of CDI Specialist · Major Joint Replacement (CMS): CJR • CMS issued final rules for the...

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Sarah Mendiola, Esq., LPN, CPCSenior Associate & Director of Clinical Services

Washington & West, LLCBaltimore, MD

Completing the Circle: The Importance of CDI Specialist Participation in the Denial Management Process

©2016 HCPro, a division of BLR. All rights reserved. These materials may not be duplicated without express written permission.

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Learning Objectives

• At the completion of this educational activity, attendees will be able to:– Recognize the most recent changes to the 2‐midnight rule.

– Identify how the CDIS can assist in decreasing denials by CMS for a variety of targeted surgical procedures.

– Understand the current high‐risk areas for DRG audits. During this presentation, we will focus on sepsis and ICD‐10 procedure code issues.


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1.Navigate to the event Agenda in the main menu

2. Tap the name of the current session to view the session details page

3. Tap Polls4. Tap the name of the poll

5. Tap your answerchoice and then tap Submit

Steps for Attendees to View/Answer POLLING QUESTIONS


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• Are your CDI staff involved in denials prevention and/or appeals?– Yes, they are involved in prevention efforts and appeals– Yes, but prevention efforts only– No, but our CDI physician advisor is– No– Other/not applicable

Polling Question 1


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Preventable Denials With CDIS Intervention

1. 2‐midnight rule 2. Surgical denials (CMS)3. Coding issues


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CMS Financial Report: Fiscal Year 2015

“The Medicare population is expected to increase from 54 million beneficiaries today to over 80 million beneficiaries by 2030.”


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Alphabet Soup of Auditors


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2‐Midnight Rule

• Effective for DOS on or after 10/01/13

• Has undergone several modifications/updates since its inception

• Requirements– Inpatient order– Expectation of hospitalization spanning two midnights

• Inpatient‐only procedures• “Unforeseen circumstances” • “Case by case” review


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2‐Midnight Rule: Current Audits

• QIO review – Took over the 2‐midnight initial payment reviews from the MAC

as of 10/01/15 • MAC review

– Reviews unrelated to patient status (e.g., coding reviews, reviews to determine the medical necessity of the procedure conducted, etc.)

• RAC review – As of January 2016, may conduct patient status reviews only for

those providers that have been referred by the QIO as exhibiting persistent noncompliance with Medicare payment policies

• Probe reviews • Conducted for stays > 2 midnights to monitor for evidence of

gaming, abuse, or delays in an effort to meet the 2‐midnight presumption of medical necessity (CERT, FATHOM, PEPPER)


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2‐Midnight Rule: General Rule for Expected 0‐ to 1‐Midnight Stays

• Revised exceptions policy pursuant to CMS‐1633‐F:– “… for admissions not meeting the two midnight benchmark, Part A payment is appropriate on a case by case basis where the medical record supports the admitting physician’s determination that the patient requires inpatient care, despite the lack of a 2 midnight expectation.”

– QIOs will consider “complex medical factors.”

• Procedures defined as “inpatient only” continue to be an exception


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2‐Midnight Rule: General Rule for Expected 2+ Midnight Stays

• If an unforeseen circumstance results in a shorter length of stay than expected, Part A payment may still be made. The circumstances must be documented in the medical record. Examples:– Death– Transfer to another facility– AMA departure– Hospice election – Unexpected recovery

• QIOs will consider “complex medical factors” that support a reasonable expectation of the needed duration of the stay.


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2‐Midnight Rule: Inpatient Order

• Inpatient order– Certification (physician) vs. inpatient order (physician or other qualified practitioner)

– Other qualified practitioner is one who is:• Licensed by the state to admit inpatients to hospitals;• Granted privileges by the hospital to admit inpatients to that specific facility; and

• Knowledgeable about the patient’s hospital course, medical plan of care, and current condition at the time of admission

– HOWEVER, the statute also says “The physician order must be furnished at or before the time of the inpatient admission.”


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2‐Midnight Rule: Inpatient Order Denial

• Claim denied for lack of physician order

• Should there be a physician countersignature?


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2‐Midnight Rule: Inpatient Order

• What are the rules in your state regarding admitting practitioners?

– Can a physician assistant or nurse practitioner admit patients?

– Is a physician countersignature/chart review required?


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2‐Midnight Rule: Expectation

• “For Medicare payment purposes, both the decision to keep the patient at the hospital and the expectation of needed duration of the stay must be supported by documentation in the medical record based on factors such as: – beneficiary medical history and comorbidities,– the severity of signs and symptoms,– current medical needs, and– the risk of an adverse event during hospitalization.”

Do these criteria look familiar?


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2‐Midnight Rule: Example of Expectation

This is an 84‐year‐old patient admitted for treatment of a COPD exacerbation. She has multiple comorbid conditions including diabetes, CHF, and coronary artery disease. She is at risk for rapid deterioration, respiratory failure, and cardiac ischemia and requires IV antibiotics, frequent nebulizer treatments, and frequent vital signs. I expect that she will require at least two midnights of hospitalization this episode because she typically requires 2–3 days of IV steroids and has increased oxygen needs during these exacerbations.


