malware and anti-virus software.

And as stakeholders and the Office of the National Coordinator of Health IT continue to push for interoperability, doing your part to ensure other organizations steer clear of hackers and malware could become even more important. "I think the more we tie systems together and we share with our partners, there are a couple things we can do. One of those is sharing information about threats," Kelley says.

 

Customer cost

No one likes to hear that their personal data has been breached, but how that dissatisfaction plays into the cost of a breach isn’t clear. According to the 2016 Ponemon study, the healthcare industry is the second most vulnerable to what it calls "churn"?a sharp drop in customers following a data breach. This may surprise those who assume healthcare is relatively immune to consumer pressure, but it’s supported by other trends that see healthcare becoming consumer-driven. It might also offer a clue as to how strongly some patients feel about breaches of PHI. It’s relatively simple to change banks, but changing healthcare insurers or providers is a more complicated process that takes more motivation, Kelley says.

"What’s it cost you to go from one bank to another bank if you don’t like their practices or they suffered a major breach?" she says. "Healthcare, it’s a little bit more difficult, but there’s still a level of choice and healthcare is very personal for people."

But privacy and security officers might want to rely on something other than consumer pressure to make the case for better security, Borten says. Often, patients simply have no better alternative and can’t switch providers or insurers if they’re unhappy over a data breach. And those who do switch may find themselves back in the same system after a few years.

"The reality is more complicated," she says. "As seen in some of the big retail breaches, after some initial falloff, customers come back in full force. In healthcare, some patients may not have other options: they may be locked in to a given provider by their health plan, or they may stay with an organization after a breach because they have long-established relationships they do not want to give up."

 

Cost conscious

Another recent study on the cost of data breaches by RAND raises questions about how the cost of a breach measures up against other financial risks organizations face. The RAND study, published in the Journal of Cybersecurity (http://cybersecurity.oxfordjournals.org/content/early/2016/08/08/cybsec.tyw001), found that the average cost of a data breach is roughly equal to an organization’s average IT budget, which is itself only 0.04% of an organization’s estimated revenue. The study authors suggest that public concerns about data breaches don’t match up with the relatively modest financial impact on organizations. Organizations, like individuals, are often motivated by self-interest and will not spend on risks that don’t have a significant impact on them; expecting them to act otherwise is not realistic, the study argues.

While that may in fact be the attitude of some executives when faced with competing demands and costs, the study leaves some significant questions unanswered. Bad debt is identified by the RAND study as the top financial risk for healthcare organizations, but data breaches can add to that cost. Victims of medical identity theft may be hit with thousands of dollars in medical expenses someone else racked up under their name. These fraudulent bills often wind up adding to an organization’s bad debt. Bad debt may often be a problem an organization can’t control, but by reducing data breaches, an organization can cut its risk of bad debt caused by medical identity theft.

 

 

HCPro.com – Briefings on HIPAA

Briefings on Coding Compliance Strategies, October 2016

Ready CDI teams for CMS’ proposed expansion of mandatory ortho episode payment models

by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer

If your hospital resides in one of the 67 metropolitan statistical areas (MSA) required to participate in the Comprehensive Joint Replacement Model (CJR), you will also be required to participate in a new orthopedic payment model called SHFFT (surgical hip and femur fracture treatment) if an August 2 proposed rule is finalized. The impact? The following assigned MS-DRGs will no longer define hospital reimbursement:

  • Major Joint Replacement or Reattachment of Lower Extremity (MS-DRGs 469, 470)
  • Hip and Femur Procedures Except Major Joint (MS-DRGs 480, 481, 482)

 

MS-DRGs 469 and 470 are included in the CJR, which we have discussed in prior articles. Let’s take a look at the proposed SHFFT episode payment model (EPM), which involves the other three MS-DRGs, and see what role the CDI program can play as reimbursement shifts to episode-based payments.

Model overview

The episode of care defined for the SHFFT EPM begins with an admission to a participating hospital of a fee-for-service Medicare patient assigned MS-DRGs 480?482. This admission is referred to as the anchor hospitalization. The episode continues 90 days post-discharge from the hospital, and payments for all related Part A and Part B services are included in the episode payment bundle. CMS holds the hospital accountable for defined cost and quality outcomes during the episode and links reimbursement?which may consist of payment penalties and/or financial incentives?to outcome performance.

This is a mandatory EPM for hospitals already impacted by the CJR; the SHFFT model will apply to the same 67 geographic MSAs. The EPM is proposed to begin July 1, 2017, and will last for five years, ending in December 2021.

Cost outcomes

CMS will initially pay the hospital and all providers who bill for services during the episode using the usual fee-for-service models. Thus, the SHFFT EPM will not impact the revenue cycle at first. However, at the end of each performance period, which typically represents 12 months (January through December), CMS will compare or reconcile the actual costs with a preestablished "target price."

CMS will set target prices using an approach that will phase in a blended rate of hospital to regional costs. In recognition of the higher costs associated with discharges in MS-DRGs with an MCC or CC, CMS has developed an algorithm to adjust the target price for this subset of the patient population.

If the reconciliation process indicates that the costs to deliver services for the episode were higher than the target price, CMS will require repayment from the hospital. If, however, the costs to deliver care for the episode were lower than the target price, CMS will provide additional payments to the hospital for the provided services. To receive additional payments, however, performance for defined quality outcomes must meet or exceed established standards.

 

Quality-adjusted target price

To receive any earned financial incentives, the hospital must meet or exceed performance standards for established quality outcomes. CMS therefore adjusts the target price based on quality performance, referred to as the quality-adjusted target price.

The SHFFT EPM uses the exact same quality outcomes as those defined for the CJR:

  • Patient experience. This is the HCAHPS measure also used in the Hospital Value-Based Purchasing Program (HVBP). The source of information for this measures is the HCAHPS survey.
  • Patient-reported outcome data. As with the CJR, the hospital can collect and submit patient-reported data elements and at present will earn quality composite points for submitting the data. These data elements are collected both before and after the procedure and will be used by CMS to create a functional status measurement tool.
  • THA/TKA complication rates. This is the Hospital-Level Risk Standardized Complication Rate (RSCR) following the THA/TKA measure. This measure already impacts financial performance under the HVBP. Like the CJR, performance for this measure is weighted the heaviest in the quality composite comprising 50% of the composite score.

 

Hospital (accountable party), collaborators, and Advanced Payment Models

The hospital is held accountable for episode cost and quality outcomes and all associated financial risks/rewards, even though a variety of providers deliver services and impact performance. As with the CJR, the hospital has been designated as the accountable party because CMS believes the hospital is best positioned to influence coordinated, efficient delivery of services from the patient’s initial hospitalization through recovery.

CMS permits the hospital to enter into collaborative arrangements with physicians and other providers to support and redesign care delivery across the episode and to share financial gains and/or losses. The proposed rule expands the list of collaborators defined in the previous CJR final rule to include other hospitals and Medicare Shared Savings Program accountable care organizations.

The proposed rule also provides an Advanced Payment Model (APM) track for the EPMs, an important step that will further incentivize collaborator participation.

 

CDI program opportunities

There are five key ways that clinical documentation and reported codes across the continuum impact SHFFT performance:

  • Identification of patients included in the EPM. The assigned MS-DRG impacts which discharges are included in the cohort. As one example, consider a patient who would fall into the EPM (MS-DRGs 480?482) unless he or she has a bone biopsy. If reported, the bone biopsy would result in assignment of different MS-DRGs (477?479) and the discharge would not be included in the EPM.
  • Establishment of target costs. The capture of the MCC and/or CC impacts establishment of the episode target price.
  • Determination of related costs. The costs for hospital readmissions within the episode are included in episode costs if the readmissions are related. The assigned MS-DRG for the readmission determines whether the readmission is related.

The costs associated with Part B claims are included in episode costs if the services are related. The primary diagnosis for each visit determines whether the visit is related.

  • Reported complications. Assignment of ICD codes for the following conditions are counted as complications when those conditions result in inpatient readmission:
  • Complication risk adjustment. As with other hospital-centric measures such as risk-adjusted readmission and mortality rates, comorbidities reported for the 12 months prior to the anchor hospitalization are used to assess case-mix complexity. The CMS risk adjustment module uses defined comorbidity categories to identify conditions that impacted predicted rates of complications for the THA/TKA cohort.

The capture of at least one condition for each of the 28 comorbid categories over the 12-month period will strengthen risk adjustment and RSCR performance. RSCR performance contributes to 50% of the quality composite score, which, in turn, impacts the quality-adjusted target price.

 

Summary

Together the CJR and SHFFT models cover all surgical treatment options (hip arthroplasty and fixation) for Medicare beneficiaries with hip fractures. These MS-DRGs typically represent one of the largest inpatient surgical volumes for most short-term acute care hospitals.

As hospitals and collaborators assess and refine the management of patients to achieve or exceed the quality-adjusted target price, the data we submit on claims will be used to assess our performance. The CDI program in the inpatient and ambulatory setting must be positioned to promote and support the capture and reporting of impactful documentation.

Additional information on the proposed rule can be located at https://innovation.cms.gov/initiatives/epm.

 

Editor’s note

Newell is the director of CDI quality initiatives for Enjoin. Her team provides CDI programs with education, infrastructure design, and audits to successfully and sustainably address the transition to value-based payments. She has extensive operational and consulting expertise in coding and clinical documentation improvement, case management, and health information management. You can reach Newell at 704-931-8537 or [email protected].

 

Computer-assisted coding: Where are we today?

by Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP

In our computer-savvy tech world, the medical field has been notoriously slow to respond to newer technologies and applications of computer-assisted enhancements. However, in the HIM market, computer-assisted coding (CAC) has been touted to boost coding accuracy and productivity, in addition to being an important tool for the remote inpatient coder. 

 

Background

The term CAC denotes technology that automatically assigns codes from clinical documentation for a human to review, analyze, and use, according to the Journal of AHIMA.

Currently, there are a variety of methodologies, software, and integration interface applications that enable a CAC application to read text and assign codes. This type of software reads the information in a similar way to how a spell-check application works on a traditional computer. According to some users, data-driven documentation (e.g., documentation that is dictated or typed) is more accurately processed by the CAC software than documents that are scanned into the system for the software to use.  

CAC software works through recognition; it learns words and phrases, as well as learning the areas within a specific document where standardized words and phrases appear. CAC software also has the ability to discern the context or meaning of those words and phrases. The program then analyzes and predicts what the appropriate ICD-10-CM/PCS codes should be for the documented diagnoses and procedures it finds within the specified documents.

Software providing CAC functionality has been available for over 10 years, but it has come to the forefront of inpatient coding with the implementation of ICD-10-CM/PCS. CAC has allowed hospitals to reduce lag times and enhance DRGs while also finding missed MCC/CC diagnoses. The usage and integration of an electronic health record (EHR) has also played a role in better code assignment and usage for data analysis and outcomes.

It is yet to be shown whether CAC actually enhances a coder’s productivity rate. On the upside, CAC does give the coder a great place to start when working on a difficult inpatient record. CAC is now where we were more than 20 years ago when encoders were first introduced into the inpatient hospital marketplace for coding, abstracting, and data analysis.

 

Pros and cons of CAC

Due to the complexity of inpatient care records, clinical documentation, and the complexity of medical terms and abbreviations, many hospitals only use CAC together with intervention by human coders. However, the latest CAC software technology employs a type of natural language and syntax processing to compare, contrast, and extract specific medical terms from electronic data or typed text?so CAC stand-alone technology does exist. In studies conducted by AHIMA, though, the combination of a CAC with a coder/auditor has been proven to be just as good, or better than, a coder or CAC alone.

The biggest challenge CAC poses might be getting buy-in from the hospital coding and HIM staff. The HIM, coding, and clinical staff must all be a part of the changes and be on board with learning how to use this technology enhancement. In the past, there has been some uncertainty and fear related to CAC eliminating coders’ jobs. However, a good CAC solution in conjunction with HIM management allows coders to apply their critical thinking and analytical skills to create well-coded documentation of patients’ care. This, in turn, results in more accurate DRG assignment and reimbursement for the facility.

HIM and coding staff’s responsibility and role in the fiscal revenue stream will change as a result of CAC and similar technology. With this change must comes the acceptance that it takes both a human and a computer to successfully transform a CAC product into good financial outcomes and even better documentation.  

As coders will surely agree, the final code selection for inpatient records should be based upon coders’ knowledge of coding guidelines, clinical concepts, and compliance regulations. When working with CAC, the coder has the ability to agree with or to override codes that the software determines.  

Coders have the education to understand why a diagnosis or procedure should or should not be coded in a specific situation, and by using CAC, they can help the software learn to identify the importance of specific documentation and its relation to ICD-10-CM/PCS codes.

Many CAC vendors will try and sell their product based on the following list of features and benefits:

  • Better medical coding accuracy
  • Faster medical billing
  • Greater coder satisfaction
  • Identification of clinical documentation gaps
  • Increased coder productivity
  • More revenue from more detailed bills
  • Return on investment?the CAC system quickly pays for itself

 

As we’ve said, it hasn’t been shown that CAC actually increases coders’ productivity. In reality, their productivity will probably stay the same, as a coder will still have to audit the information to determine whether the code generated by the software is correct. But in regard to the other CAC benefits on the above list, coder satisfaction should not be overlooked.

During AHIMA’s pilot testing of CAC software, the organization weighed in on some of the potential issues with using CAC software alone (with no human intervention). AHIMA noted that within specific areas of the pilot CAC testing in ICD-10, the coders did not accept 75% of the diagnosis codes presented, and they did not accept 90% of the procedure codes presented within the code sets. However, the information that the CAC software presented did give the coders a good starting reference to drill down to a more comprehensive diagnosis or procedure code.

