2014 Medicare Partnership Tour: Partnering to Reduce Errors · 2014-07-17 · LCDs Organizational Process Improvement Coaching Project (OPICP) Medicare Providers Improve the relevant

DISCLAIMER The information provided in this presentation

was current as of June 18, 2014. Any changes or new information superseding

the information in this presentation are provided in articles with publication dates after

June 18, 2014, posted on our website at: www.PalmettoGBA.com/J11A

CPT only copyright 2012 American Medical Association.

All rights reserved. The Code on Dental Procedures and Nomenclature is published in Current Dental

Terminology (CDT), Copyright © 2012 American Dental Association (ADA). All rights reserved.

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PALMETTO GBA – INNOVATION Use your smart phones and tablets to complete

workshop evaluations and to take a pre-test and post-test to measure education

effectiveness.

You will need a Quick Response (QR) Code

Reader application on your smartphone or

tablet, simply open the app and click on the QR

code on the screen. 3

Please take a moment to complete your Pre-Test.

4

Pre-Test

AGENDA Health Information Supply Chain (HISC) DMAIC Process Medical Review Strategy – Service-Specific Errors Medical Review Strategy

Going Forward 2 Midnight Education (2MN)

2MN Examples Preparing Audit Ready Documentation Audit Entities Comprehensive Error Rate Testing (CERT)

CERT Analysis CERT Tech Stop Process & TIP Letters

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AGENDA

Physician Queries Diagnosis Related Groups (DRGs)

Cardiac DRGs Heart Failure & Shock Pacemakers Septicemia/Sepsis Spinal Fusion

Partners in Compliance Comparative Billing Reports (CBRs) Rescue Your Resources A Call To Action! Educational Resources

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WHY ARE WE MEETING TODAY?

Collaborate to accomplish shared goals: Have your claims be processed (and approved!) the

first time (as long as the service meets medical necessity)

Eliminate documentation deficiencies Decrease errors, denials, and appeals

Why should we collaborate? It’s cheaper to get it right the first time Decrease costs of appeals Avoid delays in payment

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WORKING TOGETHER TO REDUCE ERRORS

o Requires: • Understanding of organizational cultures • Understanding of the process flows of physicians,

hospitals, and Palmetto GBA • Knowledge of the root cause of errors

o Sustainably reducing errors requires the 3

C’s: • Communication • Coordination • Collaboration

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COMMUNICATION

“The single biggest problem in communication is the illusion that it has taken place”

George Bernard Shaw

---------------------------------------- Despite the huge volume of records generated by our health care system, denials for poor or insufficient documentation persist.

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FOCUS ON QUALITY TO DECREASE DENIAL RATES

Traditional Quality Domains Clinical

Palmetto GBA’s Definition of Quality* Clinical Operational Financial Cultural * Dr. Joseph Fortuna, Chair of the American Society for Quality Healthcare Division

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PALMETTO GBA’S APPROACH TO DECREASING DENIAL RATES

Root Cause Analysis Health Information Supply Chain (HISC) Communication of Granular Errors DMAIC Procedure

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ROOT CAUSE ANALYSIS

Root cause analysis (RCA) is a method of problem solving that tries to identify the root causes of faults or problems

http://en.wikipedia.org/wiki/Root_cause_analysis 12

RCA: TRACING A PROBLEM TO ITS ORIGINS

In medicine, it's easy to understand the difference between treating symptoms and curing a medical condition When you're in pain because you've broken your

wrist, you WANT to have your symptoms treated – now!

Taking painkillers won't heal your wrist, you have to find the root cause of the pain and treat it before the symptoms can disappear for good

http://www.mindtools.com/pages/article/newTMC_80.htm

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But when you have a problem at work, how do you approach it? Do you jump in and start treating the symptoms? Or, do you stop to consider whether there's actually a

deeper problem that needs your attention? If you only fix the symptoms – what you see on the

surface – the problem will almost certainly happen again... which will lead you to fix it, again, and again, and again

If, instead, you look deeper to figure out why the problem is occurring, you can fix the underlying systems and processes that cause the problem

http://www.mindtools.com/pages/article/newTMC_80.htm

RCA: TRACING A PROBLEM TO ITS ORIGINS

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RCA: THREE BASIC TYPES OF CAUSES Problem: Company car fails to stop and has a wreck

Physical causes – Tangible, material items failed in some way (for e.g., the car's brakes stopped working)

Human causes – People did something wrong, or did not do something that was needed (no one filled the break fluid, which led to the breaks failing. Human causes typically lead to physical causes

Organizational causes – A system, process, or policy that people use to make decisions or do their work is faulty (for e.g., no one person was responsible for vehicle maintenance, and everyone assumed someone else had filled the brake fluid)

http://www.mindtools.com/pages/article/newTMC_80.htm 15

THE HEALTH INFORMATION SUPPLY CHAIN

The unit of analysis for healthcare process improvement and quality management

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HEALTH INFORMATION SUPPLY CHAIN The HISC begins with a healthcare

encounter between a Medicare beneficiary and a provider

This encounter generates a record that is then used by a coder to translate the encounter into a form that a biller can use to communicate the reason for the encounter to Medicare

The biller does so through the submission of a Medicare claim that is then processed by Palmetto GBA

Feliciano, Harry. The Importance of a Strong Health Information Supply Chain (HISC). May 29, 2012

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HEALTH INFORMATION SUPPLY CHAIN CMS then uses the information to

enforce policy aimed at continuously improving the beneficiary-provider encounter

Having complete and accurate information in healthcare records is therefore the first step in the development of a HISC that will help Medicare providers continuously improve their services while supporting the Medicare Program

Feliciano, Harry. The Importance of a Strong Health Information Supply Chain (HISC). May 29, 2012

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COMMUNICATION OF GRANULAR ERRORS

Sustainable improvements require actionable information that is easy to share

Palmetto now communicates granular errors when denying claims

Benefits of this approach: Informs providers of areas to target in their

process improvement strategy Permits determination of % first pass yield Promotes the prevention of errors

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PUTTING IT ALL TOGETHER

Some of your claims have been denied. So what do you do now? You have to: Determine what happened Determine why it happened Figure out what to do to reduce the likelihood

that it will happen again

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THE DMAIC PROCEDURE

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DECREASING DENIALS BY IMPROVING EFFECTIVENESS OF HEALTHCARE RECORDS

efine

easure

nalyze

mprove

ontrol

D

M

A

I

C

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DEFINE

Palmetto GBA Research CMS

design requirements for addressing the potential or observed vulnerability

Communicate them to providers

Medicare Providers Define business

requirements Define business

processes

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MEASURE

Palmetto GBA Determine metrics

to track improvement

Construct impact severity risk maps for error classes undergoing record audits

Medicare Providers Measure business

process performance by implementing a data collection plan that determines the types of errors and relevant metrics

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ANALYZE

Palmetto GBA Conduct medical

review to validate the problem(s), prioritize errors, and target interventions

Medicare Providers Analyze the data

and process map to identify root causes of errors and opportunities for improvement

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IMPROVE

Palmetto GBA One-on-one education Educational articles LCDs Organizational Process

Improvement Coaching Project (OPICP)

Medicare Providers

Improve the relevant process by designing sustainable solutions to reduce the error

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CONTROL

Palmetto GBA Perform analysis of

claims to identify recurrent problems

Medicare Providers

Control the improvements to make them sustainable by developing and implementing an on-going monitoring plan

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GBD BLOG AND TWITTER Palmetto GBA is using the Going

Beyond Diagnosis (GBD) blog and Twitter account to help facilitate communication on error rate reduction http://palmgba.com/gbd @BeyondDx #MedicareHISC

