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AAPC’s coding expert, Raemarie Jimenez, gives you the scoop on next year’s updates. Code update season is always an exciting time of year. With it brings new, revised, and deleted CPT® codes and coding guidelines that become effective Jan. 1. There are always a lot of changes to learn about: CPT® 2022 includes 249 new […]
The post Master 2022 CPT® Changes With This Expert Overview appeared first on AAPC Knowledge Center.
AAPC’s coding expert Raemarie Jimenez gives you the scoop on next year’s updates. Code update season is always an exciting time of year. With it brings new, revised, and deleted CPT® codes and coding guidelines that are effective Jan. 1, 2020. There are a lot of CPT changes to learn about: The CPT® 2020 code book […]
The post Master 2020 CPT Changes With This Expert Overview appeared first on AAPC Knowledge Center.
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Understanding nuances of patient status and therapeutic services
Learning objective
At the completion of this educational activity, the learner will be able to:
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:
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.
Sample form: Boost documentation improvement efforts as a team
Case management and clinical documentation improvement (CDI) specialists share a common goal: improving documentation, which is critical to quality care.
But all too often the two groups are working separately to achieve it. "Everyone is operating in a silo," says Glenn Krauss Glenn Krauss, BBA, RHIA, CCS, CCS-P, PCS, FCS, CPUR, C-CDI, CCDS, director of enterprise solutions at ZirMed in Chicago. To help the two groups work together more effectively, Krauss decided to develop a quick and easy reference guide that can be used to help foster collaboration.
"I put this form together based on my experience with denials and from reviewing denials for medical necessity," he says. "My goal was to create a document that educates CDI and case management so they can work together, collaboratively."
Working together as a team, CDI and case management can ensure that the patient moves along the continuum of care smoothly and is treated in the right setting at the right time for the right reasons. They can also ensure the proper terminology is in the report to ensure accurate payment.
The form below describes some of the most common documentation lapses, so CDI and case management can work together to address them.
"If you don’t have good processes in place to work together you may have the best value-based care in the hospital, but there is no real value if you don’t get paid," says Krauss.
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Navigating the skilled nursing benefit for Medicare
Learning objective
At the completion of this educational activity, the learner will be able to:
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:
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].
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