RE: Medicare s Post-acute Transfer Policy and Condition Code 42 BACKGROUND

Size: px
Start display at page:

Download "RE: Medicare s Post-acute Transfer Policy and Condition Code 42 BACKGROUND"

Transcription

1 Memorandum TO: FROM: Glenn Hendrix Doug M. Hance DATE: RE: Medicare s Post-acute Transfer Policy and Condition Code 42 BACKGROUND Medicare s post-acute transfer policy distinguishes between discharges and transfers of patients from hospitals. Pursuant to 42 CFR 412.4(e) and (f), Medicare pays full diagnosisrelated group (DRG) payments to hospitals that discharge patients to their homes. For certain DRGs, however, Medicare reimburses hospitals that transfer patients to various post-acute care settings (including home health care) a pier diem rate for each day of the stay, not to exceed the full DRG payment for a discharge. CMS requires that certain condition codes be used on claims for patients transferred to home for home health services that are not subject to the post-acute care transfer policy. The pertinent CMS Manual provides that the hospital should use condition code 42 with discharge status code 06 if the continuing care plan is not related to the condition or diagnosis for which the individual received inpatient hospital services. 1 CMS has also indicated that if the hospital s continuing care plan for the patient is not related to the purpose of the inpatient hospital admission, a condition code 42 must be entered on the claim. 2 Some patients are admitted to hospitals while in the middle of a home health care episode, and then subsequently discharged back to home health care. These situations ( Hospital Interludes ) raise the question of whether the home health care provided after the hospital stay can be considered unrelated to the hospitalization. 1 CMS Manual System Pub Medicare Claims Processing, Transmittal 311 (Oct. 8, 2004). Note that CMS used the phrase condition or diagnosis rather than conditions or diagnoses Fed. Reg , (Aug. 1, 2000). CMS continued by stating, If the continuing care plan is related to the purpose of the inpatient hospital admission, but care did not start within 3 days after the date of discharge, a condition code 43 must be entered on the claim. The presence of either of these condition codes in conjunction with the discharge destination code 06 will result in full payment rather than the transfer payment amount. We intend to closely monitor the accuracy of hospitals discharge destination coding in this regard and take whatever steps are necessary to ensure that accurate payment is made under this policy. 65 Fed. Reg , (Aug. 1, 2000). Note that CMS used the phrase purpose of the inpatient hospital admission, indicating that the question of whether the continuing care plan is related should be asked in relation to the purpose of the inpatient hospital admission. Note also that CMS stated that condition code 42 must be entered on the claim when it is appropriate, suggesting that the code is required rather than optional when appropriate.

2 Page 2 ISSUE 1. When there has been a Hospital Interlude, must the hospital always consider the subsequent home health care related to the hospitalization? 2. If not, what criteria should be applied in determining whether condition code 42 is appropriate? BRIEF ANSWERS 1. When there has been a Hospital Interlude, must the hospital always consider the subsequent home health care related to the hospitalization? Response: No, for reasons discussed in further detail below. In fact, because patients who are admitted to hospitals during home health episodes may have multiple, distinct medical conditions, Hospital Interludes might actually be more likely to result in the appropriate use of condition code 42 than situations involving patients admitted to hospitals directly from home. Condition code 42 asks whether the hospital s continuing care plan at the time of discharge calls for the provision of services unrelated to the condition responsible for the patient s admission to the hospital. Patients who are admitted while in the middle of a home health care episode may require additional treatment after their hospital stay for the same medical issue that was being treated by home health care prior to their hospital admission, and this medical issue could be distinct from the condition responsible for the patient s hospitalization. For instance, if someone receiving home health care for mobility issues due to a hip fracture is admitted to an acute care facility for the treatment of pneumonia, and then is subsequently discharged to home health for mobility issues related to the hip fracture, then condition code 42 would be appropriate, as the pneumonia stay should not be subject to the postacute transfer policy. 2. If not, what criteria should be applied in determining when condition code 42 is appropriate? Response:

3 Page 3 As discussed in further detail below, hospitals are responsible for deciding whether the home health care the patient is to receive as part of the hospital s discharge plan is related to the condition responsible for the inpatient hospital admission. In making that determination, the services called for in the hospital s continuing care plan should be compared with the patient s primary diagnosis not the secondary diagnoses listed on the hospital s bill. If any of the services called for in the hospital s discharge plan are related to the condition indicated by the hospital s primary diagnosis, then condition code 42 should not be used. Hospitals are not expected to compare home health bills to hospital bills in order to determine relatedness between the two providers treatment. However, whenever hospitals use condition code 42, they are expected to have documentation in the patient's record supporting their decision to use the condition code. DISCUSSION The preamble to the post-acute transfer rule demonstrates that CMS intended for hospitals to determine whether condition code 42 is appropriate at the time of discharge based on the hospital s continuing care plan and the patient s principal diagnosis. Hospitals are not expected to subsequently review the diagnosis codes on home health bills and compare these diagnosis codes to the hospital s diagnosis codes. o CMS Intended for Hospitals to Determine Relatedness at the Time of Discharge CMS indicated in the preamble to the post-acute transfer rule that hospitals would be responsible for deciding whether to use condition code 42 by reviewing the hospital s continuing care plan at the time of discharge. CMS described its decision while explaining the reasons why it ruled out alternatives. The following paragraphs demonstrate two possible methods for determining relatedness between the home health treatment and the prior hospitalization, neither of which has been adopted by CMS: With regard to an appropriate definition of home health services* * * relate[d] to the condition or diagnosis for which the individual received inpatient hospital services* * *, we considered several possible approaches. Under one approach we could compare the principal diagnosis of the inpatient stay to the diagnosis code indicated on the home health bill, similar to our policy on the 3-day payment window for preadmission services. However, we believe that such a policy is far too restrictive in terms of qualifying discharges for transfer payment. In addition, a hospital would not know when it discharges a patient to home health what diagnosis code the home health agency will put on the bill. Therefore, the hospital would not be able to correctly code the inpatient bill as a transfer or discharge.