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2‐Midnight Rule: No Expectation


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2‐Midnight Rule: No Expectation

Change in status documented, but there is no explanation as to why the conversion is appropriate.


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2‐Midnight Rule: The Future?

• Medicare Advantage– Non‐contracted MAOs are using the rule to deny claims– Contracted MAOs have started to utilize it as well

• Medicaid (and Medicaid MCOs) and other commercial insurers may start to use this requirement as well


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CDIS Keys to Prevention

Inpatient stay expected0–1 midnight

• Make sure the record has:– Inpatient order– Documentation as to WHY

inpatient care is required• Complex medical factors

• Or, is this an inpatient‐only procedure or newly initiated mechanical ventilation?

Inpatient stay expected2 midnights or more

• Make sure the record has:– Inpatient order– Documentation as to why

admission is appropriate– Documentation to support the

expectation of the needed duration

• Or, were there “unforeseen circumstances” that occurred?


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CMS and Surgical Denials

• Surgical claims are often higher‐dollar claims– Often selected for prepayment review by the MAC– Selected for post‐payment review by the SMRC and the RAC– Claims are denied for lack of medical necessity for the procedure itself

• If CMS denies the surgery for an inpatient admission, the entire stay is denied

• Easy way for high‐dollar recoveries for CMS


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• Musculoskeletal– Spinal fusion (DRGs 453–460)

• No NCD for lumbar or cervical fusion • Some LCDs for lumbar fusion

– TKR/THR (DRGs 469–470)• No NCD, some draft LCDs• MLN Matters Number SE1236 requires documentation not typically contained in the inpatient record

– Kyphoplasty & vertebroplasty• No NCD, various LCDs by contractor


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• Cardiac– Pacemakers & AICDs

• NCDs 20.8 & 20.4• There are also decision memos issued in addition to the NCDs which may provider further guidance

• Bariatric– NCD 100.1 – However, certain procedure/diagnosis codes may trigger an automated denial even if the surgery is NOT bariatric in nature


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CMS and Surgical Denials: Remit Denial

• Remit will typically deny the service as “non‐covered” or “not medically necessary”

– Denials are sometimes difficult to decode on the back end Prevention of the denial is key

“MA02Claim Level: CO A1 ‐ Claim denied charges.MA02 Alert: If you do not agree with this determination, you have the right to appeal.”


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CMS and Surgical Denials: Example ADR/Denial

• Electronic denials/rejections are being issued due to a specific code billed on the claim


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Major Joint Replacement (CMS): Example ADR


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Major Joint Replacement (CMS): Appeal Denial


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Major Joint Replacement (CMS): CJR

• CMS issued final rules for the Comprehensive Care for Joint Replacement (CJR) model on November 24, 2015.– Bundled payments for episodes of care for lower‐extremity joint

replacement.– “All related care within 90 days of hospital discharge from the

joint replacement procedure will be included in the episode of care.”

• While this is deemed a “test” of the payment model, participation is not voluntary. CMS is requiring hospitals in 67 geographic areas to participate in the “test” of the payment model.

• The first performance year begins on April 1, 2016.


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Major Joint Replacement (CMS): Prevention

• Physician education– Physician and facility claims are becoming linked for reimbursement

• Denial of “related” physician claims for surgical procedures

– Transmittal 541, issued 9/12/14, states “When the Part A Inpatient surgical claim is denied as not reasonable and necessary, the MAC may recoup the surgeon’s Part B services.”

» Allows for the possibility of future expansion.» However, CMS approval is needed prior to initiating “related” claims review.


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What Is a Provider Expected to Know?

• Know what you “should have known”– CMS presumes your knowledge of every word of every statute, rule, NCD/LCD, manual, transmittal, etc.

• Administrative Law Judge comment in an unfavorable ALJ decision:– “The Provider was unquestionably aware of the CMS regulations, manuals and rulings, CMS bulletins, past unfavorable CMS contractor actions and the lack of substantiating medical records. See 42 CFR Section 411.406(e) (knowledge presumed from experience and constructive notice of CMS publications).”


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Pre‐operatively• Ensure all documents are

present from referring provider or patient. – H&P– Records of conservative

treatment prior to surgical intervention

• For elective procedures, can you postpone scheduling until they are received?

• Is there an NCD, LCD, or other clinical policy guidance for the procedure? Is it met?

Post‐operatively• Gather all pre‐operative

documents that are necessary and merge them with the existing record.

• Is there an NCD, LCD, or other clinical policy guidance for the procedure? Is it met?

• Pay close attention to coding! – Was this an inpatient‐only

procedure?– Was this a procedure “excluded”

by CMS? – Are there specific diagnosis

codes that must be on the claim for reimbursement?


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Coding

• 5,000+ ICD‐10 codes are to be added in FY 2017!

• CMS and the CDC will add 1,900 diagnosis codes and 3,651 hospital inpatient procedure codes to the ICD‐10 coding system for fiscal year 2017.