Coders and CDI personnel will still need to be in charge of the following:

  • Ensuring clinical documentation is complete and querying when appropriate
  • Ensuring complete coding (e.g., for specificity)
  • Ensuring correct sequencing of diagnosis and procedures
  • Reviewing CCs/MCCs and DRG assignments with case complexity and severity

 

CAC, clinical documentation, EHR, and providers

Integration of clinical documentation from providers and physicians has always been a challenge, and combined with the implementation of ICD-10, it has presented a huge impetus for the adoption of CAC technology in hospital- and facility-based organizations.

Unfortunately, physicians still don’t provide thorough documentation, instead relying on CDI and coding staff to guide them. There has always been a disconnect in the language spoken by providers and the language spoken by coders. Physicians document in their comfort zone and fall back on terms such as "pneumonia," whereas a coder is looking for much more specificity. The integration of an EHR-based program and CAC for providers can lead to a good team relationship for both parties.Many CAC programs integrate well with hospital-based CDI programs and EHRs. These combination interfaces allow more real-time processing of possible code selection prior to the coder’s audit and review of the final code selection.

When the CAC software identifies these possibilities, there is an opportunity to identify and improve the DRGs with MCCs and CCs, as well as more quickly address areas for query and missed procedures or diagnoses.

Wrapping it all up

It is evident that coders and HIM professionals need to make a commitment to embrace change, which includes new technologies and integration of learning processes and opportunities. A hospital’s success depends on the coder acting as part of a team that will strive for successful outcomes for both the patient and the hospital.

 

Editor’s note

Webb is an E/M and procedure-based coding, compliance, data charge entry, and HIPAA privacy specialist with more than 20 years of experience. Her coding specialty is OB/GYN office/hospitalist services, maternal fetal medicine, OB/GYN oncology, urology, and general surgical coding. She can be reached via email at [email protected], and you can find current coding information on her blog at http://lori-lynnescodingcoachblog.blogspot.com. This article originally appeared on JustCoding, and opinions expressed are those of the author and do not represent HCPro or ACDIS.

 

Key attributes for coders moving forward amidst the 2017 coding guideline changes

by Laura Legg, RHIT, CCS, CDIP, AHIMA-approved ICD-10-CM/PCS trainer

Resiliency is the ability to spring back or rebound. In sports, it’s one of the mental attributes a player must have. Coders are resilient: bouncing back from one change after another, deciding to code smarter and faster, and having the patience to do whatever is expected?even amid closing grace periods and guideline controversies.

The change to ICD-10 in October 2015, was a solid transition, and no one in healthcare was affected by it more than coders. The changes didn’t stop there. The coming months will again prove to be challenging for coders because of the new ICD-10 codes for both CM and PCS beginning October 1, 2016. Along with that, we’ll see the end of the CMS grace period on code specificity for Part B, and updated ICD-10-CM Official Coding Guidelines. Coders have a lot to learn this fall.

The Centers for Disease Control and Prevention published guidelines for discharges effective October 1, 2016, that have been approved by the four organizations that make up the Cooperating Parties for ICD-10-CM: the American Hospital Association, the American Health Information Management Association, CMS, and the National Center for Health Statistics.

The guidelines are available at www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf. In the linked document, the changes are indicated in bold type for easy identification. Below are some of the highlighted changes.

 

Excludes1

This guideline supports the interim advice published last fall. Here, the Cooperating Parties have given instructions that two conditions unrelated to each other represents an exception to the Excludes1 definition. If it is not clear whether the two conditions are related, coders must query the provider.

 

With

Under Section I.B.7 of the guidelines, "multiple coding for a single condition" clarification has been added for interpretation of the word "with."

The word "with" should be interpreted to mean "associated with" or "due to" when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms.

These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by this term in the classification, provider documentation must link the conditions in order to code them as related.

 

Code assignment and clinical criteria

Also under Section I, the Official Guidelines for Coding and Reporting tell us that the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.

Coders are instructed to assign a diagnosis or procedure code according to physician documentation. Coders have been told in the past not to question the physician’s clinical judgment. This appears to be pretty simple until audits from outside the organization place more emphasis on the use of clinical criteria. This use of clinical criteria to assign reported codes is known as "clinical validation." When coders follow the official coding guideline instructing them that a code assignment is not based on clinical criteria used by the provider to establish the diagnosis, they will be caught between following the guideline as instructed and being presented with a claim denial based on the absence of clinical validation.

In today’s healthcare environment, it is essential that organizations face this issue head on and provide coders with guidance on how to solve the dilemma of a record that contains physician documentation but does not contain clinical validation. Clinical documentation improvement efforts to improve upon complex clinical condition documentation must continue to bring the coding and medical records together to allow coders to code correctly and avoid payer denials.

CMS must clarify the reason the Recovery Auditors are allowed to deny claims, whether auditors will bypass this official coding guideline, and how organizations can reconcile the discrepancy.

 

Laterality coding

This update clarifies that when a patient with a bilateral condition has surgical correction on both sides, the first side corrected is coded with the bilateral code. The second site is not coded using the bilateral code because the condition no longer exists on the corrected side. If the treatment on the first side did not completely resolve the condition, then the bilateral code is used.

Documentation for BMI, non-pressure ulcers, and pressure ulcer stages

Section I.B.14 says for body mass index (BMI), depth of non-pressure chronic ulcers, pressure ulcer stage, coma scale, and NIH Stroke Scale (NIHSS) codes, code assignment may be based on medical record documentation from clinicians who are not the patient’s provider. Dietitians often document the BMI, nurses often document pressure ulcer stages, and an emergency medical technician often documents the coma scale. Keep in mind the associated diagnosis must be documented by the patient’s provider. A query should be used to clarify any conflicting medical record documentation.

This guideline shows the addition of the coma scale and NIHSS to conditions where code assignment can be determined from clinicians who are not the patient’s provider. Many coders may not be familiar with the ­NIHSS?it is a 15-item neurologic examination used to evaluate the effect of acute cerebral infarction. The NIHSS evaluates:

  • Levels of consciousness
  • Language
  • Neglect
  • Visual field loss
  • Extraocular movement
  • Motor strength
  • Ataxia
  • Dysarthria
  • Sensory loss

 

The NIHSS evaluation is often done by nursing staff and can help physicians quantify the severity of a stroke in the acute setting.

 

Zika virus infection

The official guidelines instruct coders to code only confirmed cases of the Zika virus with code A92.5 as documented by the provider. Note that this is an exception to the hospital inpatient guidelines. "Confirmation" does not require documentation of the type of test performed; the physician’s diagnostic statement that the condition is confirmed is sufficient. Documentation of "suspected," "possible," or "probable" Zika is not assigned to code A92.5.

 

Hypertensive crisis

A coding guideline has been added to instruct coders to assign a code from category I16 for hypertensive urgency, hypertensive emergency, or unspecified hypertensive crisis. This may call for some physician documentation education to make physicians aware that these more specific codes are available and can be used instead of documentation of hypertension without any further description.

 

Coma scale

In addition to using the coma scale codes (R40.2-) for traumatic brain injury codes, acute cerebrovascular disease codes, or sequelae of cerebrovascular disease codes, the coma scale may be used to assess the status of the central nervous system for other non-trauma conditions. Examples include monitoring patients in the ICU regardless of their medical condition.

 

Observation

One observation Z code category has been added for use when a newborn patient is being observed for a suspected condition that is ruled out. The new code category is Z05: encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out.

 

Newly added ICD-10 codes

CMS will implement an unprecedented number of new code changes October 1. A partial code freeze prevented regular updates for the last five years, resulting in the release of over 5,000 ICD-10 revisions on that date. The newest coding updates can be found at https://www.cms.gov/Medicare/Coding/ICD10/Latest_News.html.

The new ICD-10 codes come as we thaw out from the code freeze that has been in effect since October 1, 2011. Since that time, we have received only limited code updates to both the ICD-9 and ICD-10-CM/PCS code sets. Now, the long delay is over. ICD-10-CM changes include 1,928 diagnosis code changes with expanded code choices for atrial fibrillation, heart failure, diabetes mellitus Type 2, disorders of the breast, and pulmonary hypertension.

Extensive PCS updates are also being implemented. There are 3,651 new PCS codes, revised code titles, and a grand total of 75,625 valid codes with this update. It is important to note that 87% of the PCS code updates are in the cardiovascular system.

Following adoption of the new codes, review of coding accuracy will be needed. Any misconceptions or incorrect rationale should be recognized and communicated early to prevent ongoing or costly patterns from developing. Remember to ensure software updates are also in place and scheduled on time.

The new cardiovascular PCS codes include:

  • Unique codes for unicondylar knee replacement
  • Codes involving placement of an intravascular neurostimulator
  • Expanded body part detail for the root operations Removal and Revision
  • New codes in lower joint body system
  • New codes for intracranial administration of substances such as Gliadel chemotherapy wafer using an open approach
  • Addition of bifurcation qualifier to multiple root operation tables for all artery body part values
  • Specific body part values for the thoracic aorta
  • Specific table values to capture congenital cardiac procedures
  • Unique device values for multiple intraluminal devices

 

Other PCS changes include:

  • Donor organ perfusion
  • Face transplant
  • Hand transplant

 

The impact of the new codes will depend on what you do, so it’s important for hospitals to assess how the changes will affect them specifically. If you don’t deal with the areas where the codes have changed, the updates will be much easier than if your facility uses all the affected codes. Make sure the applicable codes are integrated into your internal applications and processes, while verifying that vendor products support the new codes. You don’t want to have claims rejected because not all of the new codes were incorporated.

Overall, there are moderate changes to the Official Guidelines for Coding and Reporting. The 2017 coding updates, however, are extensive and may seem overwhelming to some coders. The addition of over 10,000 codes after only one year of using ICD-10 will require coder resiliency to learn them all and understand how to apply them.

HCPro.com – Briefings on Coding Compliance Strategies

2016 HIM roles and responsibilities survey: Survey respondents weigh in on roles and responsibilities

2016 HIM roles and responsibilities survey

HIM professionals report on their expansive role in the revenue cycle

For approximately 10 years, HIMB has been gathering data about the HIM profession through its annual salary survey. This survey often gives us a glimpse into the responsibilities of HIM professionals, but focuses primarily on the education, experience, and salary of those in the HIM field.

Time and again, the salary survey reveals that HIM directors and managers are wearing many hats and asked to oversee an increasing number of tasks. In an effort to dig a bit deeper into HIM departments, HIMB conducted its first HIM roles and responsibilities survey.

More than half of respondents were HIM directors (26%) or managers (25%), whereas the remaining 49% held other revenue cycle positions. Of the latter group, 50% were coders and 29% were CDI specialists. Responses also came in from transcriptionists, privacy officers, compliance officers, revenue integrity professionals, and consultants.

HIM demographics

The plurality of respondents work in acute care hospitals (55%) and critical access hospitals (17%) or have a corporate position at a multi-system hospital (8%). Other settings represented in the survey include long-term acute care hospitals, psychiatric/behavioral health hospitals, skilled nursing facilities, ambulatory surgery centers, and physician practices.

On average, most respondents appear to be working in a hospital with 100?199 beds, with approximately 20% of respondents selecting this option. Nearly 18% work in hospitals with fewer than 25 beds, and 15% work in hospitals with 500 or more beds.

 

HIM reporting structure

Nearly half of respondents (48%) report that more than 20 staff members report to the HIM director and/or manager at their facility. Nearly one-quarter (22%) of respondents reported that 0?5 staff members report to the HIM director/manager at their facility. The remaining 30% of respondents said the number of employees reporting to HIM is more than five but less than 20.

The majority of HIM departments represented in the survey (78%) report to their facility’s chief financial officer. Others tend to report to the chief executive officer (13%) or chief information officer (9%). Some respondents wrote in to clarify their reporting structure after selecting one of the aforementioned broader options. Write-in responses indicate HIM may also report up to:

  • Vice president of finance
  • Vice president of health data support services
  • Vice president of revenue management
  • Vice president of revenue cycle
  • Vice president of quality management
  • Chief quality officer
  • Chief medical information officer
  • Chief revenue officer

Similarly, HIMB asked respondents which roles report to the HIM director/manager. The top three roles reporting to HIM include release of information staff (90%), coders (89%), and transcriptionists (76%). Less than half of CDI specialists (45%) and privacy officers (42%) report to HIM. And less than one-quarter of information governance (22%), compliance (16%), security (14%), and revenue integrity (12%) staff report to HIM directors/managers. A lesser percentage of risk management (5%) and case management (4%) professionals fall under HIM.

Some respondents wrote in to note that HIM is often responsible for overseeing registration, billing, collections, record management, and patient access.

Respondents indicated that transcription is the most frequently outsourced role in HIM, with 61% indicating their facility outsources this function. "It is very convenient, as transcribers are situated throughout the states and reports are transcribed timely for late night physician dictations," one respondent said.

More than one-third of facilities surveyed (34%) have also opted to outsource release of information (ROI) functions. "We have a one-person department. ROI is outsourced only as it applies to requests from lawyers, courts, and disability agencies. HIM handles requests from hospitals, doctors, and patients," one respondent said.

Other functions frequently outsourced include archives/warehouse storage (33%) and inpatient (28%) and outpatient (24%) coding. (See the figure on p. 3 for more information about outsourcing.) One respondent noted that his or her coding and transcription is only partially outsourced.

"Our outsourced outpatient coding position is for only 20 hours a week. She codes clinical accounts as well as observation and outpatient surgery cases," a survey respondent said.

Respondents seemed to be split on whether outsourcing was the best option. While some respondents noted that outsourcing was helpful in terms of managing costs, others stated that it was expensive. However, for facilities with limited resources and space, it seems to be a viable option.

"Coding is outsourced due to the limited resources we had available at our facility, such as qualified coding candidates in our geographic area as well as competitive compensations with surrounding areas," one respondent said.

While some facilities reported outsourcing functions due to lack of resources, others are simply using it for backfill and vacation coverage or simply to ensure coverage after hours and on weekends for certain functions. "The services outsourced above are mainly outsourced because of the lack of resources to hire qualified personnel who can do the job. In a recent analysis it was also shown that the price we pay for outsourcing coding was low compared to the price it would cost to have it in house," one respondent said.