4 Page 4 We also considered proposing that any home health care that begins within the designated timeframe be included as related in our definition. However, this definition might be too broad and the hospital would not be able to predict which cases should be coded as transfers because the hospital often may not know about home health services that are provided upon discharge but were not ordered or planned for as part of the hospital discharge plan. 3 CMS explained that its chosen policy is for hospitals to maintain responsibility to code the discharge bill based on the discharge plan for the patient. CMS stated, In this way, the hospital would be fully aware of the status of the patient when discharged and could be held responsible for correctly coding the discharge as a transfer on the inpatient bill. 4 Notably, CMS indicated that hospitals are not expected to compare the diagnosis codes on home health bills with the principal diagnosis of the inpatient stay. o The Post-acute Transfer Policy Focuses on Hospitals Principal Diagnosis In addition to indicating that relatedness should be determined by the hospital at the time of discharge, CMS clarified that the post-acute transfer policy focuses on the hospital s principal diagnosis rather than any secondary diagnoses. CMS shed further light on its interpretation of relatedness between the home health services and the prior hospital stay in the following comment and response: Comment: One commenter argued that the best method to determine whether post-acute home health services are related to the inpatient stay would be to match the principal diagnosis codes on the inpatient and home health bills. The commenter believed this would alleviate situations where the patient is discharged from the hospital with a written plan for the provision of home health services, but the services are related to a medical condition other than the condition responsible for the inpatient stay. 5 In addition, the commenter noted that matching principal diagnosis codes would be consistent with current policy for the 3-day window for preadmission services. Response: 3 63 Fed. Reg , (July 31, 1998) Fed. Reg , (July 31, 1998). 5 Note that here the commenter describes situations when condition code 42 would be appropriate. Condition code 42 is CMS solution for addressing situations when the home health services are related to a medical condition other than the condition responsible for the inpatient stay.

5 Page 5 We disagree that the determination of whether home health care is related to the acute hospitalization should be based on the presence of identical diagnosis codes on the inpatient and home health bills. This approach would rely on the coding practices of the providers involved. Providers, especially post-acute care providers, frequently have the discretion to select from several possible diagnosis codes. A common practice of post-acute care providers is to use the V57 diagnosis code category (care involving use of rehabilitation procedures) as principal because those codes best describe the reason for the post-acute care. However, this code is seldom used by hospitals for acute care discharges because they are instructed by coding rules to code as principal the condition that required the hospital admission as determined at the time of discharge. In fact, if the hospitals coded discharges with the rehabilitation codes as principal, the discharges would never be included in the post-acute care policy because those discharges would never be classified to one of the 10 selected DRGs. We believe our proposed policy on this issue is preferable. We note that hospitals that code a discharge to home health will be permitted to indicate through a condition code on the inpatient bill that the hospital s discharge plan does not call for home care related to the hospitalization, but that other nonrelated home care is appropriate. This way, the hospital will make a conscious selection that the home care the patient is to receive is not related to the hospitalization, and would be expected to have documentation in the patient's records to that effect (emphasis added). 6 CMS statement that if the hospitals coded discharges with the rehabilitation codes as principal, the discharges would never be included in the post-acute care policy is significant because it clarifies that the post-acute care policy focuses entirely on the hospital s principal diagnosis, rather than on any secondary diagnoses. CMS stated that if a principal diagnosis is not one of the DRGs subject to the post-acute care transfer policy, then the post-acute care transfer policy does not apply to the patient, regardless of whether any secondary diagnosis lists a DRG that is typically subject to the policy. Given that the post-acute care transfer policy is either applicable or inapplicable based on the hospital s principal diagnosis code, the question of relatedness between the home health treatment and the prior hospital stay would also seem to be limited to the condition indicated on the principal diagnosis for the patient. This is consistent with CMS use of the phrase purpose of the inpatient hospital admission 7 when describing condition code 42 (since hospitals are instructed by coding rules to code as principal the condition that required the hospital 6 63 Fed. Reg , (July 31, 1998). 7 See supra, note 2.

6 Page 6 admission), as well the fact that CMS overall discussion in the preamble to the post-acute transfer rule focuses on a hospital s principal diagnosis. CMS did not intend for the post-acute transfer policy to apply whenever any of the services provided during a home health episode are related to any of the services provided during the prior hospital stay. Rather, CMS focus when it created the post-acute transfer policy was on the principal diagnosis and whether continued treatment related to that diagnosis is required upon discharge. EXAMPLES The following examples illustrate the application of the rule: o Hip Fracture/ Pneumonia In this example, someone receiving home health care for mobility issues due to a hip fracture is admitted to a hospital for the treatment of pneumonia, and then is subsequently discharged to home health for mobility issues related to the hip fracture. When determining whether to use condition code 42, the factors that should be compared are the condition responsible for the hospitalization (as indicated by the hospital s principal diagnosis) and the services called for in the hospital s continuing care plan. In this example, the condition responsible for the hospitalization was pneumonia, while the hospital s discharge plan called for only home health care related to treatment for the hip fracture. Here, the post-acute transfer policy should not apply. The pneumonia issue was resolved during the hospital stay, so the patient would have been discharged home if not for her separate, unrelated physical injury. Since the reasons for the hospital stay and the home health treatment were distinct, the hospital should bill using condition code 42. If the hospital s continuing care plan called for continued treatment and monitoring of the pneumonia, however, then condition code 42 would not be appropriate. o Bronchitis/ Kidney Failure In this example, the hospital compares the patient s initial home health treatment for obstructive chronic bronchitis to the hospital s primary diagnosis of acute kidney failure with the bronchitis diagnosis in second position. When deciding whether to use condition code 42, the question that the hospital should ask is whether the patient will continue to receive treatment for the condition that caused her hospitalization (the acute kidney failure) as part of the hospital s home health continuing care plan. This example, as stated, does not provide enough information to determine whether condition code 42 should be used because it does not include the reason for the discharge to home health care.

