Improving Quality of Care for Medicare Beneficiaries. Review Types. Linking Case Review to Quality Improvement

Size: px
Start display at page:

Download "Improving Quality of Care for Medicare Beneficiaries. Review Types. Linking Case Review to Quality Improvement"

Transcription

1 AnnualRepor t QI O CaseRevi ew I nf or mat i on Augus t1,2012-j ul y31,2013 FMQAI TheMedi car eqi Of orfl or i da

2 Improving Quality of Care for Medicare Beneficiaries FMQAI is Florida s federally designated Medicare Quality Improvement Organization (QIO), under contract with the Centers for Medicare & Medicaid Services. The QIO program is an integral part of the U.S. Department of Health and Human Services National Quality Strategy and is focused on the three aims of better patient care, better individual and population health, and lower healthcare costs through improvement. FMQAI protects beneficiaries by reviewing quality complaints and applying what we learn to help providers implement quality improvement processes, focused on the way providers deliver health care. To support our patient-centered approach, FMQAI is authorized by the Medicare Program to review medical care provided to beneficiaries to determine whether it meets medically acceptable standards of care, is medically necessary, and is delivered in the most appropriate setting. Review Types Under our current improvement efforts with Medicare, FMQAI carries out a number of activities related to Medicare case review. FMQAI conducts statutorily mandated review activities, including the following: Reviewing the quality of care provided to beneficiaries (quality of care reviews) Reviewing requests for service termination and/or discharge (notices of non-coverage) Reviewing CMS-selected cases for appropriate admission status and higher-weighted diagnosis related group assignment (coding validations, utilization). Reviewing potential Emergency Medical Treatment and Active Labor Act (EMTALA) violations (antidumping cases) Linking Case Review to Quality Improvement FMQAI links case review activities to improvements in the delivery of care by developing quality improvement activities focused on system-wide changes. FMQAI uses data from case review activities to identify problems related to the quality of care and to design quality improvement activities to help providers correct these problems. FMQAI works with patients, providers, and practitioners across organizational, cultural, and geographic boundaries to spread rapid, large-scale change, directed at improving the quality of health care that Medicare beneficiaries receive.

3 I. Total # of Reviews The total number of reviews the Quality Improvement Organization (QIO) performed in CRIS by the associated review type. Review Type # of Reviews Percent of Reviews (%) Coding Validation (120 - HWDRG) 2, % Coding Validation (All Other Selection Reasons) % Quality of Care Review (101 through Beneficiary Complaint) 1, % Quality of Care Review (All Other Selection Reasons) % Immediate Advocacy % Utilization (158 - FI/MAC Referral for Readmission Review) % Utilization (All Other Selection Reasons) 3, % Notice of Non-coverage (105 through Admission and Preadmission) % Notice of Non-coverage (118 - BIPA) 2, % Notice of Non-coverage (117 - Grijalva) 1, % Notice of Non-coverage (121 through 124 -Weichardt) 2, % Notice of Non-coverage (111 - Request for QIO Concurrence) % EMTALA 5-Day % EMTALA 60-Day % Total 14,304 II. Top 10 Principal Medical Diagnoses The top 10 principal medical diagnoses for inpatient claims billed for Medicare beneficiaries. Percent of Top 10 Medical Diagnoses # of Beneficiaries Beneficiaries (%) 1. V5789 Rehabilitation Procedure NEC* 25, % Pneumonia, Organism NOS 24, % Septicemia NOS 24, % Urinary Tract Infection NOS** 20, % Acute Kidney Failure NOS 18, % Atrial Fibrillation 18, % Obstructive Chronic Bronchitis with (Acute) Exacerbation 17, % Coronary Atherosclerosis, Native Vessel 16, % Localized Osteoarthritis NOS-Lower Leg 13, % Subendocardial Infarction, Initial 13, % Total 192, % *NEC- Not Elsewhere Classified; **NOS Not Otherwise Specified Page 1 of 11

4 III. Provider Reviews Geographics The count and percent by rural vs. urban geographical locations for Health Service Providers (HSPs) associated with a completed QIO review. Geographical Area # of Providers Percent of Providers (%) Rural % Urban % Unknown % Total % IV. Provider Reviews Settings The count and percent by setting for Health Service Providers (HSPs) associated with a completed QIO review. Setting # of Providers Percent of Providers (%) 0 - Acute Care Unit of an Inpatient Facility % 1 - Distinct Psychiatric Facility % 2 - Distinct Rehabilitation Facility % 3 - Distinct Skilled Nursing Facility % 5 - Clinic % 6 - Distinct Dialysis Center Facility % 7 - Dialysis Center Unit of Inpatient Facility % 8 - Independent-Based RHC % 9 - Provider-Based RHC % C - Free-Standing Ambulatory Surgery Center % G - End Stage Renal Disease Unit % H - Home Health Agency % N - Critical Access Hospital % O - Setting does not fit into any other existing setting code % Q - Long-Term Care Facility % R - Hospice % S - Psychiatric Unit of an Inpatient Facility % T - Rehabilitation Unit of an Inpatient Facility % U - Swing Bed Hospital Designation for Short-Term, Long-Term Care, and Rehabilitation Hospitals % Y - Federally Qualified Health Centers % Z - Swing Bed Designation for Critical Access Hospitals % Other % Total % Page 2 of 11

5 A. Quality of Care Concerns Confirmed The number of concerns by Quality of Care PRAF Category Code and the number that were confirmed at highest level of review for completed quality of care reviews. # of Concerns # of Concerns Confirmed Percent Confirmed Concerns (%) Quality of Care ( C Category) PRAF Category Codes C01 - Apparently did not obtain pertinent history and/or findings from examination % C02 - Apparently did not make appropriate diagnoses and/or assessments % C03 - Apparently did not establish and/or develop an appropriate treatment plan for a defined problem or diagnosis, which prompted this episode of care [excludes laboratory and/or imaging (see C06 or C09) and procedures (see C07 or C08) and consultations (see C13 and C14)] % C04 - Apparently did not carry out an established plan in a competent and/or timely fashion % C05 - Apparently did not appropriately assess and/or act on changes in clinical/other status results % C06 - Apparently did not appropriately assess and/or act on laboratory tests or imaging study results % C07 - Apparently did not establish adequate clinical justification for a procedure, which carries patient risk and was performed % C08 - Apparently did not perform a procedure that was indicated (other than lab and imaging, see C09) % C09 - Apparently did not obtain appropriate laboratory tests and/or imaging studies % C10 - Apparently did not develop and initiate appropriate discharge, follow-up, and/or rehabilitation plans % C11 - Apparently did not demonstrate that the patient was ready for discharge % C12 - Apparently did not provide appropriate personnel and/or resources % C13 - Apparently did not order appropriate specialty consultation % C14 - Apparently specialty consultation process was not completed in a timely manner % C15 - Apparently did not effectively coordinate across disciplines % C16 - Apparently did not ensure a safe environment (medication errors, falls, pressure ulcers, transfusion reactions, nosocomial infection) % C17 - Apparently did not order/follow evidence-based practices % C18 - Apparently did not provide medical record documentation that impacts patient care % C99 - Other quality concern not elsewhere classified % Total 1, % Page 3 of 11