Notably, one HIM director stated that his or her function is entirely outsourced. This seems like it may present a challenge given that HIM directors and managers are involved in so many projects.

HIM responsibilities

According to survey respondents, HIM directors/managers are actively responsible for the following functions (see the figure on p. 3 for more information):

  • Prepping, scanning, and quality checks for medical records (96%)
  • Record retrieval, assembly, and analysis (93%)
  • Delinquency management (88%)
  • Transcription (79%)
  • Enterprise master person index/master person index (56%)
  • Archives/warehouse management (51%)
  • Patient identity management (46%)

 

When asked to expand upon their roles in HIM, respondents described their responsibilities in various ways, backing up what we have long seen in the HIM director and manager salary survey about HIM playing many roles.

One HIM manager responding to the survey stated that he or she supervises coder education and training, "providing orientation and initial job training for coders, ongoing and new software/processes training for coders and CDI, including all ICD-10-CM and ICD-10-PCS training as job-required."

An HIM director responding to the survey stated that he or she is "responsible for direction and overall performance of all chart assembly, analysis, and coding." This respondent also noted involvement in "ROI functions and all internal and external audit reviews." As if that doesn’t sound like enough to keep one HIM director busy, this particular respondent also noted involvement in the following:

  • Quality improvement
  • Utilization review
  • Chart delinquencies and CMS reporting requirements
  • Working with CDI and physicians on chart requirements and timely documentation

 

See the sidebar on p. 5 for specific information about responsibilities of various titles within the HIM department.

Despite everything HIM directors/managers have on their plates, most respondents chimed in when we asked which committees HIM should play a role in. Respondents wrote in that HIM should participate in committees related to the following:

  • EMR/EHR
  • UR
  • Billing
  • Quality
  • Finance
  • Compliance
  • HIPAA
  • Credentialing
  • Forms creation
  • Population health
  • Patient services
  • CDI
  • Medical executive
  • Nursing
  • Appeals and denials
  • Revenue integrity
  • Information governance

 

If it seems like we just listed off the majority of hospital departments, that’s because we did. Despite an ever-growing list of demands, HIM managers and directors are well suited to take a seat at the table with any of the above departments/committees and are often eager to do so.

"HIM participates in information governance, and quality meetings. I would suggest that our HIM department also participate in medical executive meetings and also ambulatory care meetings," one respondent said.

While some respondents were specific about which committees HIM should be a part of, others simply stated that HIM had earned a seat on any committee that was related to the revenue cycle. "I think HIM should participate in any and all committees needed, as the HIM department touches every piece of PHI that enters the hospital, whether that be on paper or electronic. HIM representation at meetings, I believe, is very important," said an HIM director.

 

Challenges facing HIM today

We asked survey respondents a variety of open-ended questions about the HIM department at their facility. When asked to identify challenges facing HIM, respondents said the following:

  • "HIM professionals are rarely acknowledged for their impact and knowledge they have that benefits the facilities they work at. Most leaders and other departments have no idea what we do and typically will call us ‘glorified paper pushers.’ Because of this, compensation is not where it should be."
  • "Movement to an EMR. Dealing with issues with copy and paste functions within an EMR. Acquiring accurate information on admission with an accurate MPI. Being included in meetings and decision-making that affects the HIM function."
  • "Lack of staffing. Not all facility staff are aware of all the HIM tasks, so they think we only put papers together all day and nothing else."
  • "Building a coding department. Ensuring accurate coding and impact to patient safety indicators. Accurate physician documentation."
  • "Competing salaries with outsource companies for coders and coders wanting remote work only."
  • "It seems that most HIM jobs are outsourced and that we are having to pick a specialty (CDI, Privacy/Security, coding, EHR, etc.) to keep a foothold in our business. It’s not the old HIM department as we knew it!"
  • "Our greatest challenge is the hybrid medical record. Know what is electronic and where it is located in the HIS system and what is still paper. Some physicians still will not electronically sign. Along with EMR is the multiple systems that interfaces must be built for information to be shared which adds to cost."
  • "For us I believe that is trying to get us that last 5% totally electronic. Overall, I would say support of providers to use the electronic system, so that we can get away from pushing around so much paper. We have gone from a department of eight to a department of five in my five years here; we, as well as many other departments, are being asked to do more with less. That is a challenge."

 

Inside the HIM department

Ever wonder what the inside of another facility’s HIM department looks like? Of course you do. To satisfy our curiosity, we asked respondents to describe the makeup and location of the HIM department within their facility:

  • "HIM is on the main level of the hospital. We are located on a separate wing by ourselves away from main traffic of the hospital. It would be beneficial to be more centrally located so that patients can better find us when they need records. The coding department is across the hall from us in a separate office."
  • "Ground floor next to administration, away from the physician lounge. Would be better being closer to the physicians to get records completed. One in-house coder for ancillary coding. All staff in area for ROI, birth certificates, assembly and analysis, scanning, but file room is located across the hall."
  • "HIM at my facility is on the ground level. In fact, I think we are in the perfect location for patient access because we are right inside the door. From the HIM department we only have HIM personnel working alongside each other. Coding works at home and at our affiliate site. Transcription is outsourced. We do share space with another department, not HIM related."
  • "We are located on the first floor of the hospital. Our coding and transcription functions have been regionalized and are managed off-site. The majority of our coders work from home."
  • "Ground level. Coding, scanning, and records review share a large office. Transcription and CDI are in different areas of the hospital."
  • "All of HIM, except for CDI, are all located together in a medical office building on campus. A CDI [specialist] is assigned to a specific floor/unit and works from there."
  • "The HIM department is on the patient floor with coding being done on-site and remotely. Transcription is contracted out and performed remotely and HIM clerical personnel on-site at each building."
  • "HIM located within the core of the patient care area. Four of five HIM staff share the office with the manager."
  • "Basement of hospital for scanning, chart completion, data integrity. Off-site for HIM at rehab, skilled, homecare. Coding is in a separate building off campus."
  • "We have a separate building from the hospital for all non-clinical employees. Most of our coders work from home. All of HIM is in one big area of the second floor."
  •  

Survey respondents weigh in on roles and responsibilities

To understand the intricacies of the HIM role, we asked survey respondents a variety of open-ended questions about the HIM department at their facility. When asked to describe their role and responsibilities as they relate to HIM, respondents said the following (the title that follows each quote was selected by the respondent regardless of the scope of responsibilities described):

  • "My role is inpatient coder and involved in DRG appeals sending out letters of redetermination to insurance companies?HIM department separated from coding/CDI department." ?Coder
  • "I manage the coding and CDI functions within the HIM department. I make sure the coding service is up to date on any facility changes and monitor that they are meeting service agreements." ?HIM manager.
  • "I am a coder and credentialing coordinator by title, however, I perform every single task in HIM department?transcription filing to chart assembly and analysis, denial follow-up cases due to documentation or coding issue, physician delinquent rates, subpoenas and other ROIs, etc." ?Coder.
  • "Only employee?coder, data entry, chart completion, analysis, physician visits, medical staff, release of information." ?Non-director/manager in HIM.
  • "Revenue cycle director, HIM director, privacy officer. I wear several hats to coordinate the areas of admitting, scheduling, switchboard, business office, and medical records." ?HIM director.
  • "My role and responsibilities as the HIM director and privacy officer include education on HIPAA privacy and breach reporting, maintaining the department, conducting and reporting on closed chart reviews, coding quality and quantity, transcription quality and quantity, and other personnel’s productivity. I also play a very active role in educating physicians on using the EHR and completing their records; track delinquency rates; and assist IT in managing information." ?HIM director.
  • "I am an outpatient coder coding some clinical accounts but primarily outpatient surgery and observation accounts. In addition to coding, I check charges on each account to make sure we have a revenue code to link the CPT code to and have charges for any implants/devices that were used. Each account finalized is then sent to billing so the more we code, the faster the billing department can send the bills." ?Coder.
  • "We share/rotate responsibilities in our small department between outpatient ancillary coding, transcription, ROI, prepping charts for scanning our hybrid record, quality controlling scanned documents. I’m in training to take over for my director when she retires in two years. I’m also the module coordinator for our Meditech computer system, working with our IT lady on issues affecting our department." ?Transcriptionist.
  • "I am the HIM coordinator who wears many hats. Coding/privacy officer/quality improvement/core measure reporting/chargemaster/credentialing." ?HIM manager.
  • "Manage coding staff, perform compliance audits, provide education to coders, CDI specialists, and physicians. Support management of budget, supplies, etc. Participate in revenue cycle meetings and work closely to develop and submit appeals/address denials." ?Coding supervisor.

HCPro.com – HIM Briefings

CMS sets sights on future quality, payment initiatives in 2016 SNF PPS proposed rule

CMS sets sights on future quality, payment initiatives in 2016 SNF PPS proposed rule

In mid-April, CMS released its proposed SNF PPS rule for fiscal year (FY) 2016. Though the rulemaking document is an annual ritual, this year’s iteration, which experts who spoke with HCPro predict will pass largely unaltered, departed from its recent predecessors in one distinct aspect: its preoccupation with long-term projects.

"It was not a … rule like we’ve had in recent years," says Judy Wilhide Brandt, RN, BA, RAC-MT, C-NE, principal at Judy Wilhide MDS Consulting, Inc., in Virginia Beach, Virginia.

In lieu of remedying small-scale, immediate concerns (like FY 2015’s COT OMRA fix), the FY 2016 proposed rule lays the framework for SNF-specific value-based purchasing (VBP) and quality reporting programs (QRP)?two more distant initiatives that, through their ongoing integrations in different settings, promise to reshape long-standing paradigms, business models, and care practices across the care continuum in the coming years.

But despite the unusual foresight of the latest SNF rule, experts say its provisions hold few surprises, as the two far-off programs they detail are products of high-profile legislation passed last year:

  • The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 calls for the phasing in of various quality improvement and reporting initiatives throughout postacute care (PAC), including a SNF QRP. The legislation also requires the creation of standardized reporting metrics that allow for more equitable comparisons of care delivery strategies, patient outcomes, and overall performance across the various PAC settings (i.e., SNFs, home health agencies, inpatient rehabilitation facilities, and long-term care hospitals).
  • The Protecting Access to Medicare Act (PAMA) of 2014 added new subsections to the Social Security Act that authorize the establishment of a SNF VBP program beginning in FY 2019, under which value-based incentive payments will be distributed to SNFs based on their performance on designated quality metrics.

Payment update

In addition to these long-term projects, experts say the one major constant of annual CMS rulemaking?the payment update?was also familiar territory this year.

CMS projects that aggregate reimbursement to SNFs will increase by 1.4% ($ 500 million) in FY 2016. The proposed bump would be the result of a 2.6% market basket increase combined with two 0.6% reductions, one stemming from the forecast error adjustment, and the other from the multi-factor productivity adjustment.

But although the anticipated increase is within normal bounds?Brandt says the industry is accustomed to an annual boost between 1% and 2%?Maureen McCarthy, RN, BS, RAC-CT, president and CEO of Celtic Consulting, LLC, in Torrington, Connecticut, had hoped that SNFs would see a higher market basket raise next fiscal year. Although McCarthy says the multi-factor productivity adjustment and the forecast error affect reimbursement rates each year, she says this year’s adjustments may also be intended to fund some of the proposal’s other initiatives that center on improving quality of care and patient satisfaction. Still, McCarthy prefers this strategy over ones that would divest providers after payment was awarded or that would only target certain SNFs.

"It’s the least punitive," she explains. "It’s money we haven’t gotten yet, so it’s easier to lose."

 

Payroll-based staffing reporting

The other major change addressed in the proposed rule that will actually hit providers next fiscal year is an electronic system for submitting staffing data pulled directly from payrolls, which CMS plans to debut this October for volunteer SNF testing. The so-called payroll-based journal (PBJ) is a response to the Affordable Care Act (ACA)’s call for the introduction of more accountability into the SNF staff reporting sphere by creating a method to electronically submit data on direct care staff (including agency and contract workers). The ACA requires that such a system fulfill the following criteria:

  • Culls data that is verifiable and auditable, such as that from payrolls
  • Specifies the job classification of each employee (e.g., RN, LPN, licensed vocational nurse, CNA, therapist, or other medical personnel) and the number of care hours each employee category provides per resident day
  • Distinguishes data on agency and contract staff from that on SNF employees
  • Tracks employee turnover and tenure
  • Includes data on resident census and case mix
  • Facilitates public reporting on a regular schedule

 

Although CMS has long been developing a qualifying system and periodically updating the industry about its progress, the FY 2016 proposed rule offers a more comprehensive discussion of how the agency plans to implement these ACA stipulations. Most strikingly, the rule reiterates CMS’ recent announcement that all SNFs will be required to submit data through the PBJ beginning July 1, 2016.

Although this wholesale shift in staff reporting is coming up fast, McCarthy says the details of its execution aren’t yet set in stone. She therefore urges SNFs to parse CMS’ proposals in this domain to bring to light any potential snares, including:

  • How the PBJ will consider corporate nurses who aren’t on a facility’s payroll but may perform direct care.
  • What documentation will be required to support the new collection system. For example, will the CMS-671 and CMS-672 forms feed the PBJ until CMS develops a more tailored alternative?
  • How the PBJ will account for time worked by salaried employees. Although full-time staff are typically thought to spend 40 hours per week on the job, McCarthy says many salaried direct care staff work 50- to 60-hour weeks, meaning a facility could have higher staffing levels at any given time than the size of its workforce would suggest.

 

Despite these lingering uncertainties, Brandt believes that CMS recognizes the gravity of the industry’s upcoming transition to a much more robust?and complex?reporting mechanism. In turn, she’s optimistic that the agency will implement the new system methodically, accounting for industry feedback and not jeopardizing honest performers.