7 Page 7 The fact that the patient had been undergoing treatment for bronchitis prior to her hospitalization is not relevant to the analysis, and neither is the fact that her bronchitis was listed in second position by the hospital. The question of relatedness between the home health care treatment and the hospitalization focuses on the condition responsible for the inpatient admission (which, according to CMS coding guidelines, should be synonymous with the hospital s primary diagnosis). In this example, if the patient s home health discharge plan called for only treatment of the patient s bronchitis (but not continued care related to the acute kidney failure which was responsible for her hospitalization), then condition code 42 would be proper. CONCLUSION Condition code 42 can be used for Hospital Interludes. CMS anticipates that Hospitals will look to the patient s record to determine whether the hospital s discharge plan called for services separate and distinct from the condition responsible for the patient s hospitalization. If the record demonstrates that the patient was discharged to home health for reasons unrelated to the condition responsible for her hospitalization, then condition code 42 is appropriate.

TRENDWATCH. Medicare, Medicaid and most states. Addendum: Background On Post-Acute Care. PAC Provider Snapshot and Overlap of Patient Characteristics

TRENDWATCH. Medicare, Medicaid and most states. Addendum: Background On Post-Acute Care. PAC Provider Snapshot and Overlap of Patient Characteristics AMERICAN HOSPITAL ASSOCIATION DECEMBER 2015 TRENDWATCH Addendum: Background On Post-Acute Care Medicare, Medicaid and most states recognize four types of post-acute care (PAC) settings: long-term acute-care

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

Executive Summary. Chronic Obstructive Pulmonary Disease (COPD) Acute Exacerbation Episode

Executive Summary. Chronic Obstructive Pulmonary Disease (COPD) Acute Exacerbation Episode Executive Summary Chronic Obstructive Pulmonary Disease (COPD) Acute Exacerbation Episode OVERVIEW OF A COPD ACUTE EXACERBATION EPISODE The chronic obstructive pulmonary disease (COPD) acute exacerbation

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

Effective October 1, 2014 Spinal Surgery Medicare Severity- Diagnosis Related Groups (MS-DRGs)

Effective October 1, 2014 Spinal Surgery Medicare Severity- Diagnosis Related Groups (MS-DRGs) 2014 HOSPITAL CODING MANUAL CHAPTER 4: 2014 SPINAL SURGERY (MS-DRGS) 1 Effective October 1, 2014 Spinal Surgery Medicare Severity- Diagnosis Related Groups (MS-DRGs) DRGs are the prospective payment system

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

ICD-9 Basics Study Guide

ICD-9 Basics Study Guide Board of Medical Specialty Coding ICD-9 Basics Study Guide for the Home Health ICD-9 Basic Competencies Examination Two Washingtonian Center 9737 Washingtonian Blvd., Ste. 100 Gaithersburg, MD 20878-7364

More information

CMS Provides ACMA with FAQ Document Addressing Case Managers Concerns Surrounding the IM Second Notice

CMS Provides ACMA with FAQ Document Addressing Case Managers Concerns Surrounding the IM Second Notice CMS Provides ACMA with FAQ Document Addressing Case Managers Concerns Surrounding the IM Second Notice The Centers for Medicare & Medicaid Services (CMS) provided ACMA with the following frequently asked

More information

CMS Proposed Rule: Revising the Requirements for Discharge Planning

CMS Proposed Rule: Revising the Requirements for Discharge Planning CMS Proposed Rule: Revising the Requirements for Discharge Planning Dec. 4, 2015 2015 American Hospital Association Key Dates and Facts CMS published the rule in the Federal Register on Nov. 3, 2015. The

More information

What is a Long-Term Care Hospital ( LTCH )?

What is a Long-Term Care Hospital ( LTCH )? After the Moratorium: Long Term Care Hospitals Current Payment Issues and Future Prospects American Health Lawyers Association Institute on Medicare and Medicaid Payment Issues Program March 20-22, 2013

More information

a. General Rules for Obstetric Cases

a. General Rules for Obstetric Cases 15. Chapter 15: Pregnancy, Childbirth, and the Puerperium (O00-O9A) a. General Rules for Obstetric Cases 1) Codes from chapter 15 and sequencing priority Obstetric cases require codes from chapter 15,

More information

Long-Term Acute Care Hospitals

Long-Term Acute Care Hospitals Long-Term Acute Care Hospitals What are they? What services do they offer? Presented by: Maxi Adams MBA, BSN, RN LTACH STACH LTACH = Long-Term Acute Care Hospital STACH = Short-Term Acute Care Hospital

More information

Fighting Medicare Fraud in Long-Term Care Hospitals-within-Hospitals: OIG Documents Ongoing Failures while Industry Groups Complain

Fighting Medicare Fraud in Long-Term Care Hospitals-within-Hospitals: OIG Documents Ongoing Failures while Industry Groups Complain Fighting Medicare Fraud in Long-Term Care Hospitals-within-Hospitals: OIG Documents Ongoing Failures while Industry Groups Complain By Susan E. Cancelosi, J.D., LL.M. Candidate Medicare s reimbursement

More information

Current Issues for Long-Term Care Hospitals

Current Issues for Long-Term Care Hospitals Current Issues for Long-Term Care Hospitals Joe Geraci 512.703.5774 joe.geraci@huschblackwell.com Alison Hollender 214.999.6193 alison.hollender@huschblackwell.com Agenda Regulatory requirements to be

More information

MEDICARE INAPPROPRIATELY PAID HOSPITALS INPATIENT CLAIMS SUBJECT TO THE POSTACUTE CARE TRANSFER POLICY

MEDICARE INAPPROPRIATELY PAID HOSPITALS INPATIENT CLAIMS SUBJECT TO THE POSTACUTE CARE TRANSFER POLICY Department of Health and Human Services OFFICE OF INSPECTOR GENERAL MEDICARE INAPPROPRIATELY PAID HOSPITALS INPATIENT CLAIMS SUBJECT TO THE POSTACUTE CARE TRANSFER POLICY Inquiries about this report may

More information

John W. Baker, MD, FACS, FASMBS

John W. Baker, MD, FACS, FASMBS A Dirge for Medicare s New DRGs John W. Baker, MD, FACS, FASMBS During this past summer, the Centers for Medicare & Medicaid Services (CMS) announced a major shift in the way Medicare would reimburse hospital

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

MERCY MEDICAL CENTER INCORRECTLY BILLED MEDICARE INPATIENT CLAIMS WITH KWASHIORKOR

MERCY MEDICAL CENTER INCORRECTLY BILLED MEDICARE INPATIENT CLAIMS WITH KWASHIORKOR Department of Health and Human Services OFFICE OF INSPECTOR GENERAL MERCY MEDICAL CENTER INCORRECTLY BILLED MEDICARE INPATIENT CLAIMS WITH KWASHIORKOR Inquiries about this report may be addressed to the

More information

Discharge & Pre-Care Planning

Discharge & Pre-Care Planning Discharge & Pre-Care Planning from the California Office of Patients Rights Discharge and Pre-care planning are two of the most useful yet least utilized tools to assist clients in minimizing involuntary

More information

OVERVIEW This policy is to document the criteria for coverage of services at the acute inpatient rehabilitation level of care.