6 B. Serious Reportable Events on Quality of Care Reviews The number of Quality Improvement Activities (QIAs) initiated (initial activity date within the reporting period) for all quality of care reviews with confirmed concerns; the number and percent of those QIAs that are associated with quality of care concerns that fell into the category of Serious Reportable Events. # of QIAs Initiated # of QIAs Initiated for Serious Reportable Events Percent of QIAs Initiated for Serious Reportable Events (%) % C. Confirmed Quality of Care Concerns with Associated Interventions The number of Initial Quality Improvement Activities initiated, by activity type, for reviews with one or more confirmed Quality of Care concerns; the percent of total activities that each comprises. # of Interventions (QIAs) With this Initial Quality Improvement Activity Percent of Interventions (QIAs) with this Initial Quality Improvement Activity Initial Quality Improvement Activity 1 - Send educational/alternative approach letter % 2 - Perform intensified review Require continuing education % 4 - Request/review policy/procedure % 5 - Request development of QIP % 6 - Accept provider-initiated QIP % 7 - Conduct informal meeting or teleconference % 8 - Refer to licensing board Initiate sanction activity % 10 - Other % Total % Page 4 of 11

7 D. Discharge/Service Termination The discharge location of beneficiaries linked to discharge/service termination reviews for Selection Reasons 111 (Request for QIO Concurrence) and (Weichardt Selection Reasons). Note: Data represent discharge/service termination reviews from 8/1/2012 4/30/2013. A shortened data time frame is necessary to allow for maturity of claims data, which is the source of Discharge Status for these cases. Discharge Status # of Beneficiaries Percent of Beneficiaries (%) 01 - Discharged to home or self care (routine discharge) % 02 - Discharged/transferred to another short-term general hospital for inpatient care % 03 - Discharged/transferred to skilled nursing facility (SNF) % 04 - Discharged/transferred to intermediate care facility (ICF) % 05 - Discharged/transferred to another type of institution (including distinct parts) % 06 - Discharged/transferred to home under care of organized home health service organization % 07 - Left against medical advice or discontinued care % 09 - Admitted as an inpatient to this hospital % 20 - Expired (or did not recover Christian Science patient) % 21 - Discharged/transferred to court/law enforcement % 30 - Still a patient % 40 - Expired at home (hospice claims only) % 41 - Expired in a medical facility (e.g. hospital, SNF, ICF or free-standing hospice) % 42 - Expired - place unknown (hospice claims only) % 43 - Discharged/transferred to a Federal hospital % 50 - Hospice - home % 51 - Hospice - medical facility % 61 - Discharged/transferred within this institution to a hospital-based Medicare-approved swing bed % 62 - Discharged/transferred to an inpatient rehabilitation facility including distinct part units of a hospital % 63 - Discharged/transferred to a long-term care hospital % 64 - Discharged/transferred to a nursing facility certified under Medicaid but not under Medicare % 65 - Discharged/transferred to a psychiatric hospital or psychiatric distinct part unit of a hospital % 66 - Discharged/transferred to a Critical Access Hospital % 70 - Discharged/transferred to another type of healthcare institution not defined elsewhere in code list % Other % Total % Page 5 of 11

8 E. Beneficiary Demographics The number of beneficiaries for whom a case review activity was started, by demographic category, and the percent of beneficiaries each category represents. Demographics # of Beneficiaries Percent of Beneficiaries (%) Sex/Gender Female 6, % Male 4, % Unknown % Total 10, % Race Asian % Black 1, % Hispanic % North American Native % Other % Unknown % White 8, % Total 10, % F. Quality of Care Reviews and Concerns by Intervention Type For a QIA started within the reporting period for the current year s report, a short description of the type of intervention(s)/qia(s) employed for three diverse or different quality categories (C1-99). Description 1 Type of Intervention for Quality Category C <1-99> Confirmed Concern for Quality Category C 04 (Apparently did not carry out an established plan in a competent and/or timely fashion). During the QIO medical record review for a beneficiary complaint, it was discovered that the beneficiary was admitted to a skilled nursing facility (SNF) for rehabilitation after bilateral knee replacement surgery. The beneficiary had an order for a continuous passive motion (CPM) machine for each knee. The patient had one working CPM machine and one CPM machine that did not work. The CPM machine that did not work was not replaced, and the patient did not receive the proper treatment for that knee replacement, which resulted in the family signing the patient out and taking her to another acute care facility. QI Action Taken The provider conducted a root cause analysis (RCA), which identified that there was a failure by the staff to report the non-working CPM machine; a knowledge deficit regarding availability of equipment, operating instructions, and troubleshooting measures; and policy restrictions regarding implementation of the CPM machine. The CPM policy and procedure needed to be revised, regarding who could initiate treatment with a CPM machine, to include nursing. Equipment needed to be checked to ensure that it was in working order. Through the technical assistance provided by the QIO, the provider updated its policy and procedure regarding CPM machines to allow trained registered nurse (RN) staff members to implement the treatment if the physical therapist was not available. Staff education, regarding the policy changes and the importance of initiating CPM treatments in a timely fashion, was conducted. Staff education was also provided on proper initiation of CPM machines and troubleshooting measures. All Page 6 of 11

9 CPM machines were inspected by the plant operations department for proper function, and nonfunctioning machines were repaired or replaced. All charts with physician orders for CPM machines were audited and reported to the QIO quarterly, educational in-services were provided throughout the process for reinforcement, and a goal of 100 percent compliance was achieved at having the CPM machine initiated within 24 hours of the receipt of the order. The success of this project was reported to the administrator, quality department, and the director. The process has been adopted by their sister facilities. They will continue to perform random chart checks to ensure compliance. Description 2 Type of Intervention for Quality Category C <1-99> Confirmed Concern for Quality Category C 11 (Apparently did not demonstrate that the patient was ready for discharge). During the QIO medical record review for a beneficiary complaint, it was discovered that the beneficiary was accidently discharged by the emergency department (ED) nurse. The patient was discharged from the ED and given the discharge instructions and prescription for another patient. The ED staff realized the error and contacted the patient to return to the facility, but the family chose to go to another ED for treatment. QI Action Taken The provider conducted a root cause analysis (RCA), which identified that the patient was discharged in error by the ED nurse, who failed to verify the patient s identity via hospital policy. The nurse should have verified the patient s name and date of birth with her armband prior to discharge. The patient did not receive appropriate discharge instructions and was given the instructions for another patient. The provider had a policy and procedure in place to verify at least two patient identifiers prior to discharge, but this policy was not followed. The type of activity requested was an intervention and improvement plan (IIP). Through the technical assistance of the QIO, the staff was re-educated regarding the national patient safety goals to check at least two patient identifiers at all times when providing care. A random sample of 50 charts per month was audited to ensure that there was an order written by the physician for discharge and that the patient received the correct discharge instructions and prescriptions. The results of the audits were submitted to the QIO quarterly, educational in-services were provided throughout the process as well as direct observation, and a goal of 100 percent compliance was achieved. The success of this project was communicated to the provider s quality council on a quarterly basis, shared with its free-standing ED, and implemented. Leadership rounding and random chart audits will continue to ensure patient safety with 100 percent compliance to this process. Description 3 Type of Intervention for Quality Category C <1-99> Confirmed concern for Quality Category C 16 (Apparently did not ensure a safe environment [medication errors, falls, pressure ulcers, transfusion reactions, nosocomial infection]). During the QIO medical record review for a beneficiary complaint, it was discovered that the beneficiary acquired a decubitus ulcer while in the facility, and the nursing staff did not notify the physician of the change in the patient s skin condition. QI Action Taken The provider conducted a root cause analysis (RCA), which identified that there was also a facility-wide lack of assessment and documentation of skin. The Braden Scale was not consistently being used. The Page 7 of 11