• According to the AHA, the new codes are being added now because there was a freeze on updates to ICD‐10 codes before the October 1 implementation date.


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Coding: Denial Issues

• Two different denials for coding audits:– “Coding error”

• Documenting the clinical basis without the diagnosis being listed

– “Assumption coding”

– “The documentation lacks supporting evidence for the diagnosis of ____”

• Documenting the diagnosis with no clinical basis indicated in the medical record

– Example: Records indicate that the patient has “acute respiratory failure,” but clinical information does not support the diagnosis


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Coding: Sepsis

• Sepsis codes are often removed from the case mix as principal and/or secondary codes

• Typically denied as “not meeting clinical criteria” for sepsis


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Coding: Sepsis

• Clinical guidelines for sepsis and septic shock were last updated in 2001, but have remained largely unchanged since 1991

• Initial definitions focused on the “then prevailing view that sepsis resulted from a host’s systemic inflammatory response syndrome (SIRS) to infection”


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Coding: Sepsis

• New “Sepsis‐3” guideline– “The current use of 2 or more SIRS criteria to identify sepsis was unanimously considered by the task force to be unhelpful.”

– “Sepsis should be defined as life‐threatening organ dysfunction caused by a dysregulated host response to infection.”

– qSOFA score; 2 or more of the following is indicative of “poor outcomes typical of sepsis”:

• Respiratory rate of 22/min or greater;• Altered mentation; or• Systolic BP of 100 mm Hg or less


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Coding: Sepsis (Septic Shock)

“Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia.”


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Coding: Sepsis

• The criteria is very specific.– Pro? Could decrease instances of “inaccurate coding” when the conditions are met.

– Con? Payers may utilize for denial purposes even though the criteria is not universally accepted.


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Coding: Procedure Code Issues

• More coding denials for procedural coding errors.• The seven characters for medical and surgical procedures have the following meaning: – Character 1 = Section – Character 2 = Body system – Character 3 = Root operation – Character 4 = Body part – Character 5 = Approach – Character 6 = Device – Character 7 = Qualifier


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• Character 3 = Root operation– There are 31 different root operation values.– CMS says: “There is a clear distinction between each root operation.”

– Most common issue that we see is in the root operations that “take out some or all of a body part.”

• Excision vs.• Resection vs. • Extraction


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• Character 5 = Approach– There are seven different approaches– The approach is comprised of three components: the access location, method, and type of instrumentation

– Most common issue that we see is in deciphering the “type of opening”

• Open vs.• Percutaneous vs. • Via natural or artificial opening


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DRGs Projected for Audit Scrutiny in 2016

• 068: Non‐specific CVA and precerebral occlusion w/o infarct w/o MCC

• 192: Chronic obstructive pulmonary disease w/o CC/MCC• 195: Simple pneumonia and pleurisy w/o CC/MCC• 293: Heart failure and shock w/o CC/MCC• 308: Cardiac arrhythmia and conduction disorders w/MCC

(and DRGs 309–310) (AFIB)• 312: Syncope and collapse• 602: Cellulitis w/MCC• 684: Renal failure w/o CC/MCC• 689: Kidney and urinary tract infections w/ MCC• 872: Septicemia w/o MV 96+ hours w/o MCC

According to National Government Services (Part A MAC, Jurisdiction K) http://ehrdocs.com/time/pdf/Top10DRGs.pdf


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Sepsis/diagnosis code issues• Know what diagnosis codes

are being targeted (MCCs and CCs)

• Documentation of the diagnosis alone is not sufficient – Is the clinical documentation

there to support the diagnosis?

• Check for conflicting documentation, and

• Confirmation of the diagnosis by the attending physician

Procedure code issues• Consider assigning a

designated staff for billing surgical claims

• Periodic anatomy & physiology refreshers, especially when new surgical techniques (or procedure codes) are implemented

• Interactive meetings with the surgical team and coders regarding common techniques utilized by each surgeon


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If Prevention Is Not Enough …

• Appeal!– Know your appeal rights with your contracted, not contracted, and governmental payers; and exercise them

• Appeals should include:– A clear explanation of why the denial is incorrect, utilizing:

• Clinical and/or coding arguments– Cite the applicable policy or coding guidance in support of your argument

• Legal arguments – Applicable contract terms – State or federal law (as applicable)


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Thank you. Questions?

[email protected]

In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide.


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Please Note

Washington & West, LLC is not a law firm. The information conveyed in this presentation is for general educational purposes and is not legal advice. The application and impact of laws can vary widely based on the specific facts involved. Given the constantly changing nature of state and federal laws, there may be omissions or inaccuracies in the

information you receive during this program. Accordingly, any information is provided with the understanding that the presenter is not rendering legal, accounting, or other professional advice and

services. As such, any information obtained in this presentation should not be used as a substitute for consultation with legal counsel or other

professional advisors specifically retained for that purpose. While Washington & West, LLC has made every attempt to ensure that the

information contained in these materials is generally useful for educational purposes, Washington & West, LLC and its agents and

employees are not responsible for any errors or omissions, or for the results obtained through the use of any information herein.


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