OVERVIEW This policy is to document the criteria for coverage of services at the acute inpatient rehabilitation level of care. Medical Coverage Policy Acute Inpatient Rehabilitation Level of Care EFFECTIVE DATE: 07 06 2010 POLICY LAST UPDATED: 06 04 2013 sad OVERVIEW This policy is to document the criteria for coverage of services

More information

Regulatory Compliance Policy No. COMP-RCC 4.32 Title:

Regulatory Compliance Policy No. COMP-RCC 4.32 Title: I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.32 Page: 1 of 4 This policy applies to (1) Tenet Healthcare Corporation and its wholly-owned subsidiaries and affiliates (each, an Affiliate ); (2)

More information

Fact Sheet #1 Inpatient Rehabilitation Facility Classification Requirements

Fact Sheet #1 Inpatient Rehabilitation Facility Classification Requirements Fact Sheet #1 Inpatient Rehabilitation Facility Classification Requirements Provider Types Affected All hospitals or units of a hospital that are classified under subpart B of part 412 of the Medicare

More information

Mastering Physician Queries in the Hospital Setting

Mastering Physician Queries in the Hospital Setting Mastering Physician Queries in the Hospital Setting May 28, 2015 Date Wolters Kluwer Presentation by Presentation by Christopher G. Richards, RHIA, CCS Barry Libman, Inc. Learning Objectives Evaluate when

More information

Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments

Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments Estimating the Impact of the Transition to ICD-10 on Medicare Inpatient Hospital Payments Ronald E. Mills, Ph.D.*, Rhonda R. Butler, CCS*, Richard F. Averill, M.S.*, Elizabeth C. McCullough, M.S.*, Mona

More information

Acute Inpatient Rehabilitation Level of Care

Acute Inpatient Rehabilitation Level of Care Printer-Friendly Page Acute Inpatient Rehabilitation Level of Care EFFECTIVE DATE 07/06/2010 LAST UPDATED 07/06/2010 Prospective review is recommended/required. Please check the member agreement for preauthorization

More information

ZEPHYRLIFE REMOTE PATIENT MONITORING REIMBURSEMENT REFERENCE GUIDE

ZEPHYRLIFE REMOTE PATIENT MONITORING REIMBURSEMENT REFERENCE GUIDE ZEPHYRLIFE REMOTE PATIENT MONITORING REIMBURSEMENT REFERENCE GUIDE Overview This guide includes an overview of Medicare reimbursement methodologies and potential coding options for the use of select remote

More information

TOP 20 Best Practice Physician Queries Questions Answered ICD 10 Coding Readiness Top 20 Questions Answered Education Series (Session 3 of 3)

TOP 20 Best Practice Physician Queries Questions Answered ICD 10 Coding Readiness Top 20 Questions Answered Education Series (Session 3 of 3) TOP 20 uestions nswered ICD 10 Coding Readiness Top 20 uestions nswered Education Series (Session 3 of 3) Presented July 7, 2015 by Ed O Beirne, MHS, CCS, Senior Managing Consultant and Tina Fletcher,

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

September 4, 2012. Submitted Electronically

September 4, 2012. Submitted Electronically September 4, 2012 Ms. Marilyn Tavenner Acting Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-1589-P P.O. Box 8016 Baltimore, MD 21244-8016

More information

REHABILITATION HOSPITAL CRITERIA WORK SHEET

REHABILITATION HOSPITAL CRITERIA WORK SHEET DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES FORM APPROVED OMB NO. 0938-0986 REHABILITATION HOSPITAL CRITERIA WORK SHEET RELATED MEDICARE PROVIDER NUMBER ROOM NUMBERS

More information

Quality Improvement Organization Manual Chapter 7 - Denials, Reconsiderations, Appeals

Quality Improvement Organization Manual Chapter 7 - Denials, Reconsiderations, Appeals Quality Improvement Organization Manual Chapter 7 - Denials, Reconsiderations, Appeals Transmittals for Chapter 7 Table Of Contents (Rev. 18, 10-10-14) REVIEW OF HOSPITAL-ISSUED NOTICE OF NON-COVERAGE

More information

Alternative Payment Mechanisms in the Next Generation ACO Model

Alternative Payment Mechanisms in the Next Generation ACO Model 2016 Alternative Payment Mechanisms in the Next Generation ACO Model UPDATED MAY 2016 AMERICAN HEALTH CARE ASSOCIATION 1201 L ST NW WASHINGTON DC 20005 (202)842-4444 INTRODUCTION This document provides

More information

Discharge or Episode of Care? CMS Redefines the Interrupted Stay Rule for LTACHS. Cherilyn G. Murer, J.D., C.R.A.

Discharge or Episode of Care? CMS Redefines the Interrupted Stay Rule for LTACHS. Cherilyn G. Murer, J.D., C.R.A. Introduction Discharge or Episode of Care? CMS Redefines the Interrupted Stay Rule for LTACHS By Cherilyn G. Murer, J.D., C.R.A. When CMS first implemented the prospective payment system for long term

More information

Hospital Value-Based Purchasing (VBP) Program

Hospital Value-Based Purchasing (VBP) Program Medicare Spending per Beneficiary (MSPB) Measure Presentation Question & Answer Transcript Moderator: Bethany Wheeler, BS Hospital VBP Program Support Contract Lead Hospital Inpatient Value, Incentives,

More information

Linking Quality to Payment

Linking Quality to Payment Linking Quality to Payment Background Our nation s health care delivery system is undergoing a major transformation as reimbursement moves from a volume-based methodology to one based on value and quality.