10 facility also concluded there was a lack of documentation to substantiate that the physician was notified of changes in skin condition. It had a policy and procedure in place but realized that it needed to be updated to be more comprehensive. The electronic medical record (EMR) also needed to be upgraded, as it did not adequately contain documentation of the skin care assessment. An intervention and improvement plan (IIP) was requested, and through the technical assistance provided by the QIO, the facility updated its policy to include that the Braden Score would be documented on admission, skin/wound assessments would be completed each shift, and the physician would be notified within one hour of skin breakdown. The facility instituted a new tool in the EMR to reflect the changes in the policy and appropriate skin assessment. The facility also added a communication tool on its Kardex. Educational tools were used to reinforce the changes and to reiterate the necessity of informing the physician of any changes and the need to document those in the medical record. A random sample of 50 charts per month was audited and reported to the QIO quarterly, educational in-services were provided throughout the process, and 97 percent compliance has been obtained. The provider worked collaboratively with nursing leadership, the quality department, the computerized physician order entry (CPOE) staff, and the IT department to achieve its success. It has implemented a continuous educational component, which is now part of the annual skills fair required by all staff caring for patients. Additionally, nursing leadership and the quality department will continue random chart audits to ensure 100 percent compliance on all nursing units. Example from Description 3: How Interventions Were Determined/Best Practices Every confirmed quality of care concern is evaluated on an individual basis for several factors prior to assigning it to a category for the type of quality improvement initiative (QII) that needs to be performed. All information is reviewed, including the beneficiary complaint, the nurse analyst information sent to the peer reviewer (including supporting evidence), the peer reviewer s comments, the outcome for the beneficiary, the response that is sent from the provider/practitioner, and any supporting documentation of updated processes, policies and procedures and/or education. After reviewing all information, the quality improvement team collaborates to decide the severity of the concern, involving the medical director as needed. In Description 3 above, the provider identified the need to document skin assessments and the need to communicate changes in skin condition to the physician in a timely manner. The provider took many steps to accomplish this task, based on evidence-based guidelines and protocols for prevention of pressure ulcers. Evidence shows that a good prevention plan includes a risk assessment with a standardized tool, such as the Braden Scale, on admission, reassessment intervals whenever the patient s condition changes or every 48 hours in the acute care setting, documentation of risk scores, and implementation of prevention strategies. By ongoing monitoring of the effectiveness of the prevention interventions implemented and monitoring by the healing progress of existing pressure ulcers, the facility anticipates that pressure ulcers will be reduced. If the skin assessment reveals new breakdown, it is important to use a standardized assessment tool to document category or stage and to notify the physician as soon as possible to obtain treatment orders. This facility was able to obtain best practice through collaboration with its IT department to develop a new skin assessment tool and a way to transfer this information onto a Kardex for improved communication and ongoing staff education. Reference: National Guideline Clearinghouse prevention of pressure ulcers Page 8 of 11

11 G. Evidence Used in Decision-Making For Medical Necessity/Utilization Review and Appeals, the most common types of evidence/standards of care criteria used to support review analysts assessments and peer reviewers decisions; a brief statement of rationale for how the specific evidence/standards of care were chosen. For Quality of Care, the most common types of evidence/standards of care criteria used to support review analysts assessments and peer reviewers decisions. Review Type Quality of Care Medical Necessity / Utilization Review Diagnostic Categories Evidence/ Standards of Care Used Rationale for Evidence/ Standard of Care Selected Pneumonia CMS Core Measures; McKesson s Measures have been developed, InterQual Reference Library; tested, and accepted by various UpToDate authorities. References found within McKesson s tool have been peer reviewed and published; UpToDate is well recognized and utilized in FL. Heart Failure As noted above As noted above Acute As noted above As noted above Myocardial Infarction Pressure Ulcers As noted above and National As noted above Guideline Clearinghouse prevention of pressure ulcers Urinary Tract As noted above As noted above Infection Sepsis As noted above As noted above Adverse Drug Beers Criteria for Potentially As noted above Events Inappropriate Medication Use in Older Adults. Falls Hospital Specifications Manual; As noted above National Guideline Clearinghouse Prevention of falls (acute care); CMS Core Measures; McKesson s InterQual Reference Library; UpToDate Patient Trauma AHRQ Patient Safety Indicators As noted above Surgical As noted above Complications Hospital Specifications Manual; CMS Core Measures; McKesson s InterQual Reference Library; UpToDate McKesson s InterQual Reference Library McKesson s tool has been established for many years in FL; references found within McKesson s tool have been peer reviewed and published; UpToDate is well recognized and utilized in FL. Page 9 of 11

12 Review Type Appeals Diagnostic Categories Evidence/ Standards of Care Used McKesson s InterQual Reference Library; National Coverage Determinations (NCDs) Rationale for Evidence/ Standard of Care Selected McKesson s tool has been established for many years in FL and is reliable in screening for inpatient criteria; NCDs are established by the Medicare Program. Brief examples/case studies, where case review was linked to another Aim of the QIO contract, for example, readmissions, pressure ulcers, adverse drug events, etc.; the evidence-based criteria used to support review decisions on those cases and what influenced the selection of that criteria: Example/Case Study 1: In collaboration with the C.7 Aim team, it was identified that a healthcare facility had increased CLABSI rates. The case review team was requested to conduct medical record reviews in an effort to assist in determining causative factors. The focused quality of care retrospective case review included 15 selected patient records from one healthcare facility. The reviews were completed by a nurse Review Analyst, utilizing an extraction tool developed specific to CLABSI and also included a brief summary of the case. FMQAI conducted a total of 15 Medicare beneficiary case reviews. The physician reviewers were provided the Medicare beneficiary records, the NHSN/CDC CLABSI Guidelines, and a CLABSI review tool from each case. Based on the results of the 15 case reviews conducted, it appeared that the facility did not consistently comply with the NHSN/CDC CLABSI guidelines, which may have contributed to the increased number of central line intravascular catheter-related infections. In collaboration with CMS and the C.7 Aim team, Tier 2 Quality Improvement activities were initiated with ongoing data monitoring to ensure compliance. The hospital has implemented many of the improvement activities throughout its intensive care units, thus implementing system-wide changes. Example 2 (C.7 Aim) and Example 3 (C.8 Aim): The Improve Individual Patient Care Aim (C.7) and Integrate Care for Populations and Communities Aim (C.8) teams are readily accessible and provide information to the quality of care case review team for a variety of clinical settings. As such, when a complaint is received and areas are identified, such as healthcare-associated infections (HAIs), healthcareacquired conditions (HACs), adverse drug events (ADEs), or care transitions (CTs) the C.7 and C.8 Aim teams are contacted for additional information and/or consult. The C.7 and C.8 Aim teams provide their expertise and their knowledge of the provider, such as the use of restraints and the rates of pressure ulcers. This information was utilized as reference material for the complaint review and standard of care. This fosters a collaborative relationship not only for the quality of care case review team and the C.7 and C.8 Aim teams but also for providers. This type of cross-collaboration demonstrates boundarilessness under FMQAI s 10 th SOW. Page 10 of 11