Share this information with your colleagues

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http://palmgba.com/gbd

MEDICAL REVIEW STRATEGY

SERVICE SPECIFIC ERRORS

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MEDICAL REVIEW STRATEGY Palmetto GBA Medical Review Strategy

is consistent with the goal to reduce provider claim denials in order to affect the claims payment error rate

Identifies issues, activities, projected goals, and the evaluation of activities and goals

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MEDICAL REVIEW STRATEGY Utilize data analysis from variety of sources to

identify program vulnerabilities to: Take action to prevent and address identified

error; Publish LCDs to provide guidance about

when items and services are medically reasonable and necessary

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Medical Review accuracy of problem identification has: Improved data analysis Created a strong collaboration

between statisticians and clinicians Increased identification of problem

areas

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MEDICAL REVIEW STRATEGY Efficiency of Edit Effectiveness Period of time from when we start

requesting records until the results are sent to the provider

Period of time from the date the last claim in the probe is reviewed until the results are sent to the provider

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ADDITIONAL DOCUMENTATION REQUEST (ADR)

Include barcoded ADR letter as first page for each separate claim

Respond within 30 days or claim automatically denies for no response on day 45

Do not use staples If sending a password protected CD; send

tracking number & password to: [email protected] and [email protected]

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mailto:[email protected]

mailto:[email protected]

TWO TYPES OF REVIEW

Provider-Specific Widespread Service- Specific

Examines 20-40 claims per provider when a problem is identified

Involves 100 claims from multiple providers

Results are sent directly to provider in a letter

Conducted when a larger problem is identified Results are published at www.palmettogba.com/j11a

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http://www.palmettogba.com/j11a

REVIEWS Palmetto GBA’s Medical Review focus

concentrates on two-day inpatient stays for surgical DRGs

Claims will be selected for service specific reviews

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ERROR IDENTIFIED If an error is identified, the severity of the

problem is classified Minor, moderate, or major

All levels of error will require that providers receive education on proper billing procedures and recoupment

A letter will be sent to the provider outlining the errors identified and will have granular detailed information This helps to ensure provider receives detailed

information (hopefully to prevent future errors)

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MR CLAIM REVIEW DECISION AND EDUCATION LETTER

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MR CLAIM REVIEW DECISION AND EDUCATION LETTER

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REDETERMINATION – 1ST LEVEL OF APPEAL

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MEDICAL REVIEW DENIALS

Palmetto GBA Denial Resolution tool includes resources for resolving the top claim medical review denial reasons

Save time and resources by looking here before you pick up the phone

Access denial reasons in plain language

Part A Denial Reason Codes

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MEDICAL REVIEW DENIALS

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MEDICAL REVIEW STRATEGY GOING FORWARD

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Going Beyond “The List” • Our goal is to assist providers in

lowering their denial rate in order to ultimately reduce the paid claims error rate!

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MEDICAL REVIEW ACTIVITIES - CURRENT

Medical Review Activity Notifications

Probe of Inpatient Medicare Severity Diagnostic Related Groups (MS-DRG)

Probe Reviews for Progressive CAP for New 2-Midnight Guidance for IPPS Claims

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DRG MR Focus for Inpatient Hospital Services (Year 4) Any DRG

One-Day Stays for IPPS Providers Excluding IRF and CAH Facilities

291 Heart Failure and Shock w/ MCC – One-Day Stays 292 Heart Failure and Shock w/ CC – One-Day Stays 293 Heart Failure and Shock w/o MCC or CC – One-Day Stays 308 Cardiac Arrhythmia and Conduction w/ MCC – One-Day

Stays 309 Cardiac Arrhythmia and Conduction Disorders w/ CC – One-

Day Stays 391 Esophagitis, Gastroenteritis w/ MCC – One-Day Stays 392 Esophagitis, Gastroenteritis w/o MCC – One-Day Stays 640 - 641

Misc. Disorders of Nutrition, Metabolism, Fluid/Electrolytes w/ MCC & w/o MCC – One-Day Stays

470 Major Joint Replacement or Reattachment of Lower Extremity w/o MCC

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DRG MR Focus for Inpatient Hospital Services (Year 4) 689 Kidney and Urinary Tract Infections w MCC – One-Day

Stays 690 Kidney and Urinary Tract Infections w/o MCC – One-Day

Stays 302 Atherosclerosis w MCC – One-Day Stays

303 Atherosclerosis w/o MCC – One-Day Stays

313 Chest Pain – One-Day Stays

219–220

Cardiac Valve and Other Major Cardiothoracic Procedures

459 Spinal Fusion Except Cervical w/ MCC

460 Spinal Fusion Except Cervical w/o MCC

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2 MIDNIGHT (2MN) EDUCATION EFFORTS

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2MN EDIT BACKGROUND Inpatient hospital short stays have been

identified as prone to improper payments Most common finding: Inappropriate patient status The services furnished were reasonable and necessary, but should have been furnished on a hospital outpatient, rather than inpatient, basis Frequently related to hospital stays following minor surgical procedures and diagnostic tests

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PRIMARY REVIEW FOCUS

Principals of Documentation

Who Performing, supervising, & referring practitioners

What Services and quantities of services performed

Where Place of service (POS)

When Date of service (DOS)

Why Medical necessity and diagnosis

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DETAIL DISCOVERY

Common insufficient documentation findings: Date of service not documented Missing names, signatures, credentials Documentation not supporting services

billed Chief complaint was not determined Primary diagnosis was not documented

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DETAIL DISCOVERY Documentation Signatures: Treating physician’s signature must be present

in documentation associated with all services submitted to Medicare

Signature must be a legible identifier for the ordered rendered service

Handwritten or electronic signature required Stamped signatures are not acceptable signatures

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DETAIL DISCOVERY

Medically unnecessary services include situations where enough documentation in medical record is identified to make an informed decision that services billed were not medically necessary

If MAC determines admission is unnecessary due to not meeting an acute level of care, entire payment for admission is denied

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2MN PROBE STATUS UPDATE

State Claims Reviewed

Claims Denied

Charges Reviewed

Charges Denied

SC 120 85 $711,295.27 $521,544.28

NC 440 320 $3,551,962.39 $2,502,527.24

VA 300 186 $1,630,661.51 $1,007,754.40

WV 120 68 $586,546.52 $312,787.75

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2MN GRANULAR ERROR BREAKDOWN Denial Code Granular Description

5D908/5H908 THE PHYSICIAN CERTIFICATION SUBMITTED WAS NOT VALID AS SPECIFIED BY 42CFR 412.3(c) AND 42CFR 424.13(a).

5D910/5H910

BASED ON THE CLINICAL FACTORS DOCUMENTED IN THE MEDICAL RECORD THE MEDICAL NECESSITY OF THE INPATIENT SERVICE WAS NOT SUPPORTED AS REQUIRED BY 1862(A)(1) OF THE SOCIAL SECURITY ACT

5D909/5H909 THERE WAS NO DOCUMENTATION OF CURRENT MEDICAL NEEDS IN THE MEDICAL RECORD SUBMITTED AS REQUIRED BY 42CFR 412.3(e).

5D908/5H908 THE CERTIFICATION DOES NOT INCLUDE ORDER FOR INPATIENT ADMISSION AS REQUIRED BY 42CFR 412.3(c) AND 42CFR 424.13(a).

5D909/5H909

THERE WAS NO DOCUMENTATION OF PATIENT'S HISTORY AND COMORBIDITIES IN THE MEDICAL RECORD SUBMITTED AS REQUIRED BY 42CFR 412.3(e).

5D909/5H909 THERE WAS NO DOCUMENTATION OF SEVERITY OF SIGNS AND SYMPTOMS AS REQUIRED BY 42CFR 412.3(e).