"I trust that their goal is that it be fair and reliable, so I trust that people who are staffing to acuity are going to be just fine," she says.

Despite Brandt’s confidence in the ability of worthy providers to acclimate to the upcoming shift, Bonnie G. Foster, RN, BSN, MEd, long-term care consultant in Columbia, South Carolina, doesn’t think they should have to. Foster sees the PBJ as a symbol of the government’s misplaced distrust in an industry largely composed of scrupulous providers that are trying their best to field unforeseeable staffing challenges (e.g., last-minute callouts and heavy turnover) as they arise.

But others don’t have such a high view of the SNF provider community. In addition to fulfilling legislative mandates, the government hopes that the PBJ will quell worries expressed by industry stakeholders about the validity of today’s self-reported staffing data?worries that were stoked by an August 2014 New York Times exposé that charged some in the long-term care setting with artificially inflating reported staffing levels to fare better on Nursing Home Compare’s star ratings.

Of course, many providers have denounced these charges. Some, like Brandt, believe that they represent only a small proportion of providers?providers that may soon be exposed through the verifiable PBJ data.

"The people who have been spending their time trying to manipulate the data and … figure out ways to beef up staffing before a survey … all of those tricks are going away if these measures get implemented," Brandt says.

But Foster fears the PBJ could have the reverse effect, driving providers to enlist staff whose titles look the best on paper (or screens) rather than those who are the most qualified. For example, with increasing pressure from CMS and consumer advocates to bump up levels of RN staffing and supervision at SNFs (which will be more easily identifiable in an electronic reporting system), LPNs with years of nursing and management experience may fall by the wayside, Foster explains.

"I don’t want people to put staffing down there to satisfy the system," she says. "That part scares me a lot."

Regardless of her qualms about the forthcoming reporting system, Foster says providers have some work to do to brace for the additional staffing scrutiny ahead.

For example, while SNFs have adopted flexible intake practices to stay competitive in an evolving industry (e.g., admitting new residents late at night and on weekends), Foster says many haven’t synced their staffing schedules with these new patterns, potentially leaving a workforce that is undermanned or underqualified to cope with peak admission periods.

"If you’re going to continue to admit at those strange hours, then you better be sure that all of your staff understand everything," she says.

In addition to improving general staffing strategies, Brandt says providers should focus on understanding the specifics of the forthcoming PBJ.

"People need to read the draft manual on submitting staffing data, and it’s not too early to start preliminary talks about how they’re going to comply," she explains, encouraging providers to begin priming staffing data for the new collection process by identifying the employees who will be responsible for reporting through the system, kick-starting training initiatives, and setting away necessary budget today.

 

QRP

To satisfy provisions of the IMPACT Act that task CMS with collecting quality data, the agency is proposing to build a SNF QRP that considers the three quality measures outlined in the table below.

Under the QRP, SNFs would be required to submit certain data on these measures beginning in FY 2018, as well as on any other focuses CMS finalizes in future rulemaking. In addition, the IMPACT Act dictates that providers failing to comply with these reporting requirements will be penalized with a 2% reduction in their annual payment update.

These prospective QRP requirements will carry significant changes in SNFs’ approaches to quality improvement. The proposed fall and functional status measures have not yet been approved by the National Quality Forum for SNFs, and the latter measure could see in an additional MDS component: Section GG. This new section, which would prompt SNFs to evaluate the functional abilities and goals of residents at the start and end of care, would also foretell a new required assessment for facilities to complete when a beneficiary is discharged from a Medicare Part A stay but does not leave the facility?a status shift that CMS says affects 30% of SNF residents.

Brandt has encountered some providers that are wary about the prospect of an additional assessment on top of their already heavy documentation load?not to mention the associated data capture, training, and resource distribution changes it could carry. However, she thinks these fears are overstated because much of Section GG is pulled straight from the Continuity Assessment Record and Evaluation (CARE) item set, a tool that’s been in development since the 2005 enactment of the Deficit Reduction Act compelled CMS to examine the consistency of payment incentives across the various Medicare providers. CMS states that the CARE tool, which is an output of this directive, is "designed to standardize assessment of patients’ medical, functional, cognitive, and social support status across acute and post-acute settings." And Brandt says it has long been on the radars of central SNF departments.

"The CARE tool has been around for a long time now, and if you read through [Section GG], it’s what therapy has been doing, maybe in different formats, every time they do an evaluation in the discharge summary," she says, explaining that, consequently, many rehab providers already have the tool in their software and have been collecting data through it for some time.

"The MDS community needs to realize that adding a section to the MDS doesn’t mean that it’s going to add more to the job of the MDS coordinator," she says.

Beyond the new quality considerations CMS has posed, the agency also seeks to redefine the current bounds of the industry’s skin integrity measure. Although SNFs are presently required to submit data on changes in their residents’ skin integrity, this measurement is restricted to the development of stage 1?4 pressure ulcers that occur or worsen during facility stays. CMS is proposing to broaden this reporting criteria for SNFs (and other PAC providers) to include:

  • Unstageable pressure ulcers
  • Suspected deep tissue injuries
  • Stage 1 or 2 pressure ulcers that become unstageable due to slough or eschar (indicating progression to a stage 3 or 4 pressure ulcer) after admission

 

CMS points out that since SNFs are already required to complete items related to unstageable pressure ulcers in the MDS, the revision would require a change in the way the agency calculates the measure but would not increase the data collection burden for SNFs.

In addition, by capturing more incidences of decline, CMS says these proposed updates?which are backed by a number of experts and the agency’s own data analyses?could potentially reveal a wider range of SNF performance, improving "the ability of the quality measure to discriminate between poor- and high-performing facilities."

Brandt thinks this attempt to better discern the success of pressure ulcer prevention throughout the provider community demonstrates CMS’ overarching proposal strategy: to elevate hard workers and undercut bad actors.

"Facilities that have been sincerely and tirelessly working on achieving the highest quality of care are going to rise to the surface," she says. "There are nursing facilities all over this country that have been … doing what they can to prevent injuries from falls, preventing pressure ulcers, and I think they’re going to shine."

In addition to putting the necessary frameworks in place to highlight today’s top-performing facilities, ­McCarthy says the QRP proposals can serve as a road map for providers on shakier ground to launch targeted quality improvement initiatives.

"I think providers should take a look at what’s going to be reported for 2018 … and then look at those quality metrics within their own organizations," she says, adding that facilities should pay particular attention to the proposed methods of collecting and scoring quality data.

"They have the opportunity to correct some issues before [there’s] mandatory reporting if CMS will allow it," she continues, explaining that the agency is soliciting public comments through the proposed rule on whether to give providers this head start.

However, Brandt cautions facilities to avoid putting too much stock in the formulas for calculating these quality measures until they are finalized.

 

VBP

In addition to putting the finishing touches on the QRP’s initial aims, CMS is considering another quality-related focus intended to shape future payments dispensed through the setting’s forthcoming VBP program: the SNF 30-day all-cause readmission measure (SNFRM), which CMS specifies would assess the rate of unplanned readmissions among SNF residents that occur within 30 days of discharge from an inpatient hospital. However, McCarthy says CMS has failed to disclose whether the measure would also penalize providers for hospital readmissions that occur within 30 days after discharge from the SNF itself.

To gather preliminary data for the potential introduction of this metric?whose development was first kindled by PAMA?in October 2016, CMS plans to require facilities to report certain rehospitalization rates starting this October.

Beyond the prospect of an imminent reporting start date tied to its contents, Brandt thinks the SNFRM is significant for another reason: It would be calculated using data from claims rather than MDS documentation, an unprecedented move in the SNF quality domain and one that wouldn’t require any additional data collection or submission by providers.

"It’s kind of historic that we’ve finally got our first measure that is not MDS-based," says Brandt, who believes that the financial tie-ins carried by both the VBP and QRP will further undermine bad actors by stripping them of their primary motivation: monetary reward.

"I think the people who are in long-term care for the goal of providing the service of quality care and who are interested in quality outcomes are going to rise to the surface," she says. "I think people who are in long-term care for any other reason are going to be leaving."

Foster is more ambivalent about the financial incentives (and disincentives) that will soon underlie key performance metrics in the sector. She says that although the forthcoming measures?and their monetary drivers?target long-standing industry shortcomings, she thinks they paint with too broad a brush.

"It’s your entire building is doing a good job, or your entire building is not doing a good job," she says.

Foster worries that this stance could penalize facilities that take on the most compromised residents or reward those whose emphasis on producing favorable bodily outcomes jeopardizes the psychosocial health of the individuals they serve.

 

Today’s strategies for future success

Despite the far-off focuses of CMS’ latest SNF rulemaking, experts warn providers against lapsing into complacency in the absence of more urgent proposals. They stress that the changes, although distant, are likely to become finalized without major revision. Further, the sweeping scope of QRP and VBP demands preparation from providers today to facilitate compliance and operational stability down the road.

To address the spirit of these changes?the facilitation of effective and efficient care?Foster urges SNFs to implement new restorative nursing programs (or modernize existing ones) with an eye to addressing CMS’ focuses, such as functional status and rehospitalization. Foster says this latter quality indicator, in particular, has been an historic pain point in the industry.

"We’re just worried about the people that keep going back and forth to the hospital as [if through] a revolving door," she explains. To combat this issue, Foster says restorative programs should target services that have traditionally landed residents back in the hospital even though SNFs are equipped to render them, such as providing extra hydration through IVs.

Currently, Foster?who has extensive experience helping facilities implement restorative strategies?says many providers are failing to capitalize on the benefits of a formal restorative program, instead opting for one-off interventions (e.g., designating nursing staff to take residents for a walk once or twice a week) and dedicating the bulk of their resources to enriching therapy offerings. Although some experts say that therapy has been gaining priority throughout the industry as an adaptation to today’s influx of patients seeking short-term intensive SNF rehab services, Foster argues that restorative nursing is a more sustainable practice in some respects. For example, she says that Medicare-covered SNF therapy services have federal cost caps, while restorative programs oftentimes have no mandated expiration date.

Thus, Foster urges providers to shift some of their focus to modeling restorative programs after their often more robust therapy counterparts (e.g., by framing the program with concrete, measurable goals). Not only does Foster believe a restorative mindset will align a facility’s practices with large-scale regulatory shifts, but she says it can breed better connectivity between therapy and nursing departments, thereby fostering a unified vision of care.

In order to build a restorative program that can achieve these manifold benefits in time for the implementation of QRP and VBP measures, Foster says providers need to get started soon.

"It’s going to take you a year to get it right," she explains, citing chronic industry shortfalls as barriers to speedy implementation.

In particular, Foster says providers need to strengthen communication with physicians and the families of residents. She believes many rehospitalizations can be attributed to insistence by families that a SNF readmit a resident to the hospital for any change in condition?even one a facility is capable of remedying.

"When nurses call the families to let them know … "Something’s changed in your loved one," families are notorious for saying, ‘We’ll just send them to the hospital,’ and that’s what [SNFs] do," she says.

To combat families’ reflexive panic and facilities’ equally knee-jerk acquiescence, Foster urges SNFs to sit down with partnering physicians to write a concrete strategy for addressing condition changes. The document should list the specific events a facility can handle on its own and detail the procedures it will use to do so. This will arm SNFs and physicians with an official document to assure families that the SNF is well-equipped to stabilize their loved one’s condition after certain adverse events.

But SNFs’ current communication shortfalls aren’t restricted to external stakeholders, according to Foster, who also charges the industry with insufficient education, particularly among frontline staff. In turn, these lapses can trigger subpar care, inaccurate documentation, and high turnover among mismanaged and frustrated employees. For example, Foster says that documentation among a facility’s CNAs can be erratic and inconsistent, especially regarding a given resident’s functional status, which must be captured multiple times each day and can be evaluated very differently by varying frontline staff members.

To begin clearing up disparate clinical understandings, Foster recommends focusing training efforts around the component of the MDS that corresponds to functional status. "If nothing else, just teach Section G," she says?a directive that seems particularly fitting, given the potential implementation of Section GG, which would build on the functional data already captured today.

Beyond ramping up education, Foster proposes an unconventional solution for warding off critical quality lapses: establishing a mentor program that assigns a qualified staff member to remain by each newly admitted resident’s side for the first two days of his or her stay, a period during which Foster believes the lion’s share of adverse incidents occurs.

"Everything bad happens within the first 48 hours of admission," she says, explaining that she’s seen mentor programs targeted to this time frame reduce fall rates.

But before getting too caught up in planning any full-fledged program refurbishments, McCarthy urges providers to take advantage of the public reporting period on the proposed rule?in effect through June 15?to point out to CMS any perceived issues, discrepancies, or oversights (e.g., surrounding the PBJ and SNFRM) that could jeopardize the future success of their facility.

"Providers really should use that opportunity to voice their concerns to CMS on what issues they think may negatively impact them," she explains. "Because once they become public, they become public, and there’s no opportunity to correct the information that’s out there."

In many respects, the proposed rule provides a first glimpse into CMS’ big-picture plans for the industry in the years ahead. Although it glazes over some key nuances of the agency’s potential execution strategy, Brandt is optimistic the proposal will ultimately introduce new, more reliable methods of upholding virtuous SNFs that have been overshadowed in recent years by the industry’s small, yet potent faction of abusers.

"I think that all the good, decent, honest nursing home operators have ever asked for was a fair chance and to be measured realistically on a level playing field, and I think this is a great step in that direction," she says. "I’m excited to see what’s going to happen in our industry in the coming years."

HCPro.com – Billing Alert for Long-Term Care

Credentialing & Peer Review Legal Insider, October 2016

Interstate Medical Licensure Compact Commission proposes licensure process

The medical licensing tool aimed at expediting the process through which physicians can obtain licenses to practice in multiple states is one step closer to becoming a reality as more details of the process come into focus. Once it’s up and running, the Interstate Medical Licensure Compact will allow physicians licensed in one participating state to gain licensure in other participating states without having to repeat the entire licensing process in each state.