13 H. Effectiveness of QIAs 10 th SOW C.6 BFCC Deliverable B.4 Narrative Analysis: Quality improvement initiatives/interventions/activities are important tools to be utilized by both Quality Improvement Organizations (QIOs) and healthcare providers/practitioners to evaluate current patient care practices and/or processes and to determine what improvements can be made that will impact the greatest portion of the patient population. While the data may be limited to only those that are found in the CRIS application, they demonstrate the effort to support systematic improvements to processes, which in turn should improve care provided to all patients, regardless of the payor source. Many confirmed quality concerns resulted in a system-wide improvement activity. These activities ranged from process improvement plans with designed milestones and measureable achievements, up to and including formal Corrective Action Plans, as required by reviews with concerns identified as gross and flagrant or substantial numbers of violations. All system-wide improvement activities require healthcare providers/practitioners to engage in specific process steps including, but not limited to, conducting a root cause analysis, formulating and submitting an improvement plan, collaborating with the QIO to finalize the improvement plan, and monitoring progress toward achieving and sustaining improvement goals through the review and submission of data. Examples of such system-wide improvement activities are found in section F. Recommendations: The collaboration and information gleaned through the activities noted above can be utilized to augment the statewide aggregate data used by many of FMQAI s Aim teams. While the initial or index review may have identified one Medicare beneficiary, it may represent a snapshot of the processes in place at a particular time and may provide significant insight for the other Aim teams. Case review data should be used to supplement the data currently utilized by the other Aim teams, strengthening their improvement efforts and activities. Please refer to Section G, Case Study 1, for an example of FMQAI s boundarilessness across 10 th SOW Aims. This material was prepared by FMQAI, the Medicare Quality Improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the Department of Health and Human Services (HHS). The contents presented do not necessarily reflect CMS policy. FL-10SOW-2013FLC Page 11 of 11

UB-04 Claim Form Instructions

UB-04 Claim Form Instructions UB-04 Claim Form Instructions FORM LOCATOR NAME 1. Billing Provider Name & Address INSTRUCTIONS Enter the name and address of the hospital/facility submitting the claim. 2. Pay to Address Pay to address

More information

Florida Center for Health Information and Policy Analysis

Florida Center for Health Information and Policy Analysis Florida Center for Health Information and Policy Analysis Data Overview for the Commission on Healthcare and Hospital Funding May 20, 2015 1 Office of Data Collection and Quality Assurance Collection of

More information

Avoiding Rehospitalizations in LTC Chris Osterberg, RN BSN Pathway Health Services

Avoiding Rehospitalizations in LTC Chris Osterberg, RN BSN Pathway Health Services Avoiding Rehospitalizations in LTC Chris Osterberg, RN BSN Pathway Health Services Objectives Understand the new consequences to hospitals for discharged clients being re-admitted within selected time

More information

Regulatory Compliance Policy No. COMP-RCC 4.52 Title:

Regulatory Compliance Policy No. COMP-RCC 4.52 Title: I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.52 Page: 1 of 19 This policy applies to (1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates (each, an Affiliate ); (2)

More information

Outcomes Report through June 30, 2014

Outcomes Report through June 30, 2014 Outcomes Report through June 0, 0 Contents Introduction... Haag Pavilion (Sub-Acute Unit)... Rehabilitation Outcomes... Rehospitalization Outcomes of Sub-Acute Patients... Center for Heart Health Outcomes...

More information

Chapter 6. Billing on the UB-04 Claim Form

Chapter 6. Billing on the UB-04 Claim Form Chapter 6 This Page Intentionally Left Blank Chapter: 6 Page: 6-3 INTRODUCTION The UB-04 claim form is used to bill for all hospital inpatient, outpatient, and emergency room services. Dialysis clinic,

More information

Clarification of Patient Discharge Status Codes and Hospital Transfer Policies

Clarification of Patient Discharge Status Codes and Hospital Transfer Policies The Acute Inpatient Prospective Payment System Fact Sheet (revised November 2007), which provides general information about the Acute Inpatient Prospective Payment System (IPPS) and how IPPS rates are

More information

Billing Manual for In-State Long Term Care Nursing Facilities

Billing Manual for In-State Long Term Care Nursing Facilities Billing Manual for In-State Long Term Care Nursing Facilities Medical Services North Dakota Department of Human Services 600 E Boulevard Ave, Dept 325 Bismarck, ND 58505 September 2003 INTRODUCTION The

More information

See page 331 of HEDIS 2013 Tech Specs Vol 2. HEDIS specs apply to plans. RARE applies to hospitals. Plan All-Cause Readmissions (PCR) *++

See page 331 of HEDIS 2013 Tech Specs Vol 2. HEDIS specs apply to plans. RARE applies to hospitals. Plan All-Cause Readmissions (PCR) *++ Hospitalizations Inpatient Utilization General Hospital/Acute Care (IPU) * This measure summarizes utilization of acute inpatient care and services in the following categories: Total inpatient. Medicine.

More information

Get With The Guidelines - Stroke PMT Special Initiatives Tab for Ohio Coverdell Stroke Program CODING INSTRUCTIONS Effective 10-24-15

Get With The Guidelines - Stroke PMT Special Initiatives Tab for Ohio Coverdell Stroke Program CODING INSTRUCTIONS Effective 10-24-15 Get With The Guidelines - Stroke PMT Special Initiatives Tab for Ohio Coverdell Stroke Program CODING INSTRUCTIONS Effective 10-24-15 Date and time first seen by ED MD: The time entered should be the earliest

More information

Riverside Physician Network Utilization Management

Riverside Physician Network Utilization Management Subject: Program Riverside Physician Network Author: Candis Kliewer, RN Department: Product: Commercial, Senior Revised by: Linda McKevitt, RN Approved by: Effective Date January 1997 Revision Date 1/21/15

More information

Postacute Care Transfer Rule Review. HFMA Northern California COMPLIANCE WEBINAR SERIES California Statewide Webinar February 2012.