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2MN FOUR COMPLEX MEDICAL FACTORS

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Patient’s history and co-morbidities

Severity of signs and symptoms

Current medical needs

Risk of an adverse event if the patient is not admitted

2MN RESOURCE For more information refer to: http://cms.gov/Research-Statistics-Data-and-

Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/ReviewingHospitalClaimsforAdmissionforPosting03122014.pdf

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EXAMPLES OF THE MOST COMMON 2MN DOCUMENTATION

ERRORS

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MISSING/FLAWED INPATIENT ADMISSION ORDER Mr. Jones arrived at the Emergency Department (ED) with chest pain Physician’s notes state that Mr. Jones is to be

worked-up, but it’s unlikely pain is cardiac-related Physician’s order states “admit to

observation” Mr. Jones is kept overnight and discharged

the next day Hospital submits a claim to Medicare for a 1-

day inpatient stay

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Upon review, the MAC denies Medicare Part A payment because the medical record:

1. Failed to support expectation of a 2-midnight stay and

2. Lacked an order to admit as an inpatient

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MISSING/FLAWED INPATIENT ADMISSION ORDER

It is in the interest of a hospital for the admitting practitioner to use language that clearly expresses intent to admit a patient as inpatient

Examples of such language include physician documentation to “admit to inpatient” or “admit to inpatient care”

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CMS will continue to treat orders that specify a typically outpatient or other limited service as defining a non‐inpatient service ER, Observation, Recovery, Outpatient Surgery, Day

Surgery, or Short-Stay Surgery Such orders will not be treated as meeting the

inpatient admission requirements

Reference: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-

Certification-and-Order-01-30-14.pdf

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http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf



SHORT STAY PROCEDURES Mrs. Smith presents for a procedure in which treatment and discharge typically occur in less than 2 midnights Physician wrote an order to admit to inpatient upon arrival at hospital for pre-operative care Procedure is not on inpatient-only list Medical record did not support the

expectation of a 2-midnight stay for hospital care

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SHORT STAY PROCEDURES Mrs. Smith underwent the procedure without

any complications either during or after and was discharged within 10 hours after arrival Hospital submits claim for a 0-day inpatient

stay Upon review, MAC denies Medicare Part A

payment because the medical record failed to support an expectation of a 2-midnight stay

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SHORT STAY PROCEDURES Instances in which the typical expected

length of stay for a procedure is less than 2 midnights should be initiated as outpatient

If it later becomes clear that 2 or more midnights of hospital care is required due to a complication or other factor; Physician can order an inpatient admission at

that time

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SHORT STAYS - MEDICAL CONDITIONS Mr. Ho presents to ED with recent onset of dizziness, denies any additional complaints, but blood pressure medication was recently adjusted Physician’s notes state Mr. Ho is stable, his

blood pressure medication is to be held and dosage adjusted

Physician intends to observe Mr. Ho overnight

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SHORT STAYS - MEDICAL CONDITIONS

Mr. Ho is discharged the next day and hospital submits a claim for a 1-day inpatient stay

Upon review, the MAC denied Medicare Part A payment because the medical record failed to support an expectation of a 2-midnight stay

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Observation care is a well-defined set of specific, clinically appropriate services that include ongoing short term treatment, assessment and reassessment before a decision can be made whether further treatment as an inpatient is required or if able to discharge

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If patient requires additional monitoring, diagnostics, or treatment to determine the expected length of stay;

Physician may keep the patient as an outpatient until it’s clear that the patient will require 2 or more midnights of hospital care

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PHYSICIAN ATTESTATION STATEMENTS

Without Supporting Documentation: Physician’s order contains a checkbox with

pre-printed text stating “Patient is expected to require 2 or more midnights of hospital care.”

Plan of care however states that the patient is to have diagnostics performed post-operatively, with a plan to discharge in the morning, if stable

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PHYSICIAN ATTESTATION STATEMENTS Without Supporting Documentation: Patient is discharged the following day as

planned after a 1-midnight stay and hospital submits a claim

Upon review, MAC denied Medicare Part A payment because the medical record failed to support an expectation of a 2-midnight stay when the order was written

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PHYSICIAN ATTESTATION STATEMENTS

Without Supporting Documentation Attestation statements indicating a hospital

stay is “expected to span 2 or more midnights” are not required under inpatient admissions policy Nor are they adequate by themselves to support the expectation of a 2-midnight stay

Expectation must be supported by the entirety of the medical record

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CERTIFICATION The physician order must be furnished

at or before the time of the inpatient admission

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CERTIFICATION Certification begins with the order for

inpatient admission Medicare Part A pays for inpatient

hospital services (other than inpatient psychiatric facility services) only if a physician certifies and recertifies the following:

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CERTIFICATION Hospitalization of the patient for inpatient

medical treatment or medically required inpatient diagnostic study; or, special or unusual services for cost outlier cases

The estimated time the patient will need to remain in the hospital

The plans for post hospital care, if appropriate

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CERTIFICATION Certifications must be signed by the

physician responsible for the case, or by another physician who has knowledge of the case and who is authorized to do so by the responsible physician or by the hospital's medical staff

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PREPARING AUDIT READY

DOCUMENTATION

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PREPARING AUDIT READY DOCUMENTATION

Design an internal quality control record review

Establish protocols and procedures Identify key personnel Implement the process

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PREPARING AUDIT READY DOCUMENTATION Develop a checklist for documentation based

on the information in this session Design an Internal Quality Control Record

Review Fix bad habits Keep records of the results of the audits Educate staff on what to look for when

submitting medical records Educate professional medical staff on proper

elements of documentation, especially signatures

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EXPANDED RESOURCES Our provider outreach and education

activities will target specific documentation errors

We will create more web activities to inform you about documentation requirements

Our goal is your compliance

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REMINDER

If you can’t read it, we can’t read it!

Carefully pull and timely submit all the necessary documentation to support all

services!

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Audit Entities

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OTHER WATCHFUL EYES

• Palmetto GBA Medical Review Program • External Reviewers

– Recovery Auditors – Comprehensive Error Rate Testing (CERT)

Contractor – Zone Program Integrity Contractor (ZPIC)

Contractor – Strategic Health Solutions (SHS) – Office of Inspector General (OIG)

• Triggered by an accusation, utilization reports, legislation

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PARTNERING FOR SYSTEMIC, SUSTAINABLE FIXES

• Use the HISC and DMAIC processes • Use the Provider Outreach and Education (POE)

team to educate! • Use permanent, sustainable fixes • Keep Our Eyes Open • Avoid Regulatory Pitfalls • Manage Medicare Compliance • Develop a Strong Effective Framework • Maintain the Integrity and Credibility of the

Medicare Trust Fund

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COMPREHENSIVE ERROR RATE TESTING (CERT). .

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CERT

• Federally mandated program created by CMS • Measures paid claims error rate for Medicare

claims submitted to Medicare Administrative Contractors (MACs) • Ensures the Medicare program is paying claims correctly • Measures and compares national, contractor-specific, and

service-specific paid claim error rates

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CERT

• CERT program uses a random and service-specific sampling of claims

• Two contractors responsible for administering CERT program

• CERT Review Contractor (CRC)- selects samples of claims from Palmetto GBA

• CERT Documentation Contractor (CDC) - requests medical records, from the billing providers, physicians or suppliers and prepares the documentation for review

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CERT MEDICAL RECORDS REQUEST

• CERT requests medical records and other pertinent documentation from the billing provider • Initial request - via fax or e-mail • Failure to respond to the initial request within 30 days,

results in a second contact via fax or mail (reminder letter). Provider has 15 days to respond.