The Interstate Medical Licensure Compact Commission, which is responsible for the compact’s governing rules and administration, recently released a proposed process for expedited licensure through the compact and opened the period for public comments. The commission will consider the proposed rule at its meeting in early October.

 

The expedited licensure process

The basic process is the same as the one outlined in model legislation released two years ago, says Ian Marquand, chair of the Interstate Medical Licensure Compact Commission. Under the newly proposed process, a physician applies for expedited licensure via the compact through the state where he or she claims principal licensure. The state of principal licensure is where the physician resides, practices, is employed, or files a federal tax return.

"The physician will have to provide some information so that we can make sure that state is legitimately the state of principal license. A physician can’t willy-nilly pick a state in the compact," Marquand says. The applying physician will also have to pay the commission a service fee and submit to a criminal background check through a law enforcement agency, including providing fingerprints or other biometric data.

"There are no heavy applications at this point. The point of this is to make it much easier for a physician to get licensed in additional states and for much less time and energy expended," he says.

The principal licensure state would then review the applicant’s qualifications to determine if he or she is eligible for expedited licensure, perform a criminal background check, and issue a letter to the applicant and the compact commission verifying or denying the physician’s eligibility. Once the applicant receives that letter, he or she can then select from which member states to request expedited licensure and pay those states’ licensure fees. The relevant member boards would then issue full and unrestricted licenses to the applicant. Those licenses would be valid for as long as any other full and unrestricted license normally issued by that state board.

 

Application turnaround time

There is not a set amount of time to process the application for licensure through the compact due to several variables, Marquand says. These variables include how quickly the physician goes to a law enforcement agency to get fingerprinted, the amount of time necessary to complete the criminal background check and deliver the results to the medical board at the state of principal licensure, and how long it takes that state of principal licensure to review the criminal background check and the applicant’s other details (e.g., board certification and medical education).

A few test runs of the process have been performed in Marquand’s home state of Montana. "We find that it only really takes a matter of hours but it’s not the only thing our people have to do. So where it falls in the queue depends on how long it’s going to take for our people to actually get to do the work. That’s a variable. The communication between a state of principal license to compact commission and then compact commission to receiving state, I don’t think those should take very long at all."

In contrast, the applicant’s responsiveness will be a factor in the turnaround time. Marquand provides a hypothetical scenario to illustrate this point: Dr. Smith, whose state of principal licensure is Montana, applies for licensure in three additional states through the commission. He is prompt about providing his fingerprints and submitting to the criminal background check, which allows the staff in Montana to process his application fairly quickly. In a matter of days Dr. Smith is certified by the commission but then puts off paying the licensure fees.

"We can’t do anything until the fees have been paid. So if the physician is slow about paying fees, that’s on them, not on us," Marquand says. "But once the fees are paid and delivered to the receiving states, we don’t expect [the states] to take very long in issuing the license."

To help motivate physicians to stay on track with their applications, the proposed rule sets a 60-day limit for the applicant to submit all requested materials.

"With every application in the professional licensing world, there’s an expiration date on the application. It doesn’t sit there forever waiting for you to finish. If you don’t get it done, it expires. Putting a 60-day limit on that seems pretty reasonable to me," he says.

Returning to the example of Dr. Smith, Marquand says if the physician applies through the compact commission, pays the initial processing fee but then doesn’t have his fingerprints taken and is unresponsive to the commission’s requests for information for more than 60 days, the application is withdrawn.

"It put some onus on the physician to take some action. But will it take 60 days for processing? No, that’s just the time we give the physician to get any information that we need. But I can’t imagine that happening very often, if at all." Marquand says.

Once a physician is certified through the commission, that certification is valid for one year. This means that if Dr. Smith initially selects one compact state for licensure, such as Wyoming, and then decides six months later that he wants a license for Idaho as well, he will not have to reapply, Marquand says. Dr. Smith will simply need to inform his state of principal licensure?Montana?that he’d like to practice Idaho. The board in Montana will notify the commission and then Idaho will issue the license fairly quickly.

"The only thing that would preclude that would be if Dr. Smith gets in trouble with either the Montana or the Wyoming board and his license is suspended. Then his compact eligibility goes out the window," he says.

When a physician’s license is suspended, it is the responsibility of the member state in which the disciplinary action occurred to notify the commission, which in turn, would notify all the states in the compact. At that point, it would be up to each individual state to decide what to do.

"It’s presumed that reciprocal discipline will happen very quickly. So if Dr. Smith gets in trouble in Wyoming, Wyoming reports him to the commission and Montana would probably take very swift action to suspend his license there, Marquand says. "And if he’s licensed anywhere else in the compact, those states would have the option of doing the same. We want to at least make it possible for very swift action in all the states.

He adds that there are circumstances where reciprocal discipline is automatic, such as when a license from a state of principal licensure is revoked, suspended, or surrendered. In such cases, states can change that automatic action to something else, if they choose. So while states would have some discretion, it may come after an initial action.

Physicians who retain clean records and maintain their qualifications would be able to obtain licenses in as many compact states as they want within a year of achieving certification from the commission, as long as they’re willing to pay the fees.

 

Work to be done

Some details of this process have yet to be finalized. For example, the amount of the commission’s processing fee has yet to be determined. The commission will likely take up this issue by the end of the year.

"Each individual state within the compact also needs to have its own discussion of whether it wants to charge an application fee to cover the cost of reviewing the physician’s qualifications," Marquand says. In Montana there is a proposal put forth for a $ 100 fee. That proposal still needs to go through a public comment period and receive final approval from the state medical board.

After considering the provisions of the proposed rule, the commission will have several options: Adopt the rule as-is, adopt it with amendments, send it back to the committee for more work, or scrap it completely.

"I’m certainly optimistic that the commission will adopt these. And whether there are any changes suggested to them through comments, we’ll deal with them. I think the commission is anxious to get these rules in place and move on to the next topic," Marquand says.

If the commission decides that the proposal requires significant changes, the rule could be brought back to the commission as early as December.

Work on the application portal for expedited licensure is also underway but an open date has not been announced, Marquand says. However, the commission has set January 2017 as the target date for the first licenses to be issued by a member state using the compact process.

To assist with all the work that remains to be done, the U.S. Health Resources and Services Administration (HRSA) recently announced a $ 250,000 annual grant for three years to help the commission get up and running. The grant, which was requested by the Federation of State Medical Board, underwrites the cost of the commission.

"That takes a huge load off on us as commissioners. We know that through that grant there will be money available to cover technical costs, meeting costs, and maybe even staff costs for the next three years," Marquand says. He forecasts that after the three years, the commission should be able to stand on its own financially and operate on the service fees it collects.

 

Telemedicine

Often the Interstate Medical Licensure Compact is discussed in the same breath as telemedicine but Marquand emphasizes the distinction between the two. The compact relates exclusively to licensing and therefore does not provide any rules, regulations, or even any guidelines on the use of telemedicine. Although physicians or health organizations may want to use it to allow their own practice or corporate practice to expand into more states, they will still need to follow the regulations of those states once licensed.

"I understand that there may be benefits of the compact for physicians who want to do telemedicine in more places, but that’s not specifically why the compact exists. The compact exists for licensed physicians to get licenses in other states quickly and efficiently, regardless of what kind of practice they want to do," Marquand says.

He recalls this topic came up at a press event in Washington, D.C., designed to promote the compact to members of Congress and major healthcare organizations. When the question was posed of who would be the major user of the compact?large healthcare organizations that want to use telemedicine, or individual physicians who want to expand a practice across state lines either in person or by telemedicine?the answer that came back was it would likely be both.

"Here’s how I look at this: Think of two parallel highways. On one, there are physicians using telemedicine. The compact is on the other, with ramps between them," he explains. "The folks on the telemedicine highway may take a ramp over to the compact highway to get additional licensure, but then they’ll get back on the telemedicine highway."

 

Moving forward

As this issue of CPRLI went to print, 17 states have enacted compact legislation and nine others have introduced it. Marquand is optimistic more will adopt legislation.

"There are a couple that haven’t quite got to the finish line and we understand there are going to be states that are on the sidelines, waiting to see what the commission does and see how the compact really works," he says.

That’s why Marquand says the work the commission is doing to get the compact up and running is so important. The successful operation of the compact will be the commission’s biggest promotional tool for convincing additional states to participate. The hope is to bolster the case for joining once the commission has concrete figures on time frames and the number of licenses issued.

Protecting your facility from successful plaintiff litigation

Identifying red flags within credentialing applications can be the first step to protecting yourself and your facility from a successful plaintiff litigation. In the on-demand webcast, Negligent Credentialing: Best Practices to Prevent Successful Plaintiff Litigation, expert Mark A. Smith, MD, MBA, FACS, discusses ways to recognize issues within a credentialing application that require immediate action or additional questioning. Smith also provides best practices an organization should adopt to prevent credentialing-based lawsuits.

At the end of this on-demand program, participants will be able to:

Identify at least three red flags in credentialing applications that require action or explanation

Know what a negligent credentialing claim entails

Assemble the necessary documentation to help combat negligent credentialing

 

For more information or to order this webcast on demand, visit http://hcmarketplace.com/negligent-credentialing-best-practices-to-prevent-successful-plaintiff-litigation.

 

 

OCR ramps up HIPAA enforcement efforts

The Office for Civil Rights (OCR) stepped up HIPAA enforcement in a big way this year. The agency handed down more than $ 5 million in HIPAA settlement fines in one week in March, and in July reached a HIPAA violation settlement with Advocate Health Care in Illinois that carried a $ 5.55 million payment. OCR kicked off phase two of its HIPAA Audit Program and will likely complete desk audits of covered entities (CE) and business associates (BA) by the end of the year. Comprehensive on-site audits may occur early in 2017.

However, breaches continue to come at a relentless pace and questions have arisen about OCR’s handling of HIPAA violations, particularly repeat HIPAA offenders. And a truly permanent HIPAA audit program may not yet be in sight: OCR states that phase two audits will help the agency plan for a permanent audit program but doesn’t state when that might launch.

In a September 2015 report (https://oig.hhs.gov/oei/reports/oei-09-10-00510.pdf), the Office of Inspector General (OIG) said OCR?and the U.S. Department of Health and Human Services (HHS) as a whole?should strengthen its oversight of CEs and be proactive rather than reactive in its approach to HIPAA enforcement. The report found that in 26% of closed privacy cases, OCR did not have complete documentation of corrective actions taken by CEs. In addition, OCR’s case tracking system has significant limitations and makes it difficult for the agency’s staff to check if a CE under investigation has been the subject of previous investigations.

All of this may make some CEs and BAs feel that HIPAA compliance is merely optional, and that leads to a weaker privacy and security culture throughout the industry. Although OCR does take action to make its presence felt, it could do more, Frank Ruelas, MBA, principal of HIPAA College in Casa Grande, Arizona, says.

"I do believe that OCR is trying to let people know that it considers HIPAA compliance an important objective," he says. "With its guidance and ongoing alerts about the occasional enforcement actions here and there, I see OCR’s enforcement a small step above being a paper tiger in terms of how seriously people take it."

The waiting game

The OIG’s September 2015 report wasn’t the first time that agency has found fault with HHS and OCR’s methods, Kate Borten, CISSP, CISM, HCISSP, founder of The Marblehead Group in Marblehead, Massachusetts, says.

"OIG has published a number of reports over the years, identifying problems with HHS’ oversight and enforcement of these HIPAA rules," she says. "I know of no one in the profession who reads the OIG reports and disagrees."

But HHS and OCR have been slow to take action. More than five years passed between the end of phase one of the HIPAA Audit Program and the announcement of phase two, and OCR still has obligations it’s failed to fulfill. The agency’s slow pace may lead some to take it, and HIPAA, less seriously.

"Since the latest round of rule changes back in 2010, over six years ago, there are still outstanding rules and unmet commitments by HHS and OCR," Ruelas says. "In the end, it not only erodes credibility but also questions just how seriously is OCR taking its enforcement duties."

 

Another day, another fine

HHS and OCR regularly announce breach settlements, but 2016 saw a flurry of high-profile and costly settlements. OCR took the opportunity to make examples of a number of CEs and BAs in its statements, calling attention to the particular violations that tipped the settlements into the hundreds of thousands, or even millions, of dollars.

Although the settlements grab attention and headlines, it may be difficult to determine their positive impact. Some of the HIPAA violations in question date back years. Staff who worked at the organization, and may have been involved in the breach, are likely gone. Even administrators, executive leaders, and owners may change in that time. Some organizations may see OCR’s enforcement actions as too little, too late, Mac McMillan, FHIMSS, CISSM, cofounder and CEO of CynergisTek, Inc., in Austin, Texas, says.

"We all want the same thing: to see our industry do better," he says. "This is just more of the same old, same old. Same issues, different players."

A HIPAA settlement fine might be a crushing blow to a physician practice or small home health or physical therapy organization, but even the largest fines might not make an appreciable impact on larger organizations, McMillan says.

"To be really impactful, there will probably need to be more, they will need to happen closer to the actual event they’re related to, and possibly the fines will need to be bigger," he says. "The fines levied were really not substantial fiscally, and there was no accountability for those responsible for making security decisions, so they pay and move on."

Borten agrees that the long period of time between when a breach is reported and when OCR takes action lessens the impact. "The response or punishment must rapidly follow the event to have a significant impact on future behavior," she says.

Although some find California’s short breach notification timelines and black and white faxing rules burdensome, these measures have caused CEs and BAs to change their behavior and improved privacy and security, McMillan says.

Some CEs and BAs may be willing to take the chance they won’t be caught, Ruelas says. "I truly think that people see enforcement a lot like getting hit by lightning. However, if it does occur, it tends to be a game changer and does make for an interesting day."

But whether the change is meaningful or widespread may be difficult to determine, and any alteration to OCR’s HIPAA enforcement practices would likely be an improvement, he adds.