Postacute Care Transfer Rule Review. HFMA Northern California COMPLIANCE WEBINAR SERIES California Statewide Webinar February 2012. Postacute Care Transfer Rule Review HFMA Northern California COMPLIANCE WEBINAR SERIES California Statewide Webinar February 2012 Speaker Gloryanne Bryant, RHIA, RHIT, CCS, CCDS Regional Managing Director

More information

2.b.vii Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for SNF)

2.b.vii Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for SNF) 2.b.vii Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for SNF) Project Objective: Skilled nursing facilities (SNFs) will implement the evidence based INTERACT program developed

More information

UnitedHealthcare Medicare Solutions Readmission Review Program for Medicare Advantage Plans

UnitedHealthcare Medicare Solutions Readmission Review Program for Medicare Advantage Plans UnitedHealthcare Medicare Solutions Readmission Review Program for Medicare Advantage Plans General Clinical Guidelines for Payment Review Updated May 2015 Introduction The UnitedHealthcare Medicare Solutions

More information

Inpatient Transfers, Discharges and Readmissions July 19, 2012

Inpatient Transfers, Discharges and Readmissions July 19, 2012 Inpatient Transfers, Discharges and Readmissions July 19, 2012 Discharge Status Codes Two-digit code Identifies where the patient is at conclusion of encounter Visit Inpatient stay End of billing cycle

More information

Place of Service Codes for Professional Claims Database (updated November 1, 2012)

Place of Service Codes for Professional Claims Database (updated November 1, 2012) Place of Codes for Professional Claims Database (updated November 1, 2012) Listed below are place of service codes and descriptions. These codes should be used on professional claims to specify the entity

More information

Place of Service Codes for Professional Claims Database (updated August 6, 2015)

Place of Service Codes for Professional Claims Database (updated August 6, 2015) Place of Codes for Professional Claims Database (updated August 6, 2015) Listed below are place of service codes and descriptions. These codes should be used on professional claims to specify the entity

More information

AMERICAN BURN ASSOCIATION BURN CENTER VERIFICATION REVIEW PROGRAM Verificatoin Criterea EFFECTIVE JANUARY 1, 2015. Criterion. Level (1 or 2) Number

AMERICAN BURN ASSOCIATION BURN CENTER VERIFICATION REVIEW PROGRAM Verificatoin Criterea EFFECTIVE JANUARY 1, 2015. Criterion. Level (1 or 2) Number Criterion AMERICAN BURN ASSOCIATION BURN CENTER VERIFICATION REVIEW PROGRAM Criterion Level (1 or 2) Number Criterion BURN CENTER ADMINISTRATION 1. The burn center hospital is currently accredited by The

More information

Section 6. Medical Management Program

Section 6. Medical Management Program Section 6. Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent fraud, waste and abuse in its programs.

More information

WHAT IS MEDICAL MANAGEMENT? WHAT IS THE PURPOSE OF MEDICAL MANAGEMENT?

WHAT IS MEDICAL MANAGEMENT? WHAT IS THE PURPOSE OF MEDICAL MANAGEMENT? WHAT IS MEDICAL MANAGEMENT? How health plans make decisions to approve payment for medical treatment is a poorly understood part of the healthcare system. One part of the process, known as medical management,

More information

Place of Service Codes

Place of Service Codes Place of Service Codes Code(s) Place of Service Name Place of Service Description 01 Pharmacy** A facility or location where drugs and other medically related items and services are sold, dispensed, or

More information

Quality Provisions Ordered by Implementation Date

Quality Provisions Ordered by Implementation Date 1 3006, 10301 2 1311 3 3006, 10301 by Secretary 10/1/2011 Ambulatory Surgery Centers 10/1/2011 Providers in HBE shall be accredited with respect to local performance on clinical quality measures (e.g.,

More information

EHR Client Bulletin: Answers to Your Most Frequently Asked Condition Code 44 Questions

EHR Client Bulletin: Answers to Your Most Frequently Asked Condition Code 44 Questions EHR Client Bulletin: Answers to Your Most Frequently Asked Condition Code 44 Questions Originally Issued On: February 25, 2010 Last Update: February 20, 2013 UPDATE: The following EHR Client Bulletin was

More information

SECTION 4 COSTS FOR INPATIENT HOSPITAL STAYS HIGHLIGHTS

SECTION 4 COSTS FOR INPATIENT HOSPITAL STAYS HIGHLIGHTS SECTION 4 COSTS FOR INPATIENT HOSPITAL STAYS EXHIBIT 4.1 Cost by Principal Diagnosis... 44 EXHIBIT 4.2 Cost Factors Accounting for Growth by Principal Diagnosis... 47 EXHIBIT 4.3 Cost by Age... 49 EXHIBIT

More information

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services. Discharge Planning

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services. Discharge Planning DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services ICN 908184 October 2014 This booklet was current at the time it was published or uploaded onto the web. Medicare policy

More information

UTILIZATION MANAGEMENT PROGRAM Introduction Health Care Services

UTILIZATION MANAGEMENT PROGRAM Introduction Health Care Services UTILIZATION MANAGEMENT PROGRAM Introduction Health Care Services Call us: 1-888-898-7969, Option 1, then Option 4 Fax us: 1-800-594-7404 Business hours: Monday Friday (excluding holidays), 8:30 a.m. to

More information

HealthEast Hospitals Policies Manual Nursing Service Administration Page 1 of 5

HealthEast Hospitals Policies Manual Nursing Service Administration Page 1 of 5 Nursing Service Administration Page 1 of 5 Owners/Group: Care Management Services HealthEast Nurse Practice Committee Policy No. HE Administrative Policy: 100.C-6 HENSA Policy T-7 POLICY TITLE: Discharge/Transfer/Care

More information

HOSPITAL-ISSUED NOTICE OF NONCOVERAGE

HOSPITAL-ISSUED NOTICE OF NONCOVERAGE HOSPITAL-ISSUED NOTICE OF NONCOVERAGE Citations and Authority for Hospital-Issued Notice of Noncoverage (HINNs) The statutory authorities applicable to your review of a Hospital-Issued Notice of Noncoverage

More information

May 7, 2012. Submitted Electronically

May 7, 2012. Submitted Electronically May 7, 2012 Submitted Electronically Secretary Kathleen Sebelius Department of Health and Human Services Office of the National Coordinator for Health Information Technology Attention: 2014 edition EHR

More information

Ambulatory Surgery Center (ASC) Billing Instructions

Ambulatory Surgery Center (ASC) Billing Instructions All related services performed by an ambulatory surgery center must be billed on the UB04 claim form following the instructions listed below. Tips Claim Form Completion Claims for ASC covered services

More information

CARE GUIDELINES FROM MCG

CARE GUIDELINES FROM MCG 3.0 2.5 2.0 1.5 1.0 CARE GUIDELINES FROM MCG Evidence-based guidelines from MCG span the continuum of care, supporting clinical decisions and care planning, easing transitions between care settings, and

More information

Idaho Health Home State Plan Amendment Matrix: Summary Overview. Overview of Approved Health Home SPAs

Idaho Health Home State Plan Amendment Matrix: Summary Overview. Overview of Approved Health Home SPAs Idaho Health Home State Plan Amendment Matrix: Summary Overview This matrix outlines key program design features from health home State Plan Amendments (SPAs) approved by the Centers for Medicare & Medicaid

More information

Iowa Healthcare Collaborative (IHC) Iowa Report. Data Sources / Tools / Methods

Iowa Healthcare Collaborative (IHC) Iowa Report. Data Sources / Tools / Methods Iowa Healthcare Collaborative (IHC) Iowa Report Data Sources / Tools / Methods Table of Contents Introduction... 3 Background and Analytical Methods... 3 CMS Hospital Compare Process, Outcomes, Utilization,

More information

Comments to Legislative Workgroup on E-Prescribing

Comments to Legislative Workgroup on E-Prescribing Comments to Legislative Workgroup on E-Prescribing eqhealth Solutions is a not-for-profit, physician sponsored health care organization operating in Louisiana, Illinois, Florida and Mississippi. It has

More information

Quality Improvement Organization 11 th Statement of Work MEMORANDUM OF AGREEMENT KEPRO

Quality Improvement Organization 11 th Statement of Work MEMORANDUM OF AGREEMENT KEPRO Quality Improvement Organization 11 th Statement of Work MEMORANDUM OF AGREEMENT between KEPRO and I. AGREEMENT A. Parties: (Please Print Provider Name) The parties to this Memorandum of Agreement (herein