• If no response is received by day 45, the provider receives a contact via fax or mail

• A fourth contact is made via mail on day 60. Phone calls may be placed to the providers to collect the documentation

– Providers have 75 days to return the requested information

– On Day 76, CERT denies claims without documentation

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SAMPLE CERT RECORD REQUESTS

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Request for Additional Documentation (RAD)

Initial CERT Record Request

CERT RECORD REQUEST ENVELOPE

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RECORD REQUEST DETAILS

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BARCODED COVERSHEET

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CERT CHECKLIST

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REVIEW WHAT IS NEEDED • Know what services are being reviewed • Pull or obtain all records to support all services • Send ‘final’ authenticated records • Check for signatures • Verify records and signatures are legible • Double check request and assure all the records are

being sent • Include necessary orders, requisitions, or signed notes

documenting the intent to order for diagnostic test even if you must obtain from the ordering provider

• Include a signature attestation statement or signature log if necessary

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CERT DOCUMENTATION SUBMISSION

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Fax Submission

CD Submission Mail Submission

(240) 568-6222

CERT Documentation Office Attn: CID #: (Insert CID #) 9090 Junction Dr., Suite 9 Annapolis Junction, MD 20701

CERT Documentation Office Attn: CID #: (Insert CID #) 9090 Junction Dr., Suite 9 Annapolis Junction, MD 20701

CERT DOCUMENTATION BY ESMD

• Electronic Submission of Medical Documentation (esMD)

• Contact one or more of the Health Information Handlers (HIHs) to determine if esMD services are available to meet your needs • www.cms.gov/ESMD

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http://www.cms.gov/ESMD

ESTABLISH A CERT CONTACT

• Designate and keep updated a specific point of contact to receive CERT information in your billing or medical records office • www.CERTprovider.org

• Palmetto GBA also has dedicated resources in-house to assist with CERT

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http://www.certprovider.org/

CERT REVIEW RESULTS

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No Overpayment

Found

You will NOT hear anything else about the claim from CERT

Palmetto GBA will: • Send a Teaching and Instruction (TIP) letter • Overpayment Demand Letter • Remittance Advice showing the adjusted claim

Overpayment Found

CERT TECH STOP CALL AND CERT TIP LETTER PROCESSES

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Courtesy call made to any provider that has failed to submit any documentation or incomplete documentation to support payment of service(s)

Details regarding required information are provided Providers encouraged to respond to the Tech Stop call

by obtaining and submitting all necessary documentation identified during the call

Failure to respond will result in a CERT error being called Results in the request for a refund of paid

dollars Multiple CERT errors by the same provider may

result in further audits

CERT TECH STOP CALLS

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CERT TIP LETTER

“This letter is being sent to

you for educational purposes….”

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CERT TIP LETTER

“Claim payments that are recouped as a result of

a CERT review may be appealed….”

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PALMETTO GBA’S GOAL

• Partner to decrease CERT error rate • Improve success rate of first time claim submission • Reduce appeals • Reduce potential for future audits

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CERT Analysis

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CERT - PAYMENTS

Palmetto GBA is notified of detected overpayments and underpayments for payment adjustments Overpayments identified in sample: CERT identified $5,057,759 in actual overpayments and as of report date, CMS collected $3,814,177 of those overpayments

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CERT Error Description No Documentation

Provider or supplier fails to respond to repeated requests for the medical records or they do not have the requested documentation.

Insufficient Documentation

Submitted medical documentation is inadequate to support payment for the services billed, or a specific documentation element that is required as a condition of payment is missing (for example, physician signature on an order).

Medical Necessity

There is adequate documentation in the medical records to make the informed decision that the services billed were not medically necessary based upon Medicare coverage policies.

Incorrect Coding

Provider submits medical documentation supporting: 1. A different code than was billed; 2. That the service was performed by someone other than the billing provider; 3. That the billed service was unbundled; or 4. That beneficiary was discharged to a site other than the one coded on claim

Other When a claim error does not fit in any other category (for example, duplicate payment error, non-covered or unallowable service).

CERT - FINDINGS

Error codes with strongest impact on overall error rate are: Medically unnecessary service or treatment –

(Error Code 21) - 49.3% Insufficient documentation (Error Code 21) –

12.8% Invasive Procedure Not Medically Necessary

(Inpatient PPS Only; Error Code 26) – 19.4%

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CERT - FINDINGS

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EXAMPLE: SUMMARY -BILL TYPE AND ERROR CODE Rank Bill

Type Bill Type

Description Error Code

Error code Description

No. of claims

Medicare Final Allowed Amount

Paid Incorrect

Amount

1 11x Hospital Inpatient (Part A)

25 Medically Unnecessary service

or treatment

36 $599,554.97 $599,554.97


21 Insufficient documentation

5 $105,441.83 $105,441.83


26 Invasive Procedure Not Medically

Necessary

9 $145,445.08 $97,111.21


33 DRG change due to wrong procedure

code

4 $47,912.92 $31,718.11


32 DRG change due to wrong diagnosis code

or wrong principal diagnosis

4 $85,736.64 $20,204.19


90 Other errors 2 $36,875.79 $13.44

7 13x Hospital Outpatient

21 Insufficient Documentation

6 $3,278.19 $3,278.19

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CERT - FINDINGS Errors due to services provided in an

inappropriate setting: Patient has signs and/or symptoms severe

enough and of such an intensity they can only be furnished safely and effectively on an inpatient basis

Physician responsible for care also responsible for decision to admit as an inpatient

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CERT - FINDINGS There are situations where patient was

admitted as inpatient but clinical care and procedures should have been in outpatient or other non-hospital based setting Under Medicare statute these claims must

be denied in full, even if claim would be potentially payable in another setting

By law CMS cannot partially deny claim or allow provider to re-bill using a different setting

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CERT - FINDINGS Services Incorrectly Coded Documentation submitted does not

match service/modifier/diagnosis submitted

Providers use standard coding systems Documentation submitted supported a

lower or a higher code than code submitted

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CERT – HISC Process of coding is as follows: Patient Encounter Review of Medical Records Selection of Diagnoses and Procedure

Codes Assignment of Code Number Sequencing of Codes

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CERT - FINDINGS Issues that lead to incorrect coding are: Incomplete notes Undocumented care Missing test results Post-op complications not listed Documentation not completed timely Illegibility Inconsistent documentation

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POE AND MR COLLABORATIVE EFFORTS POE and MR have collaborated and implemented a

new process to follow-up on CERT TIP letters that are sent to the providers by MR

POE calls the provider and discusses the TIP letter to see if there are any questions: Such as how to avoid denials for a particular

reason code How to appeal Ask if additional education is needed

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POE AND MR COLLABORATIVE EFFORTS

Medical review is sending referrals to POE on providers who have received a tech stop contact by the CERT

These contacts are made due to missing documentation in the record that may result in a denial of the claim

Palmetto GBA is working diligently to reduce the CERT error rate Please join us in this effort. Together, we

can do it!

116

CERT RESOURCES CERT resources on J11 Part A website: • www.PalmettoGBA.com/j11a

CMS CERT website: •www.cms.gov/CERT

CERT Provider website: • https://www.certprovider.com/Ho

me.aspx

CMS Program Integrity Manual •www.cms.gov/manuals/downloads/pim8

3c12.pdf • Publication 100-08

117

INTRODUCTION TO CERT WEBCAST

118

Physician Queries

119

WHAT IS A QUERY?

A physician query is a method of communication used by coders to request clarification of patient diagnoses or procedures from the physician.

A physician query is the process recommended by the American Hospital Association (AHA) Coding Clinic guidelines when specificity or clarification regarding a specific diagnosis being treated is not clearly stated in the medical record

Coding Clinic 1Q 1993

120

DEFINITION OF PHYSICIAN QUERIES AHIMA’s definition is: Questions asked to physicians to obtain

additional, clarifying documentation to improve the specificity and completeness of the data used to assign diagnosis and procedure codes

OIG. Compliance Program Guidance for Hospitals. Federal Register Notices, Feb 23 1998, 63(35), p. 8991 AHIMA. Managing an Effective Query Process. Journal of AHIMA79, no.10 (October 2008): 83-88

121

AHIMA STANDARDS OF ETHICAL CODING

Coders “should consult physicians for clarification and additional documentation prior to code assignment when there is conflicting or ambiguous data in the health record.”