More information

VNAA Summary: Discharge Planning Proposed Rule

VNAA Summary: Discharge Planning Proposed Rule VNAA Summary: Discharge Planning Proposed Rule On Thursday, October 29, 2015, the Centers for Medicare and Medicaid Services (CMS) issued a proposed regulation that would revise the discharge planning

More information

GAO MEDICARE. More Specific Criteria Needed to Classify Inpatient Rehabilitation Facilities

GAO MEDICARE. More Specific Criteria Needed to Classify Inpatient Rehabilitation Facilities GAO United States Government Accountability Office Report to the Senate Committee on Finance and the House Committee on Ways and Means April 2005 MEDICARE More Specific Criteria Needed to Classify Inpatient

More information

Regulatory Compliance Policy No. COMP-RCC 4.07 Title:

Regulatory Compliance Policy No. COMP-RCC 4.07 Title: I. SCOPE: Regulatory Compliance Policy No. COMP-RCC 4.07 Page: 1 of 7 This policy applies to (1) any Hospital in which Tenet Healthcare Corporation or an affiliate owns a direct or indirect equity interest

More information

FLORIDA WORKERS' COMPENSATION REIMBURSEMENT MANUAL FOR HOSPITALS

FLORIDA WORKERS' COMPENSATION REIMBURSEMENT MANUAL FOR HOSPITALS FLORIDA WORKERS' COMPENSATION REIMBURSEMENT MANUAL FOR HOSPITALS 2006 Edition Florida Department of Financial Services Division of Workers Compensation for incorporation by reference into Rule 69L-7.501,

More information

Lowering Costs and Improving Outcomes. Patient Engagement Issues. Nancy Davenport-Ennis President & CEO. September 8 th, 2009

Lowering Costs and Improving Outcomes. Patient Engagement Issues. Nancy Davenport-Ennis President & CEO. September 8 th, 2009 The Healthcare Imperative: Lowering Costs and Improving Outcomes Patient Engagement Issues Nancy Davenport-Ennis President & CEO National Patient Advocate Foundation September 8 th, 2009 Institute of Medicine

More information

Medi-Pak Advantage: Frequently Asked Questions

Medi-Pak Advantage: Frequently Asked Questions Medi-Pak Advantage: Frequently Asked Questions General Information: What Medicare Advantage product is Arkansas Blue Cross Blue Shield offering? Arkansas Blue Cross and Blue Shield has been approved by

More information

INTERQUAL SUBACUTE & SNF CRITERIA REVIEW PROCESS

INTERQUAL SUBACUTE & SNF CRITERIA REVIEW PROCESS REVIEW RP-1 RP-2 REVIEW INTERQUAL CRITERIA The InterQual Criteria provide support for determining the appropriateness of admission, continued stay, and appropriate discharge destinations. The Subacute

More information

Inpatient Rehabilitation Facilities Relief from 75% Compliance Threshold Full Implementation. By: Cherilyn G. Murer, JD, CRA

Inpatient Rehabilitation Facilities Relief from 75% Compliance Threshold Full Implementation. By: Cherilyn G. Murer, JD, CRA Inpatient Rehabilitation Facilities Relief from 75% Compliance Threshold Full Implementation By: Cherilyn G. Murer, JD, CRA Inpatient Rehabilitation Overview Inpatient rehabilitation facilities (IRFs)

More information

The Official Guidelines for coding and reporting using ICD-9-CM

The Official Guidelines for coding and reporting using ICD-9-CM Reporting Accurate Codes In the Era of Recovery Audit Contractor Reviews Sue Roehl, RHIT, CCS The Official Guidelines for coding and reporting using ICD-9-CM A set of rules that have been developed to

More information

GUIDE TO HOME HEALTH DIAGNOSIS CODES

GUIDE TO HOME HEALTH DIAGNOSIS CODES GUIDE TO HOME HEALTH DIAGNOSIS CODES Proper selection of diagnoses codes for the Medicare OASIS Assessment The process of selecting correct diagnosis codes for the OASIS Start of Care, Re-Certification

More information

BUNDLING ARE INPATIENT REHABILITATION FACILITIES PREPARED FOR THIS PAYMENT REFORM?

BUNDLING ARE INPATIENT REHABILITATION FACILITIES PREPARED FOR THIS PAYMENT REFORM? BUNDLING ARE INPATIENT REHABILITATION FACILITIES PREPARED FOR THIS PAYMENT REFORM? Uniform Data System for Medical Rehabilitation Annual Conference August 10, 2012 Presented by: Donna Cameron Rich Bajner

More information

MLN Matters Number: MM4246 Related Change Request (CR) #: 4246. Related CR Transmittal #: R808CP Implementation Date: No later than January 23, 2006

MLN Matters Number: MM4246 Related Change Request (CR) #: 4246. Related CR Transmittal #: R808CP Implementation Date: No later than January 23, 2006 MLN Matters Number: MM4246 Related Change Request (CR) #: 4246 Related CR Release Date: January 6, 2006 Effective Date: January 1, 2006 Related CR Transmittal #: R808CP Implementation Date: No later than

More information

Purposes of Patient Records

Purposes of Patient Records CHAPTER 6 Documentation 1 Slide 1 Purposes of Patient Records Five Basic Purposes for Written Records Written communication Permanent record for accountability Legal record of care Teaching Research and

More information

The Medicare Readmissions Reduction Program

The Medicare Readmissions Reduction Program The Medicare Readmissions Reduction Program Impact on Rural Hospitals Harvey Licht Varela Consulting Group August, 2013 CMS Readmissions Reduction Program: Authority Section 3025 of the Patient Protection

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

Long-Term and Post-Acute Care Financing Reform Proposal

Long-Term and Post-Acute Care Financing Reform Proposal Long-Term and Post-Acute Care Financing Reform Proposal Section 1: Reforming and Rationalizing Medicare Post-Acute Care Benefits Overview. The proposal will reform and rationalize Medicare post-acute care

