The Heart of Revenue Integrity

Transcription

1 PAGE 1 ANTHELIO Clinical Documentation Improvement (CDI) Information Exchange July 2012 Issue 2 The Heart of Revenue Integrity WE CARE ABOUT Quality DOCUMENTATION Introducing McLaren Greater Lansing's Clinical Nutrition Support Services McLaren Greater Lansing Registered Dietitians Greenlawn Campus Lindsay Fortman, RD, CDE Cheryl Martin RD Martha Quain, RD Kathryn Stein, RD Pennsylvania Campus Peggy Apostolos, RD, CDE Contact # INSIDE THIS ISSUE: Nutritional Diagnoses Guidelines 1-2 REGISTERED DIETITIANS ANSWER YOUR QUESTIONS RAC Audit OBV vs. Inpatient Coding Beat and CDI Updates Upcoming Issues will Include Special Features from: Revenue Auditing Compliance Revenue Integrity Physician s Updates Can an overweight patient be diagnosed with severe protein calorie malnutrition? Yes. A malnutrition diagnosis is not always based a on patient s actual weight. The most defining factor is percent of intentional weight loss over time. Other factors include appearance, appetite, skin integrity and lab values. Why is low albumin a poor indicator of a patient's nutritional status? Albumin is affected by too many other factors that have nothing to do with a patient's overall status. Some of the non-nutrition facts include surgery, medications, blood loss, inflammatory processes, etcetera. Continued on page 2

2 PAGE 2 What parameters are used to diagnose severe protein calorie malnutrition or severe malnutrition (emaciation) at McLaren Greater Lansing? We look for a least 2 nutrition indicators for this diagnosis. One of the two has to include unintentional weight loss of greater than 5% in one month or greater than 15% weight loss in 3 months. The other parameter could include BMI, general condition, appetite, albumin or other labs. Are there any other important nutrition diagnoses that you document for? Yes. Pulmonary Cachexia is another nutrition diagnosis that is frequently seen. The patient must be 90% of the ideal body weight and have a diagnosis of COPD to meet the parameters of this diagnosis. Why is it important for the BMI and an associated diagnosis to be documented in the medical record? In order for a coder to capture a nutritional diagnosis, certain guidelines need to be followed. The ICD-9-CM Official Guidelines for Coding and Reporting states: For the Body Mass Index (BMI), code assignment may be based on medical record documentation from clinicians involved in the care of the patient (e.g., a dietitian or nurse). ICD-9-CM Official Guidelines for Coding and reporting indicates that the DIAGNOSIS associated with the BMI must be documented by the patient s provider. The provider is the physician or practitioner who can legally establish the patient s diagnosis. Does your patient have Malnutrition? If so, don t forget to document the type. Examples include: Cachexia Mild/Moderate/Severe Malnutrition Muscle Wasting Syndrome Specific Eating Disorder Protein Calorie Malnutrition Severe Protein Calorie Malnutrition To meet the criteria for a reportable secondary diagnosis, the malnutrition would need to have some bearing or relevance in terms of patient care. Consider if this condition required: Clinical evaluation Therapeutic treatment Diagnostic procedures Extended length of hospital stay Increased nursing care and/or monitoring

3 PAGE 3 Recovery Audit Finding: Diseases and Disorders of the Circulatory System Provider Types Affected: Inpatient hospitals Problem Description: Medicare pays for inpatient hospital services that are medically necessary for the setting that is billed. Claims with MS-DRG 312 Syncope & Collapse and MS-DRG 313 Chest Pain were reviewed for medical necessity. Review of the medical record must indicate that inpatient hospital care was medically necessary, reasonable, and appropriate for the patient s diagnosis and condition at any time during their stay. The patient must demonstrate signs and symptoms severe enough to warrant the need for medical care. He or she must also receive services of such intensity that they can only be furnished safely and effectively on an inpatient basis. Example: The patient is a 71 year old female who presented to the emergency department with chest discomfort and fatigue. The patient had a history of hypertension and aortic ascending aneurysm repair. The patient s blood pressure was 120/70, pulse 80, respirations 16, temperature 98.6, and an oxygen saturation of 98% on room air. The patient did not experience any headache, nausea, or shortness of breath. The patient's lungs were noted to be clear and she had a regular heart rate and rhythm.laboratory findings and cardiac enzyme levels remained within normal limits. A chest x-ray revealed no active disease. An electrocardiogram showed sinus rhythm. A stress test revealed no ischemia. A computed tomography of the chest revealed dilation of the aorta arch and bilateral thyroid nodules. The patient was treated with follow up testing, monitoring and supplemental oxygen. The patient s symptoms resolved with treatment and the patient did not experience any further chest discomfort. Auditor Finding: In summary, the severity and complexity of the patient s condition upon presentation did not warrant an inpatient stay by Medicare s criteria. The patient was admitted for chest discomfort and fatigue. The plan of care was to rule out an acute coronary event and treat the patient s symptoms. The patient s symptoms improved and no complications were experienced. The evaluation and planned treatment could have been rendered in an outpatient status. The admitting provider could have reasonably anticipated that the patient s problems would resolve within 24 hours or that a decision to admit to inpatient status could have been made safely within 24 hours. In conclusion, the recovery audit found that Medicare's requirements for inpatient status have not been met. Guidance on How Providers Can Avoid These Problems: Providers should educate themselves about the medical necessity of inpatient admission. The Medicare Benefit Policy Manual states that the physician or other practitioner responsible for a patient's care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient. Physicians should use a 24-hour period as a benchmark; that is, they should order admission for patients who are expected to require hospital care for 24 hours or more, and treat other patients on an outpatient basis. However, the decision to admit a patient is a complex medical judgment that can only be made after the physician has considered a number of factors. These factors include the patient's medical history and current medical needs, types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting. Factors to consider when deciding to admit a patient include: severity of the signs and symptoms exhibited by the patient; Medicare Quarterly Provider Compliance Newsletter Volume 2, Issue 2 January 2012