American Health Information Management Association. Standards of Ethical Coding. 2008

122

WHEN AND HOW TO QUERY

The generation of a query should be considered when the health record documentation: • Is conflicting, imprecise, incomplete, illegible, ambiguous, or

inconsistent • Describes or is associated with clinical indicators without a

definitive relationship to an underlying diagnosis • Includes clinical indicators, diagnostic evaluation, and/or

treatment not related to a specific condition or procedure • Provides a diagnosis without underlying clinical validation • Is unclear for present on admission indicator assignment

AHIMA. "Guidelines for Achieving a Compliant Query Practice." Journal of AHIMA 84, no.2 (February 2013): 50-53.

123

APPROPRIATE QUERY FORMAT Queries should:

• Use precise language • Identify documented clinical findings, indicators,

observations • Ask the provider to make a clinical interpretation of these

facts • Always include basic query components: – Identifiers (name, record number, account number) – Admission and query dates – Clinical indicators – Question addressing the documentation concern – Name and contact information of the coder

AHIMA. "Managing an Effective Query Process“ Journal of AHIMA79, no.10 (October 2008): 83-88.

124

INAPPROPRIATE QUERY FORMAT

AHIMA states that queries should not: • Target a diagnosis that would not be

supported by the chart • Sound presumptive, directive, prodding, or

as if leading to an assumption • Indicate financial impact or quality

reporting • Require only a physician signature

AHIMA. "Managing an Effective Query Process“ Journal of AHIMA79, no.10 (October 2008): 83-88

125

INAPPROPRIATE QUERY FORMAT

• Be leading • Be poorly constructed • Question a provider‘s clinical judgment • Utilize blanket querying • Routinely target insignificant or irrelevant

findings • Introduce new information

126

CLARIFICATION FOR SPECIFICITY OF A DIAGNOSIS EXAMPLE

Documentation: Obtunded patient admitted with three-day history of nausea and vomiting. CXR revealed right lower lobe (RLL) pneumonia. Clindamycin ordered. • Leading query:

– Is the patient’s pneumonia due to aspiration? • Nonleading query:

– Can the etiology of the patient’s pneumonia be further specified? It is noted in the admitting history and physical examination (H&P) this obtunded patient had a history of nausea and vomiting prior to admission to the hospital and is treated with clindamycin for RLL pneumonia. Based on the above, can the etiology of the pneumonia be further specified? If so, please document the type/etiology of the pneumonia in the progress notes.

127

Source: AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010): expanded web version.

QUERY EXAMPLE

Clinical Scenario 1 • Documentation: Laboratory finding of serum sodium of

120 mmol/L and the attending physician documents hypernatremia in the final diagnostic statement.

• Query: Please review the laboratory section of the present record to confirm your discharge diagnosis of hypernatremia. Laboratory findings indicate a serum sodium of 120 mmol/L.


128

QUERY EXAMPLE Clinical Scenario 2 • Documentation: Four-year old child sustains a

cautery injury to upper lip during maxillofacial surgery. Silvadene and dressing is applied to the affected area at the completion of the procedure and plastic surgery was consulted. The surgeon documented in the operative report that there were “no intraoperative complications.”

• Query: Please review the operative note notation of “a cautery lesion to the upper lip,” subsequent treatment with Silvadene and clarify your documentation of “no intraoperative complications.”

129

EXAMPLE MULTIPLE CHOICE QUERY A patient is admitted for a right hip fracture. The H&P notes that the patient has a history of chronic congestive heart failure. A recent echocardiogram showed left ventricular ejection fraction (EF) of 25 percent. The patient’s home medications include Metoprolol XL, Lisinopril, and Lasix. • Leading: Please document if you agree the patient

has chronic diastolic heart failure. • Non-leading: It is noted in the impression of the

H&P that the patient has chronic congestive heart failure and a recent echocardiogram noted under the cardiac review of systems reveals an EF of 25 percent.

Source: AHIMA. “Guidance for Clinical Documentation Improvement Programs.” Journal of AHIMA 81, no.5 (May 2010): expanded web version

130

QUERY EXAMPLE - CONTINUED

• Can the chronic heart failure be further specified as:

• Chronic systolic heart failure ____________________

• Chronic diastolic heart failure ____________________

• Chronic systolic and diastolic heart failure ____________________

• Some other type of heart failure ____________________

• Undetermined ____________________

131

COMPLIANT OR NON-COMPLIANT? Clinical scenario: On admission bilateral lower extremity edema is noted, however, there are no other clinical indicators to support malnutrition. Query: Do you agree that the patient’s bilateral lower extremity edema is diagnostic of malnutrition? Please document your response in the health record or below. • Yes______________ • No ______________ • Other ___________ • Clinically Undetermined ______________ • Name: ___________________ Date:__________

Physician Query Examples Feb 01, 2013 Journal of AHIMA

132

COMPLIANT OR NON-COMPLIANT Clinical scenario: A patient is admitted with an acute gastrointestinal bleed, and the hemoglobin drops from 12 g/dL to 7.5 g/dL and two units of packed red blood cells are transfused. The physician documents anemia in the final discharge statement.

Physician Query Examples Feb 01, 2013 Journal of AHIMA

133

http://journal.ahima.org/2013/02/01/physician-query-examples/

COMPLIANT OR NON-COMPLIANT

Query: In this document your response in the health record or below accompanied by clinic patient admitted with a gastrointestinal bleed and who underwent a blood transfusion after a drop in the hemoglobin from 12 g/DL on admission to 7.5 g /dL, can your documentation of anemia be further specified as an acute blood loss anemia? Please call substantiation. Yes ______________ No ______________ Other ____________ Clinically Undetermined ____________ Name: ___________________ Date:__________

134

COMPLIANT OR NON-COMPLIANT?

Clinical scenario: In the impression of the pathology report, ovarian cancer is documented; however, only ovarian mass is documented in the final discharge statement by the provider. Query: Do you agree with the pathology report specifying the “ovarian mass” as an “ovarian cancer”? Please document your response in the health record or below. Yes____________ No ____________ Other ___________ Clinically Undetermined __________ Name: ___________________ Date:__________


135

COMPLIANT OR NON COMPLIANT? Clinical scenario: Consulting pulmonologist documents pneumonia as an impression based on the chest X-ray. However, the attending physician documents bronchitis throughout the record, including in the discharge summary. Query: Do you agree with the pulmonologist’s impression that the patient has pneumonia? Please document your response in the health record or below. Yes ______________ No _______________ Other _____________ Clinically Undetermined____________ Name: ___________________ Date:__________


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Diagnosis Related Groups (DRGs)

Top 25 By Disbursement

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TOP 25 DRG BY DISBURSEMENT

Rank DRG Code

DRG Description

No. of Claims Total Disbursed

1 470 Major Joint Replacement Or Reattachment Of Lower

Extremity W/O MCC 48,727 447,905,058 2 871 Septicemia Or Severe Sepsis W/O Mv 96+ Hours W MCC 45,456 428,588,249

3 003

ECMO (extracorporeal membrane oxygenation) or Tracheostomy with Mechanical Ventilation 96+ Hours

Principal Diagnosis Except Face, Mouth and Neck with Major O.R. 1,731 177,269,980

4 885 Psychoses 26,147 171,392,683

5 460 Spinal Fusion Except Cervical W/O MCC 8,460 166,358,801

6 291 Heart Failure & Shock W MCC 22,630 162,203,879 7 853 Infectious & Parasitic Diseases W O.R. Procedure W MCC 5,497 157,837,978 8 193 Simple Pneumonia & Pleurisy W MCC 17,117 117,516,864