 

Learning from others’ mistakes

However, CEs and BAs can get something out of HIPAA settlements. Conscientious entities will fulfill the terms of the corrective action plan and even improve on it. And other CEs and BAs can take valuable lessons from OCR’s breach announcements. The agency often draws attention to specific issues that led to the breach, levies a pricey fine, and points out how the organization could have avoided the problem in the first place.

"HIPAA enforcement actions are important teaching tools," Borten says. "Workforce members can be asked if the same problem could arise in their organization, and how individuals can avoid the same fate."

Many privacy or security failures that lead to breaches are the result of human error and are still relevant regardless of when the breach occurred, she adds.

Although the security landscape has expanded beyond missing laptops and smartphones, Ruelas says there’s still a lot CEs and BAs can learn from these enforcement actions. Organizations may see ransomware, phishing, and privacy and security breaches on social media as the biggest threats?and rightly so. Yet many breaches still come down to 10-year-old HIPAA basics: misdirected faxes, incorrectly addressed emails, or handing the wrong documents to a patient.

 

While human error is still a concern, McMillan is most worried about the increasing number of breaches due to hacking, particularly the greater loss of data due to hacking and the effects such breaches have on the industry. "Human errors are still an issue, but the relative impact of those incidents compared to the impacts we see from hacking recently pales in comparison. Many of those attacks were the result of misconfigured or poor administration of systems resulting in serious outages and millions of lost records," McMillan says. "This is where OCR needs to focus attention."

 

Phase two

The launch of phase two of the HIPAA Audit Program may promise some positive change. The audits are intended to help the agency improve HIPAA guidance and tools and pinpoint common problems and challenges CEs and BAs face. Desk audits of CEs began in July, with BAs scheduled to follow in the fall. However, it may take 90 days after submitting documents for CEs to receive a draft audit report. Until then, it will be difficult to predict what OCR’s response to the audits might be.

The audit reports will not be made public, although OCR representatives indicated they will likely be available through a Freedom of Information Act request. Sharing some data might help CEs and BAs.

"I do think that if audit results can somehow be summarized and shared, just by their detailed nature, the audits can be wonderful sources of information for the HIPAA community," Ruelas says.

It took three years for the agency to update the audit protocols to reflect changes made by the HIPAA omnibus rule, he adds. It’s too soon to tell how long it might take the agency to revise or refocus its guidance based on the results of the phase two audits, but it would no doubt be beneficial for all CEs and BAs to see results sooner rather than later.

Establishing a permanent audit program is one of OCR’s responsibilities under HIPAA, and the agency’s failure to develop one has drawn criticism from the industry and from other regulatory agencies such as the OIG. OCR agreed with the OIG’s latest call for a permanent audit program. Phase two is an encouraging step in that direction, but still not quite enough.

"It has been very vocal on its commitment to establishing an effective and permanent auditing program," Ruelas says. "Let’s see if it really is going to walk the talk."

 

Legal and regulatory news roundup

Find out what’s happening in the world of federal healthcare regulations by reviewing some recent headlines from across the country.

 

EMTALA violations declining

The number of U.S. hospitals cited for violating the Emergency Medical Treatment and Active Labor Act (EMTALA) has decreased over a 10-year period, according to a study published in the Annals of Emergency Medicine. Researchers analyzed a list from CMS of EMTALA investigations conducted from 2005?2014 and found that the percentage of U.S. hospitals cited for violations citations decreased from 5.3% to 3.2%. The percentage of hospitals investigated also declined during this period from 10.8% to 7.2%.

EMTALA aims to prevent the practice of discharging or transferring patients to other hospitals before stabilizing treatment is provided for emergency medical conditions. It requires hospital emergency departments to provide medical screening examinations to patients seeking medical treatment regardless of their ability to pay, citizenship, or legal status.

 

Stark Law, EMTALA violation penalty amounts increase

Due to several years of inflation, the U.S. Department of Health and Human Services recently issued an interim final rule that calls for steeper maximum penalties for violating federal regulations, including EMTALA and the Stark Law.

For hospitals with more than 100 beds, the maximum penalty for an EMTALA violation is $ 103,139, up from the previous maximum of $ 50,000 set in 1987. For hospitals with less than 100 beds, the maximum penalty is $ 51,570, up from $ 25,000.

Circumventing the Stark Law’s self-referral restriction can now result in a maximum penalty of more than $ 159,000, up from previous maximum of $ 100,000 set in 1994. Submitting claims in violation of the Stark Law can result in a penalty of nearly $ 24,000, up from $ 15,000.

 

Home health agency owner sentenced for healthcare fraud, kickbacks

Khaled Elbeblawy, the former owner and manager of three home health agencies in the Miami area, will spend 20 years in prison for his role in a scheme that fraudulently billed Medicare for millions of dollars.

Elbeblawy was sentenced to prison and ordered to pay more than $ 36 million in restitutions following his conviction in January of one count of conspiracy to commit healthcare fraud and wire fraud and one count of conspiracy to defraud the United States and pay healthcare kickbacks. According to evidence presented at trial, from 2006?2013, Elbeblawy and his co-conspirators claimed to have provided medically necessary home health services to Medicare beneficiaries through the three agencies: Willsand Home Health Agency Inc., JEM Home Health Care LLC, and Healthy Choice Home Services Inc. In reality, those services were either medically unnecessary or never provided. The conspirators also paid kickbacks to physicians, patient recruiters, and staffing groups for referrals of beneficiaries.

In all, Elbeblawy and his co-conspirators submitted $ 57 million in false or fraudulent claims and received approximately $ 40 million in payments. In 2012, Eulises Escalona, a former owner of Willsand and JEM, pled guilty to one count of conspiracy to commit healthcare fraud and was sentenced to 10 years in prison. Cynthia Vilches, former co-owner of Healthy Choice, also pled guilty to one count of conspiracy to commit healthcare fraud and is awaiting sentencing.

Healthcare systems calls for dismissal of antitrust lawsuit

Carolinas HealthCare System (CHS) has argued that the joint antitrust lawsuit filed against it by the U.S. Justice Department and the North Carolina Attorney General’s office has no basis. According to the Charlotte Observer, the lawsuit alleges CHS uses its size to drive up prices to prevent competition. CHS operates 10 hospitals in the Charlotte area. Its closest competitor, Novant Health, operates five.

The lawsuit alleges CHS uses its clout to encourage health insurers to steer patients away from other lower-priced hospitals and toward CHS hospitals.

In asking for a dismissal, CHS has said the lawsuit has failed to allege any actual competitive harm to the marketplace.

Exciting updates: More content, tools, and news at your fingertips!

The challenges healthcare professionals tackle each day don’t wait for solutions, and neither should you. That’s why Credentialing & Peer Review Legal Insider (CPRLI) is transitioning to a more frequent and robust publishing model this fall by combining with the Credentialing Resource Center (CRC)’s flagship publication, Credentialing Resource Center Journal (CRCJ), to create a single source for all your credentialing, privileging, peer review, and legal news, tools, and best practice strategies.

Your updated member benefits gain you access to expanded content and tools on CRC?with new resources added weekly to the website (www.credential-ingresourcecenter.com). Plus, as a CRC member you gain instant access to over 300 clinical privilege white papers, core privileging forms, Medical Staff Talk, and Credentialing Resource Center Daily (CRCD), CRC’s daily e-newsletter for medical staff leaders and MSPs. If you are already a CRC member, you will continue to receive the news and analysis you’ve come to rely on, plus expanded member benefits this fall.

To help readers keep tabs on available content, we will announce new articles in CRCD. At the end of each month, we’ll roll the corresponding weekly articles into a digital issue of the newly expanded 16-page CRCJ that mirrors the current digital format.

As a member of CRC, you can continue to download and print high-quality PDFs of the current issue, as well as several years of back issues of CRCJ and CPRLI, directly from CRC’s website. We’re looking forward to delivering your peer review and credentialing guidance in a timelier, efficient, and more convenient manner.

Stay tuned for additional details as we near implementation. In the meantime, feel free to contact Editor Son Hoang at [email protected] with any questions.

 

HCPro.com – Credentialing and Peer Review Legal Insider

Case Management Monthly, August 2016

CMS puts short-stay audits on hold

Learning objective

At the completion of this educational activity, the learner will be able to:

  • Identify what prompted CMS’ decision to temporarily suspend 2-midnight short-stay Quality Improvement Organization audits and what the decision means for compliance efforts

 

There’s good news and bad news on the 2-midnight rule front.

The good news: CMS has put short-stay inpatient audits related to the 2-midnight rule on hold as of May 4.

The bad news: This isn’t a free pass, and it isn’t going to last.

"Response at hospitals should be to do nothing different," says Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health in Chicago. "Follow the rules on every case. This is not a three-year delay; the audits will resume soon, and we have no idea if the look-back period will be altered to account for this delay."

 

The May announcement

Livanta, one of the two Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIO) charged with conducting 2-midnight rule compliance audits, posted a notification about the audit suspension on its website: http://bfccqioarea5.com/twomidnight.html. The announcement stated:

On May 4, 2016, CMS notified the BFCC-QIOs of a temporary pause of Two-Midnight Reviews in order to improve standardization across the program. During this period, Livanta will be collaborating with CMS and the other BFCC-QIO to ensure consistency in how the rule is applied to QIO case review. If your facility has submitted Livanta requested medical records, they will remain in the pipeline for review upon further direction from CMS. Going forward it is CMS’ intention that providers will have at least six weeks to implement changes prior to the next round of BFCC-QIO reviews.

 

"It seems that inconsistencies had resulted in many complaints, which is what prompted the suspension," says Stefani Daniels, RN, MSNA, CMAC, ACM, president and managing partner at Phoenix Medical Management, Inc., in Pompano Beach, Florida.

This suspension marks the second time CMS auditors have apparently fumbled 2-midnight rule interpretation. Medicare Administrative Contractors who conducted the initial probe and educate audits of the 2-midnight rule were also accused by hospitals of misinterpreting the standard?and hospitals had hoped that having BFCC-QIOs take over the task would solve the problem, says Hirsch. Unfortunately, it appears BFCC-QIOs are running into the same challenge.

When the BFCC-QIO audits first began back in October 2015, they brought some unwelcome surprises. Many hospitals anticipated that the reviews would only look at records from October 2015 forward. But hospitals soon began reporting that BFCC-QIOs were requesting records for cases as far back as May 2015, according to Hirsch. That wasn’t the only issue?BFCC-QIOs were also missing deadlines. Audit results were late, and the BFCC-QIOs were slowing the scheduled education for providers.

This created two problems for hospitals. First, the late BFCC-QIO audit results meant that hospitals with denied claims were poised to miss the filing deadline to rebill denied claims to Part B. Because of the delays in scheduling education related to the first round of claim denials, hospitals didn’t have an opportunity to understand their mistakes and fix them before the next set of audits began.

In addition, there was also some online buzz that BFCC-QIOs were misinterpreting the rule, says Hirsch. The main problem: benchmark admissions. Some hospitals reported that BFCC-QIOs were routinely denying inpatient admissions when patients spent one night as an outpatient in the emergency room or in observation services before they were admitted. This was the case even though these patients then spent a second night in the hospital as an inpatient that the physicians documented as medically necessary. This is a clear misinterpretation of the rule, says Hirsch. In other cases, the BFCC-QIOs were also denying the second midnight due to a lack of medical necessity, essentially overruling the judgment of hospital physicians.

 

Moving forward

As of presstime, it was unclear when the audits were going to resume or what the outcome of the suspension would be. In the meantime, though, hospitals should continue with business as usual?after all, it’s always good practice to assume claims will be audited and to be prepared for such a situation.

Best practices to follow to prepare for audits include those listed below:

  • Review every short-stay admission?those between zero and one day?prior to billing.
  • Ensure every patient’s status is appropriate up front, says Hirsch. Review the chart of every patient that goes upstairs.
  • Use the physician advisor to check compliance on cases that are murky to ensure they meet one of the exceptions under the 2-midnight rule. Change cases that don’t meet an exception using condition code 44. If the problem isn’t discovered until after discharge, self-deny and rebill the claim.
  • Ensure that case managers and physicians are up-to-date about any potential changes to the 2-midnight rule and how to comply with them.

 

In addition, it’s important to understand how audits work and be aware of any changes that will occur when they resume. KEPRO said before the audit suspension that auditors of short-stay claims need to see the following two components:

1.Documentation of medical necessity

2.Application of the 2-midnight rule

 

Reviewers also were charged with looking for quality-of-care issues and will validate coding associated with the claims. Before the suspension, a nonphysician using InterQual® would perform the first BFCC-QIO audit. If the case fails the initial review, a physician review would then follow, which is based on the physician’s medical judgment

Specifically, the physician reviewer would look at:

  • Acuity of the patient’s signs and symptoms
  • Medical predictability of adverse events
  • Need for diagnostic studies

 

Another concurrent review was designed to look at physician documentation to ensure patients needed hospital-level care and that their admission was not for social, custodial, or convenience reasons.

Ultimately, when it comes to BFCC-QIO reviews, the advice remains the same despite the temporary suspension: Stay on top of this issue, make sure physicians are assigning patients to the proper status, and ensure docs have the documentation to back up their decisions.

 

Ask the expert

Navigating the skilled nursing benefit for Medicare

Learning objective

At the completion of this educational activity, the learner will be able to:

  • Identify strategies to help patients who don’t qualify for inpatient admission find postacute options

 

Assigning the correct patient status is important not only to ensure that the hospital gets accurate payment for a patient stay, but also to ensure that the patient receives access to the postacute benefits to which he or she is entitled. One of the more problematic topics in this arena is the three-day inpatient stay required by Medicare for a patient to qualify for a covered postacute stay in a SNF. One reader submitted the question below on this topic, and we asked Janet L. Blondo, MSW, LCSW-C, LICSW, CMAC, ACM, CCM, the manager of case management at Washington Adventist Hospital in Takoma Park, Maryland, to supply an answer.

