Laureen shows you her proprietary “Bubbling and Highlighting Technique”
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Don’t let this 2022 regulation catch your organization off guard. Born out of the Consolidated Appropriations Act, 2021 of the 116th Congress, the No Surprises Act (NSA) should be called anything but that. My opinion, of course! Unless you’re an attorney, reading Congressional documents leaves much to be desired. However, the complexities of the NSA […]
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Adhere to the Medicare requirements and bundling rules for SNF coverage payment. If you don’t work in a skilled nursing facility (SNF), you may not understand how SNF consolidated billing (CB) affects you. The way you answer the following two questions may help you to see the connection: Have you ever had a Medicare patient […]
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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:
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.