9 207 Respiratory System Diagnosis W Ventilator Support 96+

Hours 3,687 113,133,911

10 329 Major Small & Large Bowel Procedures W MCC 3,967 110,099,290

11 682 Renal Failure W MCC 13,643 105,422,565

12 004

Tracheostomy with Mechanical Ventilation 96+ Hours or Principal

Diagnosis Except Face, Mouth and Neck without Major O.R. 1,764 101,958,665

138

TOP 25 DRG BY DISBURSEMENT

139

Rank DRG Code

DRG Description No. of Claims Total Disbursed

13 189 Pulmonary Edema & Respiratory Failure 16,619 100,711,080

14 247 Percutaneous cardiovascular procedure with drug-eluting

stent without MCC 10,574 98,006,945 15 292 Heart Failure & Shock W CC 22,032 97,964,884 16 870 Septicemia Or Severe Sepsis W MV 96+ Hours 3,013 94,893,556

17 208 Respiratory System Diagnosis W Ventilator Support <96 Hours 7,833 92,406,427 18 177 Respiratory Infections & Inflammations W MCC 8,776 89,751,834 19 190 Chronic Obstructive Pulmonary Disease W MCC 16,584 85,476,947 20 194 Simple Pneumonia & Pleurisy W CC 18,649 83,773,324 21 683 Renal Failure W CC 19,057 82,270,241

22 219 Cardiac Valve & Oth Maj Cardiothoracic Procedure W/O Card

Cath W MCC 1,683 80,707,887 23 064 Intracranial Hemorrhage Or Cerebral Infarction W MCCc 8,653 79,356,359 24 481 Hip & Femur Procedures Except Major Joint W CC 8,349 76,310,934 25 378 G.I. Hemorrhage W CC 16,718 73,425,313

DOLLARS MR DENIED BY DRG DRG Region(s) Claims

Reviewed Claims Denied Dollars Denied CDR%

DRG 074 NC 29 3 $12,896.00 11.42%

DRG 192 NC, SC,VA, WV 49 5 $47,631.08 8.93%

DRG 195 NC, SC,VA, WV 43 4 $21,357.03 10.06%

DRG 227 NC, SC,VA, WV 44 6 $38,427.85 12.50%

DRG 244 NC, SC,VA, WV 38 10 $131,626.00 36.48%

DRG 245 SC 3 1 $30,350.00 34.00%

DRG 247 NC, SC 29 6 $118,615.22 38.00%

DRG 251 NC, SC, VA 39 11 $121,054.25 28.91%

DRG 253 NC, VA 31 0 $0.00 0.00%

DRG 264 NC, SC,VA, WV 43 5 $62,589.89 7.85%

DRG 287 NC, SC,VA, WV 38 6 $40,782.53 12.65%

140

DOLLARS DENIED BY DRG

DRG Region(s) No. Claims Reviewed

Claims Denied Dollars Denied CDR%

DRG 291 NC, SC, VA/WV 328 281 $2,321,607.86 77.6%

DRG 292 NC, SC, VA/WV 348 314 1636818.06 91.5%

DRG 293 NC, SC,VA, WV 29 6 $16,165.47 8.75%

DRG 392 NC, SC,VA, WV 433 386 $1,414,781.60 89.1%

DRG 392 NC, SC,VA, WV 43 9 $45,840.04 12.97%

DRG 460 NC, SC, VA 65 14 $232,949.33 17.05%

DRG 470 NC, SC,VA, WV 83 17 $241,564.45 21.09%

DRG 490 NC, SC,VA, WV 22 2 $20,760.00 11.40%

DRG 491 NC, VA, WV 8 2 $13,162.00 21.00%

DRG 493 NC, SC,VA, WV 22 5 $87,263.20 35.00%

DRG 494 NC 8 1 $10,141.93 32.00% DRG 517 VA 3 0 $0.00 0.00% DRG 641 NC, SC,VA, WV 41 12 $83,604.69 27.00%

DRG 689 NC, SC, VA/WV 278 260 $1,534,494.50 93.6%

Total 2,097 1,366 $8,284,482.98

141

ALL DRGS

Claims Reviewed 1,837

Claims Denied 1,248

Dollars Denied $6,796,098.65 CDR 67.7%

142

Cardiac DRGs

143

TOP CARDIAC DRG CERT DATA

Nat

iona

l Im

prop

er

Pay

men

t R

ate

J11

Pro

ject

ed

Err

or R

ate

J11

Pro

ject

ed

Impr

oper

P

aym

ent

Overall Part A(Inpatient Hospital PPS) 9.9% 7.7% $661,574,767

Permanent Cardiac Pacemaker Implant (242, 243, 244)

35.2% 53.2% $74,063,332

Circulatory Disorders Except AMI, W Cardiac Catheterization (286, 287)

17.1% 18.6% $24,784,696

Cardiac Defibrillator Implant W/O Cardiac Catheterization (226, 227)

40% 35.5% $17,880,435

Heart Failure & Shock (291, 292, 293) 8.3% 3.2% $8,978,901

144

WHICH DRG SHOULD I USE?

DRG 311: Angina Pectoris DRG 313: Chest Pain DRG 303: Atherosclerosis without MCC DRG 302: Atherosclerosis with MCC

145

DOLLARS AT RISK

DRG 313 DRG 302 DRG 303 Total dollars at risk

$16,122,130 $1,924,624 $5,637,162

Dollars at risk per claim

$2,072

$4,979 $2,400

146

DRG 313 NC

DRG 313 Claims Reviewed 107 Claims Denied 103 Dollars Denied $275,396.46 CDR 96% Top Granular Error(s):

Need for service/item is not medically necessary – 100%

147

DRG 313 VA/WV

DRG 313

Claims Reviewed 95 Claims Denied 93 Dollars Denied $230,896.88 CDR 98% Top Granular Error(s):

Need for service/item is not medically necessary – 95% No orders for inpatient admission – 5%

148

CODING CORONARY ARTERY DISEASE VS. ANGINA

• When a patient presents with both unstable angina and CAD and some type of intervention is performed, such as a Percutaneous Transluminal Coronary Angioplasty, the CAD is sequenced as the principal diagnosis

• The rationale for this is that unstable angina pectoris requires immediate attention and the underlying cause is the CAD

• A diagnostic test does not need to be performed in order to list the atherosclerosis as the principal diagnosis

• The provider needs only to state that CAD is the cause of the angina pectoris

Coding Clinic, Second Quarter 2004, p. 3-4 149

MS DRG 313 CHEST PAIN • MS DRG 313 results when the principal diagnosis is

chest pain, precordial pain or observation for suspected cardiovascular disease

• Since chest pain is a symptom code, certain coding rules apply: – Code chest pain as principal diagnosis when it is

followed by contrasting/ comparative diagnoses – Do not code chest pain as principal diagnosis when

a related definitive diagnosis has been established

Coding Clinic 4th Q 2008 302-304

150

PRINCIPAL DIAGNOSIS

Myocardial Infarction (MI) Angina Coronary Artery Disease Costochondritis Gastroesophageal Reflux

Disease Cholecystitis Cholelithiasis Viral Syndrome Cocaine Poisoning

Pleurisy Pulmonary Hypertension Esophageal Spasm Gastritis Hiatal Hernia Constipation Anxiety Attack Bronchitis Cardiac Device, Implant or

Graft Complication

151

Change the principal diagnosis when the underlying etiology of the chest pain is determined. Look for these possibilities:

http://www.faircode.net/blog-ms-drg-of-the-month/ms-drg-of-the-week-ms-drg-313-chest-pain

DOCUMENTATION TO SUPPORT THE PRINCIPAL DIAGNOSIS

When reviewing these charts, determine whether or not a cause was established for the chest pain