 

Q: As a case manager, I already know that my patients placed in observation don’t qualify to use their Medicare SNF benefits after a hospital stay. However, family members often oppose a patient’s discharge date, citing safety concerns and demanding that the patient be admitted as an inpatient for three days so that he or she can be transferred to a SNF to use the patient’s Medicare SNF benefit to pay for nursing home care. What do I do when the patient’s family members resist the plan of discharging their loved one home?

 

A: Family members often become concerned about how their loved one will manage when there is a change in the patient’s ability to provide self-care. An injury or illness that results in a hospital stay?even a short one?can prompt a temporary or permanent loss of function. Patients and families may have some knowledge that insurance could pay for some rehabilitation services.

Beginning in August 2016, the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act requires all hospitals to explain to patients?both verbally and in writing?what it means when they are placed in observation. The NOTICE Act also compels the hospital to inform patients that they do not qualify to use their Medicare SNF benefits to recover from a hospital stay. This may result in more patients demanding that they be admitted for inpatient care.

Despite the current emphasis on population health, few patients have long-term care plans in place. This means that seniors are caught unprepared after a short stay in hospital observation care. They may not be able to return to a home that lacks a 24-hour caregiver or that has stairs they can no longer negotiate.

Patients and family members often believe that their insurance, Medicare, will pay the entire cost for care in a nursing home. They don’t fully understand the difference between skilled versus custodial care, or that if Medicare does provide coverage, it won’t pay the entire cost of care and will cover costs only for a short time.

Since explaining the above information to patients can be challenging, the smart case manager should get busy and assess what options are available to the patient. First, review the situation and determine that the patient truly does not meet inpatient criteria. When in doubt, refer the case to your physician advisor without delay.

The 2016 OPPS final rule, CMS-1633-F, effective January 1, 2016, allows the physician to document the need for inpatient care based on a set of "complex medical factors," which include:

  • Severity of signs and symptoms
  • Current medical needs
  • Risk of an adverse event occurring

 

Qualifying for inpatient care does not mean a patient must require hospitalization that extends for more than two midnights. If the patient truly does not meet inpatient criteria, next determine if he or she is a candidate for acute rehab. Acute rehab does not require a prior three-day or greater hospital stay. Does your patient have Medicare Part C? A managed Medicare plan does not require an inpatient stay of three days or more, although it does require an authorization for a SNF benefit.

Some secondary payers will cover a rehab stay in a SNF. Look at all of the patient’s insurance policies and call the payers. A Medigap policy will pay only if Medicare pays, which requires a three-day inpatient admission. Some patients, however, are covered by a spouse’s policy or have a policy from a previous job that is not a Medigap policy?these policies will potentially cover a SNF stay.

Ask if the patient has been in a nursing facility prior to the current hospital stay while using his or her Medicare SNF benefits. If the patient was in a SNF after a three-day qualifying hospital stay, and his or her discharge from the SNF was within 30 days of the expected date of admission for the new SNF stay, then chances are the patient’s stay will be covered under Medicare.

Case managers often don’t ask about private-pay funds. Patients may pay privately for care in a nursing home. Ask if the patient has a long-term care policy that will cover the cost. Alternatively, the patient’s family may assist with the funding. Some patients who own a home use a home equity line of credit to pay for the cost or apply for a reverse mortgage.

Applying for long-term care Medicaid is an option, but this can take a long time, and many nursing homes want a source of funding at the time the patient enters the facility.

A patient can also go home with family members who are able to help with care until the patient is able to make a more permanent plan. Family members who work can apply for family and medical leave while they are serving as caregivers.

Adult medical day care facilities also have all-day programs where patients can be cared for during the day while family members work. Patients can receive nursing education about their illness, undergo blood pressure and blood sugar checks, and receive physical and occupational therapy. Payment is provided through sliding-scale or private-pay funding, or by community Medicaid.

Finally, patients may benefit from skilled home health care services, covered by insurance or by private-duty aide care paid for with the patient’s (or family’s) funds.

If, after reviewing these options, none are acceptable to the patient or family, you may have to give the patient the Hospital-Issued Notice of Noncoverage, or HINN, which notifies the patient that you do not anticipate the hospital bill or subsequent rehab will be paid by Medicare. The notice may help the patient determine what course of action to take.

 

Editor’s note: Got a question? Email it to us and we’ll send it to one of our experts. Send questions to Kelly Bilodeau at [email protected].

 

10 things you should know to ensure successful discharge planning

Learning objective

At the completion of this educational activity, the learner will be able to:

  • Identify strategies to comply with proposed Medicare changes to the discharge process

 

One of the more challenging aspects of a case manager’s job is helping to ensure a patient successfully transfers from the hospital to the next level of care. Under a set of proposed revisions to Medicare’s Conditions of Participation (CoP) announced in November 2015. This job may get even harder, more specific, and apply to more patients. The changes, among other things, will require hospitals, including critical access hospitals, to create discharge plans for more patients. Case managers will need a more direct plan to include patients and their caregivers in the discharge planning process, in particular taking into account their individual "goals and preferences." This discharge planning process will also need to start sooner?within 24 hours of admission instead.

So what can you do to ensure your organization is up for the challenge? In an April webinar titled "Discharge Planning: Realignment of Standards and Workflow," speaker Jackie Birmingham, RN, BSN, MS, CMAC, vice president emerita of clinical leadership for Curaspan Health Group in Newton, Massachusetts, and Janet L. Blondo, MSW, LCSW-C, LICSW, CMAC, ACM, CCM, the manager of case management at Washington Adventist Hospital in Takoma Park, Maryland, offered up some compliance tips that you can use to ensure your hospital is ready:

1.Assess your current discharge process. Under the proposed changes, the discharge planning process needs to start in the first 24 hours after the patient arrives at the facility. You’ll need to identify how your current processes work in order to make sure they comply with this timeline. Identify your current workflow?specifically, who does what, why they do it, and how it’s done. Ask the following questions:

  • What is your current case management model?
  • Who’s on your team?
  • What’s their role?
  • Who does the screening right now in the current
  • Who does the patient assessment?
  • Who makes referrals when you need to refer patients for services?
  • In your current model, do the nurses perform the assessment for patients who go home while the social workers do the placements? Or do you have nurses and social workers assess everyone? "If you’re having all your patients assessed right now, well, you’re ahead of the game already, because that’s the new proposal," said Blondo.

 

Also think about why your processes were designed the way they are. "If you have it on one unit a certain way and not on another, think about what you need to do to change your practice so that perhaps every unit you can do assessment on every patient," said Blondo. "If your model is something that doesn’t seem to make sense with the proposal, what can you do to change it?"

Changes to bring the model in line could include adding technology (e.g., laptops, tablets) to speed up the process, adding staff members, or reassigning current staff members. "Perhaps some of your social workers can do UR," said Blondo. Alternatively, maybe a staff nurse can do an initial assessment instead of a case manager, or perhaps a nonclinical staff member can take over certain tasks. Taking the time to examine your current processes and think about how they can be switched up to meet the new requirements will give you the foundation for a new plan.

2.Drill documentation. Hold physicians accountable for following through and documenting discharge plans and dates. "If they’re documenting in the chart the discharge date and plan, that makes your job a little easier, because you have that in the chart already and can discuss that with the patient and their family," said Blondo. Take advantage of pre-procedure assessments by ensuring they are included in the chart, then making sure staff members follow through on that plan. "You don’t want Joint Commission or the state coming to do their survey and then you find out the assessment is not getting done because your staff has decided they want to do something different. So make sure everyone is doing the same," said Blondo.

3.Focus on delays. Use these potential discharge changes in the CoPs as an opportunity for process improvement. Look at what’s causing delays in your current process?use this information to improve systems and boost patient satisfaction. "You’re going to improve, perhaps, length of stay with this increased attention with discharge planning," said Blondo.

4.Make rounds count. If you are currently using rounds, examine what they’re being used for and how they’re working. Blondo says it’s important to ask:

  • Are rounds being used for discharge planning?
  • Are they used for the patient experience to improve your scores?
  • Are they used for throughput or for some other reason?

 

After thinking about the current purpose your rounds serve, consider how they can be modified to fit your new objectives. "Many people just do one type of rounds per day, but you could actually be creative with these. There are some hospitals that I know of that divide rounds into different parts of the day," said Blondo. "For instance, you might want to think about doing rounds early in the morning for those patients that will be discharged [later] that day." The discussion could center on determining whether those patients are prepared to leave and have the right resources. Another idea is to add rounds to the short-stay area or outpatient area for procedures done late in the day. "And if you have case managers in the emergency room, you could ask them to round for those areas, catching any patients that might need something late in the day after your regular case management staff have left," said Blondo.

5.Understand patient options. This topic includes both big-picture and smaller issues. Case managers should focus on patient-based issues, which relate to talking to the patient, as well as on setting the patient’s broader goals and preferences. The organization’s systems must be set up to give patients a choice of postacute options. But keep in mind, when working with patients, you’ll always come across those who don’t like what you’re doing or who don’t agree with you and want to go another direction. "You need to have something standardized and something that you can fall back on when you’re presented with a patient and family who, in their eyes, have a reasonable goal and clinically or medically or psychosocially, they don’t," said Birmingham. Staff members must understand the concept of patient choice. "The staff must be comfortable that they are doing the right thing for the patient and the right thing for networks and the right thing for the organization."

It’s also important for staff to understand that the patient has the right to refuse the plan. "[The patient] may be in denial. They may be suffering grief," said Birmingham. The hospital should have a policy for patients leaving against medical advice (AMA), but case management must have its own discharge planning policy for those leaving AMA. In these instances, it’s not just enough to have the patient sign a paper, but rather actively assist the patient with the transition by ensuring that he or she has transportation and needed prescriptions. Even though there is an exemption for patients who signed out AMA and are readmitted the hospital, the hospital should have a plan for how to work with these patients, said Birmingham., said Birmingham.

You should also consider planning for a patient’s deficits related to loss of functioning, whether it be ADLs or IADLs. Birmingham recommended asking the following questions:

  • Is the patient medicated and therefore unable to participate in planning?
  • Does the patient need to have a conservatorship?
  • Is there conflict among the patient’s children or the patient’s siblings?
  • Does the patient have a family or responsible person?
  • Is the patient appealing the discharge?

 

A plan should be in place to address the answers to these questions.

6.Help patients achieve their goals. This is something that organizations should have been doing all along, but there is much more emphasis on it now. A problem arises when the patient’s goals and preferences don’t align with what is medically necessary or what is reasonable and necessary. In these instances, it may be wise to involve social workers. "Look at some of the things that patients might be going through?denial, grief that might affect their decision-making at the time," said Birmingham. "With the family dynamics, there might be family members trying to convince the patient to make a decision that isn’t really what the patient wants." Ultimately, the goal is to help the patient make the decision that is best for him or her, but also to think about what is medically the best option.

7.Involve the physician. Physicians are an integral part of discharge planning, so it’s important to make sure they are actively involved in the process. This communication between the patient and the physician needs to be sensitive to generational and cultural differences. "To involve perhaps some of the older patients, just have the doctor come in and say, ‘We want you to do this,’ " said Blondo. "That might not work for younger generation or baby boomers who are used to rebelling, but if you have the doctor come in and say, ‘This is what we’re recommending and this is why’ and help the patient to understand why it is recommended."

While it may be easier to foster good communication if you’re working with a hospitalist, it can be more of a challenge if the physician is community based. "How will you manage when the patient is transferred to another facility? It’s not been a problem if you’re transferring the patient to another hospital, but if that patient is being transferred to a SNF, there haven’t been that many times when the doctors have called to the doctor in that SNF to give them an update," said Blondo. Have a plan in place to ensure the communication lines are always open.

8.Work to decrease unplanned readmissions and improve patient outcomes. "Readmissions are an old problem with new incentives," said Birmingham. Readmissions can be strongly linked to location and patient access to resources, which shows that they often depend on factors other than the medical treatment the patient received. This underscores the importance of ensuring your patients have access to things like food and transportation when they leave the facility. "Is your [patient’s] area in a food desert? No car, no supermarket store within a mile?and that makes a huge difference," said Birmingham. If this is the case, your organization might want to develop or contact an existing program that delivers food to the homes of qualifying individuals. "Home health agencies could do that too for some programs to be able to provide some fresh groceries to some patients," she said.

Also find out if your patient has been readmitted in the past, a risk factor for readmissions. "You can look to see if a patient is readmitted from an acute level of care, but you’ll need to ask the patient if they’ve been in the emergency room in the past 30 days, if they were admitted from a facility SNF," said Blondo. "Often, that information is sent with them to the hospital, but you can ask them." Ask if the patient was receiving home health services prior to admission. Encourage physicians to include this type of information in the history and physical to ensure it won’t be missed.

"We’re never going to be perfect and have no readmissions, because some patients have a legitimate need to come back to the hospital within those 30 days, but look at your readmissions. Learn from who is coming back and think about what strategies you can put in place for that," said Blondo.

9.Keep the focus where it belongs. "Discharge planning is a patient-centered function," said Birmingham. "You can do utilization review without talking to the patient. You can do quality improvement without talking to the patient and family, but you can’t do discharge planning." For this reason, discharge planning can be very rewarding to clinicians who want to be involved in the patient’s care, and to be there for them when they’re at their most vulnerable.

10.Take your cues from the experts. While Medicare’s CoPs aren’t a cookbook on how to run your organization, they are a good place to start because they’re based on years of evidence. "Many of the changes in the original CoPs happen because commenters send in a comment to CMS and CMS responded and actually changed the proposed rule," said Birmingham. "Now, will they change these proposed [discharge planning] rules? I don’t think so, and I think that’s because they’ve been published as interpretive guidelines for over two years." That means these discharge changes are likely here to stay. Like all other CoPs, they should be blended into your workflow and your strategies and partnerships with other departments, said Birmingham.