More information

Chapter 4 Health Care Management Unit 1: Care Management

Chapter 4 Health Care Management Unit 1: Care Management Chapter 4 Health Care Unit 1: Care In This Unit Topic See Page Unit 1: Care Care 2 6 Emergency 7 4.1 Care Healthcare Healthcare (HMS), Highmark Blue Shield s medical management division, is responsible

More information

Supplemental Technical Information

Supplemental Technical Information An Introductory Analysis of Potentially Preventable Health Care Events in Minnesota Overview Supplemental Technical Information This document provides additional technical information on the 3M Health

More information

High Rehospitalization Rates: Evaluation and Impact

High Rehospitalization Rates: Evaluation and Impact High Rehospitalization Rates: Evaluation and Impact May 29, 2009 Denise Remus, PhD, RN Chief Quality Officer, BayCare Health System BayCare Health System BayCare is the largest full-service, community-based

More information

High Desert Medical Group Connections for Life Program Description

High Desert Medical Group Connections for Life Program Description High Desert Medical Group Connections for Life Program Description POLICY: High Desert Medical Group ("HDMG") promotes patient health and wellbeing by actively coordinating services for members with multiple

More information

Chapter 7: Inpatient & Outpatient Hospital Care

Chapter 7: Inpatient & Outpatient Hospital Care 7 Inpatient & Outpatient Hospital Care ACUTE INPATIENT ADMISSIONS All elective and emergent admissions require prior authorization and/or notification for all Health Choice Generations Members admissions.

More information

Patient Optimization Improves Outcomes, Lowers Cost of Care >

Patient Optimization Improves Outcomes, Lowers Cost of Care > Patient Optimization Improves Outcomes, Lowers Cost of Care > Consistent preoperative processes ensure better care for orthopedic patients The demand for primary total joint arthroplasty is projected to

More information

APPENDIX 1. Medicaid Emergency Psychiatric Demonstration Application Proposal Guidelines

APPENDIX 1. Medicaid Emergency Psychiatric Demonstration Application Proposal Guidelines APPENDIX 1 Medicaid Emergency Psychiatric Demonstration Application Proposal Guidelines INTRODUCTION Section 2707 of the Affordable Care Act authorizes a 3-year Medicaid Emergency Psychiatric Demonstration

More information

Performance Measurement for the Medicare and Medicaid Eligible (MME) Population in Connecticut Survey Analysis

Performance Measurement for the Medicare and Medicaid Eligible (MME) Population in Connecticut Survey Analysis Performance Measurement for the Medicare and Medicaid Eligible (MME) Population in Connecticut Survey Analysis Methodology: 8 respondents The measures are incorporated into one of four sections: Highly

More information

Mar. 31, 2011 (202) 690-6145. Improving Quality of Care for Medicare Patients: Accountable Care Organizations

Mar. 31, 2011 (202) 690-6145. Improving Quality of Care for Medicare Patients: Accountable Care Organizations DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services Room 352-G 200 Independence Avenue, SW Washington, DC 20201 Office of Media Affairs MEDICARE FACT SHEET FOR IMMEDIATE RELEASE

More information

Making the Grade! A Closer Look at Health Plan Performance

Making the Grade! A Closer Look at Health Plan Performance Primary Care Update August 2011 Making the Grade! A Closer Look at Health Plan Performance HEDIS (Healthcare Effectiveness Data and Information Set) is a set of standardized measures designed to track

More information

Principal Source of Payment

Principal Source of Payment Principal Source of Payment Principal Source of Payment Length: 2 Expected principal source of payment for this hospital admission. 01 = Medicare (Fee For Service Plans Only) 02 = Medicaid/QUEST Expanded

More information

BlueAdvantage SM Health Management

BlueAdvantage SM Health Management BlueAdvantage SM Health Management BlueAdvantage member benefits include access to a comprehensive health management program designed to encompass total health needs and promote access to individualized,

More information

PA PROMISe 837 Institutional/UB 04 Claim Form

PA PROMISe 837 Institutional/UB 04 Claim Form Table of Contents 2 1 Appendix H Bureau of Provider Support (BPS) Field Operations Review Process Contents: A. General Background B. Explanation of Forms and Terms used in the Field Operations Section

More information

MONTANA. Downloaded January 2011

MONTANA. Downloaded January 2011 MONTANA Downloaded January 2011 37.40.202 PREADMISSION SCREENING, GENERAL REQUIREMENTS (1) This rule provides the preadmission screening requirements of the Montana Medicaid program for applicants to nursing

More information

Provider Billing Manual. Description

Provider Billing Manual. Description UB-92 Billing Instructions Revision Table Revision Date Sections Revised 7/1/02 Section 2.3 Form Locator 42 and 46 Description Language is being added to clarify UB-92 billing instructions for form locator

More information

Reducing Hospital Readmissions & The Affordable Care Act

Reducing Hospital Readmissions & The Affordable Care Act Reducing Hospital Readmissions & The Affordable Care Act The Game Has Changed Drastically Reducing MSPB Measures Chuck Bongiovanni, MSW, MBA, NCRP, CSA, CFE Chuck Bongiovanni, MSW, MBA, NCRP, CSA, CFE

More information

BILL TYPES PAGE 1 OF 8 UPDATED: 9/13

BILL TYPES PAGE 1 OF 8 UPDATED: 9/13 INPATIENT HOSPITAL 111 REGULAR INPATIENT 112 FIRST PORTION: CONTINUOUS STAY INPATIENT 113 SUBSEQUENT PORTION: CONTINUOUS STAY INPATIENT 114 FINAL PORTION: CONTINUOUS STAY INPATIENT 115 INPATIENT: LATE

More information

Overview of Hospital Utilization Review

Overview of Hospital Utilization Review Overview of Hospital Utilization Review Legal Authority The Inspector General (IG) hospital utilization review function operates under guidelines and regulations contained in: Texas Administrative Code

More information

Broad Issues in Quality Measurement: the CMS perspective

Broad Issues in Quality Measurement: the CMS perspective Broad Issues in Quality Measurement: the CMS perspective Shari M. Ling, MD Deputy Chief Medical Officer Centers for Medicare & Medicaid Services Workshop on Quality Measurement Developing Evidence-Based

More information

Emergency Department Planning and Resource Guidelines

Emergency Department Planning and Resource Guidelines Emergency Department Planning and Resource Guidelines [Ann Emerg Med. 2014;64:564-572.] The purpose of this policy is to provide an outline of, as well as references concerning, the resources and planning

More information

HSAG: The QIN-QIO for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands

HSAG: The QIN-QIO for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands HSAG: The QIN-QIO for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands Jim Barnhart, BSH LNHA Quality Improvement Specialist Carol Saavedra, BA Health Informatics Specialist November 18,

More information

CHAPTER 59A-23 WORKERS COMPENSATION MANAGED CARE ARRANGEMENTS 59A-23.001 Scope. 59A-23.002 Definitions. 59A-23.003 Authorization Procedures.