More information

RE: CMS-3819-P; Medicare and Medicaid Programs; Conditions of Participation for Home Health Agencies

RE: CMS-3819-P; Medicare and Medicaid Programs; Conditions of Participation for Home Health Agencies January 6, 2015 Marilyn Tavenner Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Room 445 G Attention: CMS-3819-P Hubert H. Humphrey Building, 200 Independence

More information

SENATE, No. 368 STATE OF NEW JERSEY. Introduced Pending Technical Review by Legislative Counsel PRE-FILED FOR INTRODUCTION IN THE 1996 SESSION

SENATE, No. 368 STATE OF NEW JERSEY. Introduced Pending Technical Review by Legislative Counsel PRE-FILED FOR INTRODUCTION IN THE 1996 SESSION SENATE, No. STATE OF NEW JERSEY Introduced Pending Technical Review by Legislative Counsel PRE-FILED FOR INTRODUCTION IN THE SESSION By Senators MATHEUSSEN and LYNCH 0 0 AN ACT concerning subacute care

More information

Using Medicare Hospitalization Information and the MedPAR. Beth Virnig, Ph.D. Associate Dean for Research and Professor University of Minnesota

Using Medicare Hospitalization Information and the MedPAR. Beth Virnig, Ph.D. Associate Dean for Research and Professor University of Minnesota Using Medicare Hospitalization Information and the MedPAR Beth Virnig, Ph.D. Associate Dean for Research and Professor University of Minnesota MedPAR Medicare Provider Analysis and Review Includes information

More information

Moving Towards Bundled Payment

Moving Towards Bundled Payment ISSUE BRIEF Moving Towards Bundled Payment Introduction The fee-for-service system of payment for health care services is widely thought to be one of the major culprits in driving up U.S. health care costs.

More information

The Nursing Home (Rehabilitation) Experience: Some Questions for You as a Family Caregiver

The Nursing Home (Rehabilitation) Experience: Some Questions for You as a Family Caregiver The Nursing Home (Rehabilitation) Experience: Some is working on an important project to improve how we work with family caregivers. As part of that project, we are asking you to fill out this survey because

More information

MEDICARE HOSPICES HAVE FINANCIAL INCENTIVES TO PROVIDE CARE IN ASSISTED LIVING FACILITIES

MEDICARE HOSPICES HAVE FINANCIAL INCENTIVES TO PROVIDE CARE IN ASSISTED LIVING FACILITIES Department of Health and Human Services OFFICE OF INSPECTOR GENERAL MEDICARE HOSPICES HAVE FINANCIAL INCENTIVES TO PROVIDE CARE IN ASSISTED LIVING FACILITIES Daniel R. Levinson Inspector General January

More information

RE: CMS-1455-P Medicare Program; Part B Inpatient Billing in Hospitals

RE: CMS-1455-P Medicare Program; Part B Inpatient Billing in Hospitals Marilyn Tavenner Acting Administrator and Chief Operating Officer Centers for Medicare and Medicaid Services Department of Health and Human Services Room 445-G Hubert H. Humphrey Building 200 Independence

More information

PL 111-148 and Amendments: Impact on Post-Acute Care for Health Care Systems

PL 111-148 and Amendments: Impact on Post-Acute Care for Health Care Systems PL 111-148 and Amendments: Impact on Post-Acute Care for Health Care Systems By Kathleen M. Griffin, PhD. There are three key provisions of the law that will have direct impact on post-acute care needs

More information

The electronic health record (EHR) has been a game-changer for CDI specialists.

The electronic health record (EHR) has been a game-changer for CDI specialists. Physician queries and the use of prior information: Reevaluating the role of the CDI specialist WHITE PAPER Summary: The following white paper examines the issue of whether to use information from a prior

More information

Guide to EHR s Concurrent Commercial. Frequently Asked Questions: 2014 CMS IPPS FINAL RULE

Guide to EHR s Concurrent Commercial. Frequently Asked Questions: 2014 CMS IPPS FINAL RULE Guide to EHR s Concurrent Commercial Frequently Asked Questions: 2014 CMS IPPS FINAL RULE September 12, 2013 FAQ Categories Inpatient Admission Criteria 2 Midnight Rule... 3 Medical Review Criteria...

More information

NOVOSTE BETA-CATH SYSTEM

NOVOSTE BETA-CATH SYSTEM HOSPITAL INPATIENT AND OUTPATIENT BILLING GUIDE FOR THE NOVOSTE BETA-CATH SYSTEM INTRAVASCULAR BRACHYTHERAPY DEVICE This guide is intended solely for use as a tool to help hospital billing staff resolve

More information

Top MS-DRG and ICD-9 Codes for Home Health Episodes, By State: Prepared for the Alliance for Home Health Quality and Innovation

Top MS-DRG and ICD-9 Codes for Home Health Episodes, By State: Prepared for the Alliance for Home Health Quality and Innovation Top MS-DRG and ICD-9 Codes for Home Health Episodes, By State: Prepared for the Alliance for Home Health Quality and Innovation November 2014 avalere.com Top 10 MS-DRG Codes for Home Health Episodes, Alabama

More information

MVP Health Care Frequently Asked Questions/General Information

MVP Health Care Frequently Asked Questions/General Information Q: What is the relationship between MVP and ValueOptions? A. ValueOptions administers the mental health and substance abuse benefits for MVP. MVP has contracted with ValueOptions, Inc. (ValueOptions )

More information

42 C.F.R Comprehensive person-centered care planning.[sae62]

42 C.F.R Comprehensive person-centered care planning.[sae62] 42 C.F.R. 483.21. Comprehensive person-centered care planning.[sae62] (a) Baseline care plans. (1) The facility must develop a baseline care plan for each resident that includes the instructions needed

More information

West Penn Allegheny Health System

West Penn Allegheny Health System West Penn Allegheny Health System System Compliance Department Medical Necessity and Billing for Inpatient Rehabilitation Lessons Learned from an Inpatient Rehab Unit Billing Audit 2006 HCCA Compliance