 

HCPro.com – Case Management Monthly

Case Management Monthly, September 2016

Case study

Using physician advisors as an agent for change

Learning objective:

At the completion of this educational activity, the learner will be able to:

  • Identify the advantages and challenges of having physician advisors involved in performance improvement efforts.

 

Physician advisors (PA) are an important ally for case managers at many organizations when it comes to ensuring proper patient status. But one organization has greatly expanded the role of PAs to include performance improvement and as a result has seen improvements in everything from readmissions to length of stay.

Ven Mothkur, MD, MBA, LSSBB, the corporate physician advisor at the Franciscan Alliance, a 14-hospital health system based in Illinois and Indiana, says that the organization shifted from an outsourced group of PAs to an internal team of 13 PAs and five physician clinical documentation improvement (CDI) specialists over a one-year period in 2014.

"I think we’re quite traditional in some respects," he says. "The primary function of the PAs is to perform patient status reviews. But what makes the role unique is its emphasis on the PA as a leader in performance improvement."

In the past, PAs at the organization were very much in figurehead roles. That has since changed dramatically. Today, PAs at the health system are still visible leaders but are also engaged, active full-time staff members that serve as a bridge between the medical staff, case management, and the C-suite.

The PAs run daily interdisciplinary rounds and are essentially the physician representative for case management and utilization review, but they are also liaisons between the chief medical officer (CMO) and the chief financial officer (CFO), helping to translate corporate goals into actionable plans. This includes global efforts to improve continuity of care and work as part of multiple accountable care organizations.

When an issue crops up, the PA’s are in a position to investigate the challenge. For example, if the observation rate starts creeping up they may jump in and start asking questions.

"What’s happening on the ground? Is it an issue with a payer? Are they being too delayed in getting back with authorizations? Is it a delay in communication between the attending physicians and case managers? Is it a delay on the end of the physician advisor getting back?" says Mothkur.

This new, "mid-revenue cycle" position allows the PAs to focus on what’s going on in the organization as a whole and help make performance improvements in response.

The health system implemented the new PA program after looking at its outsourced PAs and the value they were bringing to the organization. "When we looked at the cost to benefit ratio, it was just not there," says Mothkur.

The health system realized that there may be a real benefit to having well-respected members of the medical staff take on this role working alongside their colleagues.

Today, the PAs at Franciscan Alliance perform regular status reviews and ensure that the hospital is running a tight ship on the front end, but they also keep an eye on all the organization’s dashboards, metrics, and trends and turn those numbers into performance improvements.

Making the shift to the new model required a multi-step process that began by taking a good look at the organization and its needs.

Below are the main steps an organization will need to take to begin a similar program.

 

Shifting the role of the PA

Step 1: Financially justifying the change. The most challenging aspect of allowing PAs to shift their focus is justifying the change to upper management. "You have to give as much of a financially justifiable ROI as possible to the CFO. They’re the ones who approve it," says Mothkur.

When analyzing data to determine whether changing the focus of PAs, consider all the soft returns on investment, such as decreases in the observation rate, fewer denials, more medical staff engagement, or a higher case mix index, he says.

Step 2: Assessing the need. What are the problems your organization wants to address and will they be best solved by a wholly internal group of PAs or a hybrid model?

Some organizations use internal PAs during the week and switch to outsourced PAs to handle calls on nights and weekends, says Mothkur.

"I think the first step in doing this is to look at where you have huge gaps," he says. One starting point might be to look at the organization’s gross revenue write-offs. If this number is beyond national benchmarks, there may be an immediate and readily apparent benefit to having PAs move in and address the problem areas you find.

Also look at your mix of physicians. Are they primarily employed or independent? It may be easier to gain compliance from employed doctors with educational initiatives while independent physicians may require more intervention from PAs to accomplish the same goals.

Also look for other areas that could use improvement. For example, if your denials are high then your observation rate is high, or you are having trouble with payers then PAs can help smooth over some of these problem areas.

The PAs at Franciscan Alliance have become the oil that keeps the machine humming. If the oil was not there, the machine wouldn’t be operating as effectively. "There are now gaps that are picked up, there is improved compliance, nurses are happier, CM is ecstatic, the CFO has answers to what they’re seeing in numbers, the CMO has a second in command," says Mothkur.

Step 3: Choose the right PA. Finding the right person to fill this challenging role can be difficult. "It’s a matter of identifying the right person who is willing to do it all," says Mothkur. But this person also has to be someone who has the respect of the medical staff, someone who is ready to move on from practicing medicine daily to an administrative role and is excited about the opportunity to make improvements at a hospital level.

This job is not for the physician who took the opportunity in the past to scale back and work remotely, he says.

"Our PAs have to come to the hospital, attend leadership meetings, sit in the medical staff office for lunch, just to be there," he says. "This is very much a full-time job. The docs that we’ve gotten into it say it’s harder than clinical practice."

Often the PAs work 50 hour weeks. They also have to have thick skin, because they need to push back against their peers in some instances.

"It’s hard to find someone like I just described," says Mothkur.

To make its selections, Franciscan Alliance asked the CMO, among others, to identify potential candidates who were well respected, possessed leadership qualities, and were potentially interested in leaving clinical practice. Also look for physicians who have an appetite for looking at data and analyzing numbers.

Step 4: Ensure proper training. Once candidates are identified, training should begin as quickly as possible, says Mothkur. In the absence of formal training programs, organizations often have to cobble together their own programs, which should involve the following:

  • Getting the candidate introduced to and embedded in the case management and CDI departments.
  • Linking PA with educational resources, such as professional organizations like the American Case Management Association, Case Management Society of America, ACDIS, or the American College of Physician Advisors.
  • Ensuring familiarity with different payers and health plans and ensuring proper education on InterQual® and MCG® (formerly Milliman) standards.
  • Encouraging PAs to attend conferences on related topics and to join industry list-servs where PA topics are discussed. "The training is really very much on-the-job training, learning as you go," says Mothkur.

 

Step 4: Follow up. After the initial adjustment period, determine how the PAs are performing by polling case management and other departments, including the medical staff. Don’t be surprised if the medical staff is a little agitated by PAs, after all the job can be and should be a little adversarial.

The relationship between case management and PAs should always be one of mutual respect. A good PA will have respect and empathy for the increasingly complex and evolving case management role. A PA should have the attitude of "how can I help you," says Mothkur.

"There is often a shared bonding [between the PA and case management] over war stories because you’re fighting the same payers," he says.

A functional and positive relationship can pay dividends.

Franciscan Alliance has not only saved money by using an internal group of physicians. The other benefits of this approach include a reduction in the following:

  • Denials
  • Inappropriate admissions
  • Avoidable days
  • Readmissions
  • Observation length of stay
  • Overall length of stay

 

And case management has an important ally to support them and to help drive organizational change. "For case management it’s about knowing they have this leader and champion standing behind them that they never had," says Mothkur.

 

NOTICE Act confusion continued into the summer

Learning objective

At the completion of this educational activity, the learner will be able to:

  • Identify challenges related to the lack of information about the Medicare Outpatient Observation Notice and the Notice of Observation Treatment and Implication for Care Eligibility Act.

 

Hospitals were struggling this summer to comply with the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, which was signed by President Barack Obama August 6, requiring hospitals to provide a verbal and written notice of outpatient status to any patient in observation who has been in the hospital for more than 24-hours.

With only a preliminary form on the PRA website to guide them (http://ow.ly/7TPE302eSiM), many organizations were finding more questions than answers in their quest to comply with the regulation.

"[The preliminary form] does not have an Office of Management and Budget approval number, so it is not finalized," says Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at Accretive Health in Chicago. "And there are several comments that it is not written to the federal standard for understanding by someone with limited education, so it may not even be approved in its present form. CMS has also said they will give further guidance on the requirement for verbal explanation so it is hard to know who will be allowed to present and explain the form."

In July, Janet Blondo, MSW, LCSW-C, LICSW, CMAC, ACM, CCM, C-ASWCM, ACSW, the manager of case management at Washington Adventist Hospital in Takoma Park, Maryland, was still looking to have a number of questions about the rule answered.

"I contacted the Maryland Hospital Association who researched this issue," she says. "The staff at MHA are conferring with experts at the Maryland Department of Health and Mental Hygiene about my questions and concerns and expect to have a response soon."

This lingering uncertainty not only was making it difficult for hospitals to start planning for compliance, but also led some to speculate that the compliance date would be extended.

The Ohio Hospital Association (OHA) in June told its members that the requirement date could be pushed back until October.

"The implementation of the Medicare Outpatient Observation Notice, or MOON, was set for August 6, 2016. However, as hospitals await the details of the federal fiscal year 2017 inpatient prospective payment system final rule, CMS is now stating that the MOON requirement date may be pushed back to October. Stay tuned for a final decision on the MOON implementation date," the OHA stated in a written release (http://ow.ly/z0qZ302fmvH). But as of mid-summer this talk still amounted to unsubstantiated rumors, says Hirsch.

"Unless someone knows someone at CMS, there is no official word. I did read many of the comments to the rule and many asked for a six-month delay. My guess is that they cannot delay the implementation since it is a law but they will delay enforcement for three months," he says.

In the meantime, organizations were trying to do what they could to get ready.

The NOTICE Act stipulates hospitals must inform patients within 36 hours from the start of the service, or at the time of discharge, about their status.

The goal of the legislation is to ensure patients are aware of their status and what it might mean for them financially?in particular, how it might affect their post-acute care options.

Patients often (wrongly) assume that if they’re in a hospital bed, they are an inpatient.

They also don’t understand the implications of outpatient billing status.

One of the biggest issues that can crop up when a patient’s care orders place him or her on observation status is that he or she will not be eligible for Medicare coverage for a post-acute stay in a skilled nursing facility (SNF), and instead may need to pay more out of pocket. Medicare currently only covers SNF extended care rehabilitation services for patients who have three consecutive inpatient days in a hospital. For example, one day in observation and two days as inpatient equals three days in the hospital, but does not meet the three-day inpatient day stay requirement because it only includes two inpatient days.

"An Office of Inspector General report found that the average out-of-pocket cost for SNF services not covered by Medicare was more than $ 10,000 per beneficiary," states a press release issued by the congressional leaders who promoted the bill (http://ow.ly/S6JSB).

To comply with the rule, hospitals will now need to designate someone?in some cases it may be the case manager?to provide this notification.

Stefani Daniels, RN, MSNA, ACM, CMAC, founder and managing partner of Phoenix Medical Management, Inc., in Pompano Beach, Florida, says a few of her clients were trying to get the form included in a packet of admission papers that are given to each Medicare patient to sign.

But even so, as of press time most organizations had more questions than answers about compliance. Stay tuned for updates in future issues of CMM.

 

Ask the expert

Understanding nuances of patient status and therapeutic services

Learning objective

At the completion of this educational activity, the learner will be able to:

  • Identify strategies to comply with condition code 44 and the Medicare Outpatient Observation Notice (MOON), and understand rules related to some aspects of therapeutic services.

 

Assigning the correct patient status is a constant challenge for hospitals and the case managers who are charged with ensuring these decisions are accurate. CMM often gets questions from readers on related topics and we forward them to our experts to get the answers. This month’s questions were answered by Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at Accretive Health in Chicago. 

 

Q: If a Medicare patient is downgraded from inpatient to observation is it expected that the patient will be issued the MOON and condition code 44 will be used on the claim? 

 

A: First, it must be noted that all patients who are downgraded using the condition code 44 process are being downgraded from inpatient status to outpatient status. If the patient then needs continuing hospital care (i.e., is not ready to be discharged), then observation can also be ordered. If observation is needed and is ordered, the MOON will be required only if the patient receives observation for 24 or more hours from the time of this order for observation services.  

 

Q: I have a question about how to interpret the CMS Standard Operating Procedures. If a requisition/order for physical therapy treatment is received at a hospital facility and is not authenticated (e.g., signed, timed, dated) by a community physician who is not credentialed at the hospital, is it true that facility can begin treatment but the order must be authenticated when it will be filed in the record?

A: Therapy services (e.g., physical, occupational, speech-language pathology) are unique in that an actual order from a physician or non-physician practitioner is not required (see the Medicare Benefit Policy Manual, Chapter 15, Section 220.1, at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf). The following is required:

  • The patient must be under the care of a physician
  • The therapy must be provided under a plan of care
  • The physician must certify that plan of care by way of signature and date

 

In this case, the therapy provider may develop a plan of care and forward it to the physician for certification. Treatment may begin while awaiting the return of the signed plan of care. But the organization staff should do their best to get the signed certification returned within 30 days of start of therapy services.

Because the physician is not on the medical staff, the therapy provider may want to confirm that the physician is enrolled with Medicare and therefore eligible to order and certify services on Medicare recipients.

Got a question on any case management topic that you’d like to ask our experts? Email it to Kelly Bilodeau at [email protected].

 

Bonus question

Q: What do you do with a patient who does not have a safe discharge plan, but does not meet inpatient criteria and has been in observation status for 48 hours?

A: The original instruction from CMS that still stands is that we give the patient an advance beneficiary notice that says his or her care in the hospital setting is no longer medically necessary and is not being billed to Medicare and that he or she will be financially responsible.

 

HCPro.com – Case Management Monthly

Implications of the Joint Commission’s 2016 deletions for staff education and training requirements for 2017

This article was written by Marlene K. Strader, RN, PhD, and Elizabeth Di Giacomo-Geffers, RN, MPH, CSHA, a healthcare consultant in Trabuco Canyon, California, and a former Joint Commission surveyor.
 
In the first quarter of 2016, there were 46 topics that were required for education and training of hospital staff, including physicians, nurses, and other allied healthcare personnel. In May 2016, The Joint Commission deleted many standards and elements of performance (EP), reducing the number to around 40. A few of those deletions impact the Human Resources (HR) chapter as well as other chapters.

HCPro.com – Briefings on Accreditation and Quality