CHAPTER 59A-23 WORKERS COMPENSATION MANAGED CARE ARRANGEMENTS 59A-23.001 Scope. 59A-23.002 Definitions. 59A-23.003 Authorization Procedures. CHAPTER 59A-23 WORKERS COMPENSATION MANAGED CARE ARRANGEMENTS 59A-23.001 Scope. 59A-23.002 Definitions. 59A-23.003 Authorization Procedures. 59A-23.004 Quality Assurance. 59A-23.005 Medical Records and

More information

S E C T I O N. Post-acute care Skilled nursing facilities Home health agencies Inpatient rehabilitation facilities Long-term care hospitals

S E C T I O N. Post-acute care Skilled nursing facilities Home health agencies Inpatient rehabilitation facilities Long-term care hospitals S E C T I O N Post-acute care Skilled nursing facilities Home health agencies Inpatient rehabilitation facilities Long-term care hospitals Chart 8-1. Number of post-acute care providers increased or remained

More information

Professional Practice Medical Record Documentation Guidelines

Professional Practice Medical Record Documentation Guidelines Professional Practice Medical Record Documentation Guidelines INTRODUCTION Consistent and complete documentation in the medical record is an essential component of quality patient care. All Participating

More information

Florida Medicaid. Nursing Facility Services Coverage Policy

Florida Medicaid. Nursing Facility Services Coverage Policy Florida Medicaid Agency for Health Care Administration May 2016 Table of Contents Florida Medicaid 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal Authority... 1 1.3 Definitions... 1 2.0 Eligible

More information

Reducing Readmissions with Predictive Analytics

Reducing Readmissions with Predictive Analytics Reducing Readmissions with Predictive Analytics Conway Regional Health System uses analytics and the LACE Index from Medisolv s RAPID business intelligence software to identify patients poised for early

More information

HITECH Act Update: An Overview of the Medicare and Medicaid EHR Incentive Programs Regulations

HITECH Act Update: An Overview of the Medicare and Medicaid EHR Incentive Programs Regulations HITECH Act Update: An Overview of the Medicare and Medicaid EHR Incentive Programs Regulations The Health Information Technology for Economic and Clinical Health Act (HITECH Act) was enacted as part of

More information

Inpatient Services. Guide to Billing Facility Services. November 2013. Preface. Summary of Changes. Table of Contents.

Inpatient Services. Guide to Billing Facility Services. November 2013. Preface. Summary of Changes. Table of Contents. Inpatient Services Preface Summary of Changes Table of Contents Service Contacts November 2013 Replaces: December 2012 S-5781 11/13 Preface The Wellmark Provider Guide and specialty guides are billing

More information

UTILIZATION MANGEMENT

UTILIZATION MANGEMENT UTILIZATION MANGEMENT The Anthem Health Care Management Division has a singular dynamic focus - to continually improve the system of health care delivery that influences utilization and cost of services

More information

Prescription For Pennsylvania

Prescription For Pennsylvania Prescription for Pennsylvania A set of integrated practical strategies for Improving the health care of all Pennsylvanians, Making the health care system more efficient, and Containing costs. PA Family

More information

01/22/2010 1. Program Objectives. Quality and Poor Care Coordination

01/22/2010 1. Program Objectives. Quality and Poor Care Coordination Building Community Engagement in Indiana Communities: The Conduit to Transforming Healthcare Empowerment 34 th Annual InAHQ Conference on Healthcare Quality The Triple Crown of Healthcare Quality Nancy

More information

Medicare- Medicaid Enrollee State Profile

Medicare- Medicaid Enrollee State Profile Medicare- Medicaid Enrollee State Profile Montana Centers for Medicare & Medicaid Services Introduction... 1 At a Glance... 1 Eligibility... 2 Demographics... 3 Chronic Conditions... 4 Utilization... 6

More information

Changing Clinical Behaviors to Lower Costs and Reduce Catheter-Associated Urinary Tract Infections (CAUTI)

Changing Clinical Behaviors to Lower Costs and Reduce Catheter-Associated Urinary Tract Infections (CAUTI) Changing Clinical Behaviors to Lower Costs and Reduce Catheter-Associated Urinary Tract Infections (CAUTI) ARKANSAS METHODIST MEDICAL CENTER: How a foley catheter management system combined with education

More information

ACCOUNTABLE CARE ANALYTICS: DEVELOPING A TRUSTED 360 DEGREE VIEW OF THE PATIENT

ACCOUNTABLE CARE ANALYTICS: DEVELOPING A TRUSTED 360 DEGREE VIEW OF THE PATIENT ACCOUNTABLE CARE ANALYTICS: DEVELOPING A TRUSTED 360 DEGREE VIEW OF THE PATIENT Accountable Care Analytics: Developing a Trusted 360 Degree View of the Patient Introduction Recent federal regulations have

More information

Utilization Review and Denial Management

Utilization Review and Denial Management September 2014 Clinical Resource Management Series Part 3 of 10 Utilization Review and Denial Management Part 3 in our Clinical Resource Management (CRM) series is focused on utilization review and denial

More information

Optum By United Behavioral Health. 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines

Optum By United Behavioral Health. 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines Optum By United Behavioral Health 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines Therapeutic group care services are community-based, psychiatric residential treatment

More information

LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT MEDICAL RECORDS CONTENT/DOCUMENTATION

LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT MEDICAL RECORDS CONTENT/DOCUMENTATION LOUISIANA STATE UNIVERSITY HEALTH SCIENCES CENTER - SHREVEPORT MEDICAL RECORDS CONTENT/DOCUMENTATION Hospital Policy Manual Purpose: To define the components of the paper and electronic medical record

More information

PLAN OF CORRECTION. Provider's Plan of Correction (Each corrective action must be cross-referenced to the appropriate deficiency.)

PLAN OF CORRECTION. Provider's Plan of Correction (Each corrective action must be cross-referenced to the appropriate deficiency.) ID Prefix Tag (X4) R000 R200 Provider's Plan of Correction (Each corrective action must be cross-referenced to the appropriate deficiency.) Submission and implementation of this Plan of Correction does

More information

It s Time to Transition to ICD-10

It s Time to Transition to ICD-10 July 22, 2015 It s Time to Transition to ICD-10 What do the changes mean to your SNF? Presented by: Linda S. Little, RN-BSN Clinical Consultant HMM Consulting Office: (631) 265-6289 E-Mail: llittle@horanmm.com

More information

Utilization Management Program

Utilization Management Program Utilization Management Program The Utilization Management (UM) Program facilitates quality, cost-effective and medically appropriate services across a continuum of care that integrates a range of services

More information

Long term care coding issues for ICD-10-CM

Long term care coding issues for ICD-10-CM Long term care coding issues for ICD-10-CM Coding Clinic, Fourth Quarter 2012 Pages: 90-98 Effective with discharges: October 1, 2012 Related Information Long Term Care Coding Issues for ICD-10-CM Coding

More information

Resources and Services Directory for Head Injury and Other Conditions

Resources and Services Directory for Head Injury and Other Conditions Resources and Services Directory for Head Injury and Other Conditions Section 2: Accessing and Paying for TBI and Related Services 1000 NE 10 TH ST. OKC, OK 73117 TEL 405.271-3430 OR 800.522.0204 (OK only)

More information

Quality and Corporate Compliance

Quality and Corporate Compliance Quality and Corporate Compliance Compliance Program: Components for Long Term Acute Care Linda Dean-Hayes, RN, MSN, FNP Chief Corporate Clinical and Compliance Officer Solara Healthcare October 12, 2009