More information

Pain Quick Reference for ICD 10 CM

Pain Quick Reference for ICD 10 CM Pain Quick Reference for ICD 10 CM Coding of acute or chronic pain in ICD 10 CM are located under category G89, Pain, not elsewhere classified. The subcategories are broken down by type, temporal parameter,

More information

Risk Adjustment Definitions and Methodology

Risk Adjustment Definitions and Methodology Illness Burden Illness burden measures the relative health of the population based upon the number and types of health care services used by that group of people. For instance, if the number is in reference

More information

Support: Andrew Gardner Clinical Data manager Mount Auburn Hospital Email: agardner@mah.harvard.edu Tel: 617-441-1625 Pager: 6707

Support: Andrew Gardner Clinical Data manager Mount Auburn Hospital Email: agardner@mah.harvard.edu Tel: 617-441-1625 Pager: 6707 Support: Andrew Gardner Clinical Data manager Mount Auburn Hospital Email: agardner@mah.harvard.edu Tel: 617-441-1625 Pager: 6707 Mount Auburn Hospital Case Management Department PROCESS STEP See page...

More information

SAME DAY/SAME SERVICE

SAME DAY/SAME SERVICE SAME DAY/SAME SERVICE REIMBURSEMENT POLICY Policy Number: ADMINISTRATIVE 7. T0 Effective Date: June, 20 Table of Contents APPLICABLE LINES OF BUSINESS/PRODUCTS... APPLICATION... OVERVIEW... REIMBURSEMENT

More information

Quality Credentialing or Why Should a Long Term Care Facility Pay Attention to Health Care Reform?

Quality Credentialing or Why Should a Long Term Care Facility Pay Attention to Health Care Reform? Quality Credentialing or Why Should a Long Term Care Facility Pay Attention to Health Care Reform? Richard J. Brockman, Esq. Susan D. Doughton, Esq. I. Introduction The Patient Protection and Affordable

More information

Patient Criteria: Modeling in LTRAX

Patient Criteria: Modeling in LTRAX Patient Criteria: Modeling in LTRAX Mary Dalrymple Managing Director, LTRAX Kristen Smith, MHA, PT Senior Consultant Overview Objectives Review background on upcoming LTCH patient criteria Examine LTRAX

More information

Chapter 6 Section 8. Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Adjustments To Payment Amounts)

Chapter 6 Section 8. Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Adjustments To Payment Amounts) Diagnosis Related Groups (DRGs) Chapter 6 Section 8 Hospital Reimbursement - TRICARE Diagnosis Related Group (DRG)-Based Payment System (Adjustments To Payment Amounts) Issue Date: October 8, 1987 Authority:

More information

New York State UB-04 Billing Guidelines

New York State UB-04 Billing Guidelines New York State UB-04 Billing Guidelines [Type text] [Type text] [Type text] Version 2014 01 03/27/2014 EMEDNY INFORMATION emedny is the name of the New York State Medicaid system. The emedny system allows

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

Deciphering the Details:

Deciphering the Details: Deciphering the Details: An update on implementing PPS for inpatient rehabilitation facilities. By: Cherilyn G. Murer, J.D., C.R.A. President & CEO - The Murer Group Reimbursement for operating costs of

More information

CLINICAL CRITERIA FOR UM DECISIONS Skilled Nursing Facilities

CLINICAL CRITERIA FOR UM DECISIONS Skilled Nursing Facilities COMMERCIAL CLINICAL CRITERIA FOR UM DECISIONS Skilled Nursing Facilities Capital Health Plan (CHP) will provide coverage for care in a skilled nursing facility, subject to the benefit limitations of the

More information

GENERAL ADMISSION CRITERIA INPATIENT REHABILITATION PROGRAMS

GENERAL ADMISSION CRITERIA INPATIENT REHABILITATION PROGRAMS Originator: Case Management Original Date: 9/94 Review/Revision: 6/96, 2/98, 1/01, 4/02, 8/04, 3/06, 03/10, 3/11, 3/13 Stakeholders: Case Management, Medical Staff, Nursing, Inpatient Therapy GENERAL ADMISSION

More information

CATEGORY 4 - OASIS DATA SET: FORMS and ITEMS

CATEGORY 4 - OASIS DATA SET: FORMS and ITEMS CATEGORY 4 - OASIS DATA SET: FORMS and ITEMS Category 4A - General OASIS forms questions. Q1. [Q&A RETIRED 09/09; Outdated] Q2. When integrating the OASIS data items into an HHA's assessment system, can

More information

Medicare Advantage Outreach and Education Bulletin

Medicare Advantage Outreach and Education Bulletin Medicare Advantage Outreach and Education Bulletin Anthem Blue Cross Medicare Advantage Reimbursement Policy Changes Summary of change: Anthem Blue Cross (Anthem) Medicare Advantage reimbursement policies

More information

Coding. Future of Hospice. and the. An educational resource presented by

Coding. Future of Hospice. and the. An educational resource presented by An educational resource presented by Coding and the Future of Hospice You know incorrect coding hurts your reimbursement. Did you know it also shapes CMS rules? Prepared by In this white paper, we will:

More information

Post-Acute Care and Long-Term Care: A Complex Relationship

Post-Acute Care and Long-Term Care: A Complex Relationship Post-Acute Care and Long-Term Care: A Complex Relationship PRESENTED TO: 2011 Long-Term Care Interest Group Policy Seminar PRESENTED BY: Allen Dobson, Ph.D. PREPARED BY: Allen Dobson, Ph.D., Joan E. DaVanzo,

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

EFFECT OF THE HOME HEALTH PROSPECTIVE PAYMENT SYSTEM

EFFECT OF THE HOME HEALTH PROSPECTIVE PAYMENT SYSTEM Department of Health and Human Services OFFICE OF INSPECTOR GENERAL EFFECT OF THE HOME HEALTH PROSPECTIVE PAYMENT SYSTEM ON THE QUALITY OF HOME HEALTH CARE Daniel R. Levinson Inspector General January

More information

Record. John F. Morrall. Subject: Regulatory Reform Improvements ; Fed Register, Vol 67, Num. 60,3/28/02. Dear Mr. Morrall,