If a cause was established, the principal diagnosis becomes the cause of the chest pain, since chest pain is a symptom

Chest Pain ICD-9-CM CODING GUIDELINES

152

CHEST PAIN GUIDELINES 2012 ACCF/AHA Focused Update of the

Guideline for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update)

Circulation August 14, 2012 vol. 126 no. 7 875-910

153

DRG EXAMPLE 66 year old patient presented with altered

mental status and chest ‘tightness’ Past Medical History Arthritis Diabetes HTN

154

COURSE OF TREATMENT Elevated Troponin 0.21 Ruled in for non-Q wave MI Transferred to admitting facility for

cardiac catheterization

155

HOSPITAL CODING ICD-9 code 786.59 Chest pain; other Procedure code 37.22 Left Heart Cardiac Catheterization

DRG code 287 Circulatory disorders except AMI, W

Cardiac Catheterization W/O MCC

156

WRONG DIAGNOSIS CODE Change ICD 9 code to 410.71 Subendocardial infarction, initial episode of

care Change DRG to 281 Acute myocardial infarction, discharged

alive W/CC

157

CHEST PAIN AFTER MYOCARDIAL INFARCTION

Chest Pain Less Than 8 Weeks After a Myocardial Infarction: DRG 280 - Acute Myocardial Infarction, Discharged

Alive W MCC DRG 281 - Acute Myocardial Infarction, Discharged

Alive W CC DRG 282 - Acute Myocardial Infarction, Discharged

Alive W/O CC/MCC DRG 283 - Acute Myocardial Infarction, Expired W

MCC DRG 284 - Acute Myocardial Infarction, Expired W CC DRG 285 - Acute Myocardial Infarction, Expired W/O

CC/MCC

158

CHEST PAIN AFTER MYOCARDIAL INFARCTION

DRG: Acute Myocardial infarction, subsequent episode: 341 – with MCC 315 – with CC 316 – without MCC/CC

159

Heart Failure and Shock

• 291 Heart failure & shock with MCC

• 292 Heart failure & shock with CC

• 293 Heart failure & shock without CC/MCC

160

DOLLARS AT RISK

291 292 293 Total

dollars at risk

$98,302,153 $78,721,246 $13,976,208

Dollars at risk per

claim

$7,299 $4,627

$4,627

161

DRG 291 NC

DRG 291 J11 – NC Claims Reviewed 118

Claims Denied 107 Dollars Denied $902,471.45

CDR 89% Top Granular

Error(s):

Need for service/item is not medically necessary – 99.0% Information submitted does not support dates of service

billed – 1.0%

162

DRG 291 SC

DRG 291 J11 – SC Claims Reviewed 95



Error(s):

Need for service/item is not medically necessary – 97.7%

Records not submitted timely – 2.3%

163

DRG 291 VA/WV

DRG 291 J11 – VA/WV Claims Reviewed 95

Claims Denied 85

Dollars Denied $682,282.17 CDR 89%

Top Granular Error(s):


Information submitted does not support dates of service billed – 3.5% No orders for inpatient admission –

4.7%

164

DRG 292 SC

DRG 292 DRG 292 SC Claims Reviewed

96



Error(s): Need for service/item is not medically necessary – 100%

165

DRG 292 NC

DRG 292 DRG 292 NC Claims Reviewed 127



Error(s): Need for service/item is not medically necessary – 99.1%

No orders for inpatient admission – 0.9%

166

DRG 292 SC

DRG 292 DRG 292 SC Claims Reviewed 96




167

DRG 292 VA/WV

DRG 292 DRG 292 VA/WV Claims Reviewed 125

Claims Denied 111

Dollars Denied $571,024.40

CDR 89%




Information submitted does not support dates of service billed – 3.8%

168

DRG 293 NC




Error(s): Need for service/item is not medically necessary – 93.1%

Information submitted does not support dates of service billed –

1.0% No response to ADR within 30 days

– 5.9%

169

DRG 293 SC

DRG 293 DRG 293 SC Claims Reviewed 100

Claims Denied 99

Dollars Denied $334,439.11 CDR 99%



No response to ADR within 30 days – 6.4%

170

DRG 293 VA

DRG 293 DRG 293 VA Claims Reviewed 67




171

DRG 293 WV DRG 293 DRG 293 WV

Claims Reviewed 39 Claims Denied 39 Dollars Denied $119,385.82


Error(s):

Need for service/item is not medically necessary – 81%


Information submitted does not support dates of service

billed – 9.5%

172

HOW DOES THE BLOOD FLOW?

http://www.phschool.com/science/biology_place/biocoach/cardio1/intro.html

173

CHF DOCUMENTATION SUGGESTIONS

Describe clinical signs and symptoms (e.g., exertional dyspnea, orthopnea, peripheral edema, pulmonary rales or crackles, or jugular vein distention, etc.)

Document work-up (e.g., chest x-ray, EKG, Swan-Ganz, echocardiogram, etc.)

Document treatment (e.g., diuretics, ACE inhibitors, digitalis, beta-blockers, O2, morphine sulfate, monitoring input and output, daily weights, etc.)

“Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from website: http://www.hce.org/medicare/mcareHPMP.html

174

http://www.hce.org/medicare/mcareHPMP.html

CHF DOCUMENTATION SUGGESTIONS

Etiology (e.g., valvular heart disease, renal failure with volume overload, congestive cardiomyopathy, myocardial ischemia, new onset atrial fibrillation, etc.)

Note LVEF (Left ventricular ejection fraction), assessment for ACE inhibitor (angiotensin-converting-enzyme inhibitor) use, and contraindications for non-use of ACE inhibitors

“Reference Materials", Health Care Excel, Medicare Quality Improvement Organization, and contractor of the Centers for Medicare & Medicaid Services (downloaded from website: http://www.hce.org/medicare/mcareHPMP.html

175

http://www.hce.org/medicare/mcareHPMP.html

SYMPTOMS AND SIGNS TYPICAL OF HEART FAILURE

Symptoms Signs Typical More specific

Breathlessness Elevated jugular venous pressure

Orthopnea Hepatojugular reflux Paroxysmal nocturnal

dyspnoea Third heart sound (gallop

rhythm) Reduced exercise tolerance Laterally displaced apical

impulse Fatigue, tiredness, increased

time to recover after exercise

Cardiac murmur

Ankle swelling

176

SYMPTOMS AND SIGNS TYPICAL OF HEART FAILURE

Symptoms Signs Less typical Less Specific

Nocturnal cough Peripheral edema (ankle, sacral, scrotal)

Wheezing Pulmonary crepitations

Weight gain (>2 kg/week) Reduced air entry and dullness to percussion at lung bases (pleural effusion)

Weight loss (in advanced heart failure) Tachycardia

Bloated feeling Irregular pulse

Loss of appetite Tachypnea (>16 breaths/min)

Confusion (especially in the elderly) Hepatomegaly

Depression Ascites

Palpitations Tissue wasting (cachexia)

Syncope

177

CONGESTIVE HEART FAILURE (CHF) Document the criteria that substantiate CHF:

Results Of The Chest X-ray Presence Of Dyspnea With Mild Exercise Presence Of Rales Paroxysmal Nocturnal Dyspnea Orthopnea Fatigue With Exertion Jugular Vein Distention Ankle Swelling Pitting Edema Of The Lower Extremities

TMF® Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.

178

TYPE OF HEART FAILURE

Document if known: • Systolic • Diastolic • Congestive, unspecified

TMF® Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services.

179

IS 291-293 THE CORRECT DRG?

If the patient….. Consider DRG…. Have acute MI?

DRG 280-282 if

discharged alive 283-284 if expired

Have a pulmonary embolism?

DRG 175-176

Did patient have major

cardiovascular procedure?