More information

OFFICE OF INSPECTOR GENERAL

OFFICE OF INSPECTOR GENERAL Department of Health and Human Services OFFICE OF INSPECTOR GENERAL Nursing Home Medical Directors Survey JANET REHNQUIST INSPECTOR GENERAL FEBRUARY 2003 OEI-06-99-00300 OFFICE OF INSPECTOR GENERAL http://www.oig.hhs.gov/

More information

Innovations@Home. Home Health Initiatives Reduce Avoidable Readmissions by Leveraging Innovation

Innovations@Home. Home Health Initiatives Reduce Avoidable Readmissions by Leveraging Innovation How Does CMS Measure the Rate of Acute Care Hospitalization (ACH)? Until January 2013, CMS measured Acute Care Hospitalization (ACH) through the Outcomes Assessment and Information Set (OASIS) reporting

More information

PSYCHIATRIC UNIT CRITERIA WORK SHEET

PSYCHIATRIC UNIT CRITERIA WORK SHEET DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES PSYCHIATRIC UNIT CRITERIA WORK SHEET RELATED MEDICARE PROVIDER NUMBER ROOM NUMBERS IN THE UNIT FACILITY NAME AND ADDRESS

More information

THE ROLE OF LONG TERM ACUTE CARE HOSPITALS IN THE ACUTE CARE CONTINUUM. Wednesday, June 02, 2010

THE ROLE OF LONG TERM ACUTE CARE HOSPITALS IN THE ACUTE CARE CONTINUUM. Wednesday, June 02, 2010 THE ROLE OF LONG TERM ACUTE CARE HOSPITALS IN THE ACUTE CARE CONTINUUM Wednesday, June 02, 2010 As A Provider Of Continuing Nursing Education, Triumph Healthcare Is Required By Texas Nurses Association

More information

Follow-up information from the November 12 provider training call

Follow-up information from the November 12 provider training call Follow-up information from the November 12 provider training call Criteria I. Multiple Therapy Disciplines 1. Clarification regarding the use of group therapies in IRFs. Answer: CMS has not yet established

More information

Clinical Coverage Criteria Extended Care Facility

Clinical Coverage Criteria Extended Care Facility Clinical Coverage Criteria Extended Care Facility Document Number: 018 Commercial MassHealth* Commonwealth Care Authorization required X X X Notification within 24 hours of service or next business day

More information

A Project to Reengineer Discharges Reduces 30-Day Hospital Readmission Rates. April 11, 2014

A Project to Reengineer Discharges Reduces 30-Day Hospital Readmission Rates. April 11, 2014 A Project to Reengineer Discharges Reduces 30-Day Hospital Readmission Rates April 11, 2014 About the QIO Program Leading rapid, large-scale change in health quality: Goals are bolder. The patient is at

More information

Preface. Summary of Changes. Table of Contents. Service Contacts. October 2014 Replaces: May 2014 S-5781 10/14

Preface. Summary of Changes. Table of Contents. Service Contacts. October 2014 Replaces: May 2014 S-5781 10/14 Preface Summary of Changes Table of Contents Service Contacts October 2014 Replaces: May 2014 S-5781 10/14 Preface The Wellmark Provider Guide and specialty guides are billing resources for providers doing

More information

Medweb Telemedicine 667 Folsom Street, San Francisco, CA 94107 Phone: 415.541.9980 Fax: 415.541.9984 www.medweb.com

Medweb Telemedicine 667 Folsom Street, San Francisco, CA 94107 Phone: 415.541.9980 Fax: 415.541.9984 www.medweb.com Medweb Telemedicine 667 Folsom Street, San Francisco, CA 94107 Phone: 415.541.9980 Fax: 415.541.9984 www.medweb.com Meaningful Use On July 16 2009, the ONC Policy Committee unanimously approved a revised

More information

Andrew C. Bledsoe, MBA, CHPA, PCMH CCE Executive Director. Northeast KY Regional Health Information Organization. www.nekyrhio.org

Andrew C. Bledsoe, MBA, CHPA, PCMH CCE Executive Director. Northeast KY Regional Health Information Organization. www.nekyrhio.org Andrew C. Bledsoe, MBA, CHPA, PCMH CCE Executive Director Northeast KY Regional Health Information Organization www.nekyrhio.org NCQA Program Setup Standards Six Standards Outline Program Elements Six

More information

Center for Medicaid and State Operations/Survey and Certification Group

Center for Medicaid and State Operations/Survey and Certification Group DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop S2-12-25 Baltimore, Maryland 21244-1850 Center for Medicaid and State Operations/Survey

More information

Population Health Management

Population Health Management Population Health Management 1 Population Health Management At a Glance The MedStar Medical Management Department is responsible for managing health care resources for MedStar Select Health Plan. Our goal

More information

HIPAA Notice of Privacy Practices

HIPAA Notice of Privacy Practices HIPAA Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. This Notice

More information

Glossary of Health Coverage and Medical Terms

Glossary of Health Coverage and Medical Terms Glossary of Health Coverage and Medical Terms This glossary defines many commonly used terms, but isn t a full list. These glossary terms and definitions are intended to be educational and may be different

More information

Unit 1 Core Care Management Activities

Unit 1 Core Care Management Activities Unit 1 Core Care Management Activities Healthcare Management Services Healthcare Management Services (HMS) is responsible for all the medical management services provided to Highmark Blue Shield members,

More information

Introduction. The History of CMS/JCAHO Measure Alignment

Introduction. The History of CMS/JCAHO Measure Alignment Release Notes: Introduction - Version 2.2 Introduction The History of CMS/JCAHO Measure Alignment In early 1999, the Joint Commission solicited input from a wide variety of stakeholders (e.g., clinical

More information

Medical Management Program

Medical Management Program Section 7. Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent fraud, waste and abuse in its programs.

More information

Medicare- Medicaid Enrollee State Profile

Medicare- Medicaid Enrollee State Profile Medicare- Medicaid Enrollee State Profile North Centers for Medicare & Medicaid Services Introduction... 1 At a Glance... 1 Eligibility... 2 Demographics... 3 Chronic Conditions... 4 Utilization... 6 Spending...

More information

Optum By United Behavioral Health. 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines

Optum By United Behavioral Health. 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines Optum By United Behavioral Health 2015 Florida Medicaid Managed Medical Assistance (MMA) Level of Care Guidelines Statewide Inpatient Psychiatric Program Services (SIPP) Statewide Inpatient Psychiatric

More information

Improving Hospital Performance

Improving Hospital Performance Improving Hospital Performance Background AHA View Putting patients first ensuring their care is centered on the individual, rooted in best practices and utilizes the latest evidence-based medicine is

More information

Online Supplement to Clinical Peer Review Programs Impact on Quality and Safety in U.S. Hospitals, by Marc T. Edwards, MD

Online Supplement to Clinical Peer Review Programs Impact on Quality and Safety in U.S. Hospitals, by Marc T. Edwards, MD Online Supplement to Clinical Peer Review Programs Impact on Quality and Safety in U.S. Hospitals, by Marc T. Edwards, MD Journal of Healthcare Management 58(5), September/October 2013 Tabulated Survey

More information