Record. John F. Morrall. Subject: Regulatory Reform Improvements ; Fed Register, Vol 67, Num. 60,3/28/02. Dear Mr. Morrall, 54 Bob Losby BTLosby@rehabcare.com 05 28 2002 PM Record Type: Record To: John F. Morrall Subject: Regulatory Reform Improvements ; Fed Register, Vol 67, Num. 60,3/28/02 Dear Mr. Morrall, We submit the

More information

STATEMENT OF WORK LONG TERM CARE HOSPITAL PAYMENT SYSTEM REFINEMENT/EVALUATION

STATEMENT OF WORK LONG TERM CARE HOSPITAL PAYMENT SYSTEM REFINEMENT/EVALUATION STATEMENT OF WORK LONG TERM CARE HOSPITAL PAYMENT SYSTEM REFINEMENT/EVALUATION I. SCOPE: The contractor shall provide a wide variety of statistical, data and policy analysis to support the CMS need to

More information

Key Stakeholders Included: Corporate Coding HIM Compliance Hospital HIM Director Inpatient Coding Staff HIM Coding Vendor

Key Stakeholders Included: Corporate Coding HIM Compliance Hospital HIM Director Inpatient Coding Staff HIM Coding Vendor For Looking at Retro MS-DRG Audits and Identifying Opportunities Gloryanne Bryant, RHIA, RHIT, CCS Former Senior Director Coding HIM Compliance Catholic Healthcare West (CHW) and Patti Ashley, LVN, CCS

More information

MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS

MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS Department of Health and Human Services OFFICE OF INSPECTOR GENERAL MEDICARE PAYMENTS FOR DIAGNOSTIC RADIOLOGY SERVICES IN EMERGENCY DEPARTMENTS Daniel R. Levinson Inspector General April 2011 OEI-07-09-00450

More information

Home Health Face-to-Face Encounter Question & Answers

Home Health Face-to-Face Encounter Question & Answers Home Health Face-to-Face Encounter Question & Answers Question 1: Will requirements be met if a community physician certifies a patient and completes a plan of care when a face-to-face encounter was conducted

More information

IWCC 50 ILLINOIS ADMINISTRATIVE CODE 7110 7110.90. Section 7110.90 Illinois Workers' Compensation Commission Medical Fee Schedule

IWCC 50 ILLINOIS ADMINISTRATIVE CODE 7110 7110.90. Section 7110.90 Illinois Workers' Compensation Commission Medical Fee Schedule Section 7110.90 Illinois Workers' Compensation Commission Medical Fee Schedule a) In accordance with Sections 8(a), 8.2 and 16 of the Workers' Compensation Act [820 ILCS 305/8(a), 8.2 and 16] (the Act),

More information

Coding with. Snayhil Rana

Coding with. Snayhil Rana Coding with ICD-9-CM CM Snayhil Rana ICD-9-CM CM Index Pre-Test Introduction to ICD-9-CM Coding The Three Volumes of the ICD-9-CM ICD-9-CM Coding Conventions Other ICD-9-CM Sections ICD-9-CM for Claim

More information

New York State Nursing Home Quality Pool. New York State Department of Health May 2, 2012

New York State Nursing Home Quality Pool. New York State Department of Health May 2, 2012 New York State Nursing Home Quality Pool New York State Department of Health May 2, 2012 1 Overview First meeting in January discussed performance measurement for the Quality Pool Materials were sent to

More information

THE CITY OF VIRGINIA BEACH AND THE SCHOOL BOARD OF THE CITY OF VIRGINIA BEACH

THE CITY OF VIRGINIA BEACH AND THE SCHOOL BOARD OF THE CITY OF VIRGINIA BEACH THE CITY OF VIRGINIA BEACH AND THE SCHOOL BOARD OF THE CITY OF VIRGINIA BEACH OPTIMA November 7, 2013 TABLE OF CONTENTS Executive Summary... 1 Process Overview... 4 Areas of Testing... 5 Site Visit Selection...

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

ORTHOPAEDIC BUNDLED PAYMENT INITIATIVES:

ORTHOPAEDIC BUNDLED PAYMENT INITIATIVES: RELIANCE CONSULTING GROUP ORTHOPAEDIC BUNDLED PAYMENT INITIATIVES: RISKS & RETURNS Sponsored by: 8-28-12 TENNESSEE ORTHOPAEDIC SOCIETY Presenters: John P. Schmitt, Ph.D. - RCG Managing Director & Joane

More information

DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD DECISION OF MEDICARE APPEALS COUNCIL

DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD DECISION OF MEDICARE APPEALS COUNCIL DEPARTMENT OF HEALTH AND HUMAN SERVICES DEPARTMENTAL APPEALS BOARD DECISION OF MEDICARE APPEALS COUNCIL In the case of Claim for Medicare Advantage (MA) L.L. o/b/o G.L. (Part C) (Appellant) **** **** (Enrollee)

More information

Preventing Readmissions

Preventing Readmissions Emerging Topics in Healthcare Reform Preventing Readmissions Janssen Pharmaceuticals, Inc. Preventing Readmissions The Patient Protection and Affordable Care Act (ACA) contains several provisions intended

More information

HEART FAILURE NATIONAL HOSPITAL INPATIENT QUALITY MEASURES. Measure Short Name. Adult Smoking Cessation Advice/Counseling

HEART FAILURE NATIONAL HOSPITAL INPATIENT QUALITY MEASURES. Measure Short Name. Adult Smoking Cessation Advice/Counseling Release Notes: Measure Information Form Version 2.6 HEART FAILURE NATIONAL HOSPITAL INPATIENT QUALITY MEASURES Set Measure ID # HF-2 Discharge Instructions Evaluation of LVS Function ACEI or ARB for LVSD

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

Medicare Long-Term Care Hospital Prospective Payment System

Medicare Long-Term Care Hospital Prospective Payment System Medicare Long-Term Care Hospital Prospective Payment System May 5, 2015 Payment Rule Brief PROPOSED RULE Program Year: FFY 2016 Overview, Resources, and Comment Submission On May 17, the Centers for Medicare

More information