4 PAGE 4 medical predictability of something adverse happening to the patient; need for diagnostic studies that are appropriate for outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to help assess whether the patient should be admitted; and, availability of diagnostic procedures at the time and location where the patient presents. The Medicare Benefit Policy Manual, Chapter 1, Section 10, Covered Inpatient Hospital Services Covered Under Part A, is available at Downloads/bp102c01.pdf on the CMS website. The Medicare Learning Network (MLN) publication, Medicare Physician Guide, is designed to provide education on the Medicare Program and includes a section on Part A inpatient hospitals. This publication is available at: MLNProducts/downloads/ MedicarePhysicianGuide_ ICN pdf on the CMS website. The Local Coverage Determination (LCD) for Acute Care: Inpatient, Observation and Treatment Room Services (L27548) discusses hospital inpatient services and is available at gov/medicare-coverage-database/details/lcd-details. aspx?lcdid=27548 on the CMS website. The Medicare Claims Processing Manual states that observation care is a well-defined set of specific, clinically appropriate services. These services include ongoing short term treatment, assessment, and reassessment that are furnished while a decision is made about whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation services are commonly ordered for patients who present to the emergency department and then require a significant period of treatment or monitoring to make a decision about their admission or discharge. Observation services are covered only when provided by a physician s order or another individual authorized by State licensure law and hospital staff by-laws to admit patients to the hospital or to order outpatient services. Observation services must also be reasonable and necessary to be covered by Medicare. In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. In most cases, the decision to discharge a patient from the hospital after resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours. The Medicare Claims Processing Manual, Chapter 4, Sections 290.1, Outpatient Observation Overview, and General Billing Requirements for Observation Services, is available at cms.gov/manuals/downloads/ clm104c04.pdf on the CMS website. Did you know... Visit the Medicare Learning Network (MLN) Provider Compliance web page at cms.gov/ MLNProducts/45_ProviderCompliance.asp for the latest educational products designed to help Medicare Fee-For-Service providers understand and avoid common billing errors and otherimproper activities. Medicare Quarterly Provider Compliance Newsletter Volume 2, Issue 2 January 2012

5 PAGE 5 THE CODING BEAT A physician s documentation should provide a coder, a fellow provider, the patient, a third-party payer, an auditor, a lawyer, or even a judge with the following answers: Is the reason for the patient encounter documented in the medical record? Are all the services you provided documented? Does the medical record clearly and accurately explain why support services, procedures, and/or supplies were prescribed? Is the assessment of the patient s condition apparent in the medical record? Does the medical record contain information of the patient s progress and treatment results? Does the medical record include a plan of treatment for the patient? Does the information in the medical record describing the patient s condition provide reasonable medical rationale for the services and the choice of setting that is to be billed? Does the information in the medical record support the care given in the event that another healthcare professional must assume the patient s care or perform a medical review?

6 Anthelio Clinical Documentation Improvement (DCI) Information Exchange July 2012 Issue 2 Recent Events In early June, Dr. Wendy Whittington, Medical Director of Anthelio Healthcare Solutions visited McLaren Greater Lansing to meet with the medical staff, and discuss clinical documentation. McLaren Greater Lansing generously provided lunch for three lunch and learn sessions. There was a large turnout of physicians and Wendy s presentation was well received. During her visit she was able to meet directly with A Service and D Service groups, along with Pulmonology and Nephrology groups. On June 26 and 28, Kimberly Rupright, RHIT, one of our Coding Professionals, and June Murray RN, one of our Clinical Documentation Specialists presented information on coding and clinical documentation to the new residents as part of their orientation to McLaren Greater Lansing. On July 24, Dr. Dennis Perry, Physician Advisor, met with the residents and interns to discuss clinical documentation, billing and reimbursement. Lunch was served and a great deal of information was covered in that fast hour. Stay tuned for the upcoming celebration of.. Clinical Documentation Improvement Week September 16-22, 2012 Contact Information for CDI Team Members Michelle Crist RN, BSN, CDI Specialist Office Cell Ann Millis RN, MA CDI Specialist Office Cell Robyn Long, RN, BS CDI Specialist Office Cell June Murray RN, MSN Office Cell Sandra Palmer RHIA, CCS Compliance Audit Coordinator Office Suzie Coe, RHIA Director of HIM/Revenue Integrity Office Cell Dennis Perry, MD Physician Advisor Office Questions Regarding This Newsletter: If you have questions regarding this newsletter, the information it contains, would like to see information regarding a specific topic, or would like to have something published in the next publication, you may June.Murray@antheliohealth.com or call Thank You!