DRG 237-238

180

Pacemakers

181

USE THE CORRECT PACEMAKER DRG

182

Temporary pacemaker and permanent pacemakers are different DRGs

Replacing a pacemaker is not the same as inserting a new pacemaker


DRGs 242 -244 are for Permanent Cardiac Pacemaker Implant when a pacemaker was not in place already

183


DRGs 260-262 are for Cardiac pacemaker revision (not removed)

184


DRGs 258-259 Cardiac pacemaker device replacement of an existing pacemaker

185


Commonly Assigned DRGs for Temporary Pacemaker Procedures are DRGs 308-310

(Cardiac Arrhythmia and Conduction Disorders)

186

DOLLARS AT RISK

DRG 308 DRG 309

Total dollars at risk

$26,232,057 $25,219,505

Dollars at risk per claim

$6,026 $3,614

187

SINGLE CHAMBER AND DUAL CHAMBER PERMANENT CARDIAC PACEMAKERS

Single chamber pacemakers typically target either the right atrium or right ventricle

Dual chamber pacemakers stimulate both the right atrium and the right ventricle

188

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R161NCD.pdf Change Request 8525 Transmittal 161

SINGLE CHAMBER PACEMAKER

http://www.ohsu.edu/xd/health/services/heart-vascular/getting-treatment/test-procedures/images/pacemaker-1.gif

189

DUAL CHAMBER PACEMAKER

http://stanfordhospital.org/images/greystone/heartCenter/images/ei_0344.gif

190

COVERAGE GUIDELINES

Nationally Covered Indications Nationally Non-Covered Indications Diagnoses for Pacemaker Placement https://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/Downloads/R161NCD.pdf

191

COMMON DUAL-CHAMBER PACEMAKER ERRORS

Common Dual-Chamber Pacemaker Errors Identified Through the CERT Review Process No documentation to support the choice of a

dual-chamber rather than a single-chamber pacemaker

Dual-chamber pacemaker implantation in patients with a clear contraindication, such as chronic atrial fibrillation

Hospitalization for Elective Cardiac Electrophysiology Procedures August 13, 2013 Heart rhythm Society

192

CONDITIONS THAT MAY WARRANT INPATIENT ADMISSION STATUS

Urgent implantation of any device • Hospitalization is triggered by onset of

symptoms or detection of a potentially serious condition, i.e. syncope, heart block, ventricular tachycardia

• Any resynchronization therapy device implant

• Device implantation during hospitalization for another problem

PHYSICIAN GUIDELINES Inpatient Admission Criteria for Implantable Cardioverter-Defibrillator and Pacemaker Placement Effective 07-01-2013

193


Required lead extraction as part of the implantation or re-implant procedure

Complex anticoagulation needs that require admission for the peri-surgical management of these anticoagulation issues

194


Pacemaker/implantable cardiac defibrillator (ICD) implants or electrophysiologic(EP)/ ablation in patients with uncontrolled co-morbidities including, but not limited to, renal insufficiency, angina, congestive heart failure, severe chronic obstructive pulmonary disease (COPD), and electrolyte disturbances in whom in the attending physician’s best judgment requires inpatient admission for optimal medical management

The physician must clearly document in the medical record the comorbidities, whether they are uncontrolled or of recent onset, and the treatment plan to address these issues

PHYSICIAN GUIDELINES Inpatient Admission Criteria for Implantable Cardioverter-Defibrillator and Pacemaker Placement Effective 07-01-2013

195


New ICD implants or patients undergoing ICD generator replacement with concomitant lead replacement who are New York Heart Association (NYHA) class II, III or IV

Patients undergoing an atrio-ventricular junction (AVJ) ablation and acute device implant due to the need for extended monitoring for potentially life-threatening arrhythmias


196


Determination of hospital status should be a clinical decision made by the patient’s attending physician after a careful consideration of multiple clinical factors including, but not limited to: Specific procedure planned Urgency of the procedure


197


Hemodynamic stability of the patient Patient co-morbidities and the likelihood

and consequences of complications arising from the procedure

The rationale for the decision should be documented in the medical record

198


Septicemia/Sepsis

• 870 Septicemia w/ MV 96+ hours • 871 Septicemia w/o MV 96+ hours w/

MCC • 872 Septicemia w/o MV 96+ hours

w/o MCC

199

DEFINITIONS

Systemic Inflammatory Response Syndrome Sepsis Severe Sepsis Septic Shock Septicemia Bacterima

200

SIRS Systemic inflammatory response

syndrome (SIRS) is an inflammatory state affecting the whole body

May be due to: Infection Burn Trauma

201

SEPSIS Sepsis can have many causes but is often due

to an infection when an unusually large number of microorganisms are present in a body cavity or in a patient’s bloodstream for which there is no pathological response

In many cases, the microorganisms are found in a body cavity that is normally sterile

Sepsis and Septicemia: Clear Up Coding and Documentation Confusion http://www.hcpro.com/content/241083.pdf

202

SEVERE SEPSIS

Severe sepsis refers to sepsis associated with organ dysfunction or failure, hypoperfusion (i.e., decreased blood flow through an organ), or hypotension (i.e., abnormally low blood pressure)


203

SEPTIC SHOCK Sepsis can lead to septic shock or organ dysfunction or

failure without treatment Is a sudden disturbance of mental or physical

equilibrium and is a condition of hemodynamic and metabolic disturbance marked by the circulatory system’s failure to maintain adequate blood flow to vital organs

Inadequate blood volume (i.e., hypovolemic shock) may cause septic shock, as can inadequate cardiac function (i.e., cardiogenic shock) or inadequate vasomotor function (i.e., neurogenic shock)


204

BACTEREMIA VS. SEPTICEMIA

Bacteremia is the presence of bacteria in the blood and denotes only an abnormal laboratory finding

Septicemia is the presence of microorganisms or their toxins in the blood

Bacteremia and Septicemia are not necessarily the same

205

A QUICK REFERENCE A quick reference guide is available at: http://www.acsteam.net/sites/acs/uplo

ads/documents/newsletters/sepsis_newsletter_FY13.pdf

206

DOCUMENTATION TIPS

According to the American College of Chest Physicians and the Society of Critical Care Medicine, the clinical manifestations include: • Fever of greater than 100.4 or hypothermia

with a temperature of less than 98.6 • Leukocytosis, white blood cell count of

greater than 12,000 cells per cubic millimeter

Wiedemann, Lou Ann. "Coding Sepsis and SIRS." Journal of AHIMA 78, no.4 (April 2007): 76-78.

207

DOCUMENTATION TIPS

Leukopenia, white blood cell count of less than 4,000 cells per cubic millimeter Tachycardia Hyperventilation

208

DOCUMENTING CONSEQUENCES OF SEPSIS Acute Kidney Failure - not insufficiency Acute Respiratory Failure – not hypoxia Critical Illness Myopathy – not weakness DIC (Disseminated intravascular coagulation) –

not coagulopathy Encephalopathy – not AMS (Achalasia

microcephaly) Acute Hepatic Failure – Not Elevated Liver

Enzymes Note: State ALL manifestations of Sepsis in the Discharge Diagnosis!

Sepsis – Impact of Coding upon Metrics Paul Evans, RHIA, CCS, CCS-P, CCDS Manager, CDI

209

ORGAN SYSTEMS • Review carefully the documentation regarding the

following organ systems: – Lungs: early fall in arterial PO2 (Arterial Partial

Pressure of Oxygen) , ARDS (Acute Respiratory Distress Syndrome), capillary leakage into alveoli, tachypnea, hyperpnea, acute respiratory failure

– Kidneys: acute renal failure or acute kidney injury, olguria, anuria, azotemia, proteinuria

Note: Clinical information, queries help reduce confusion when coding sepsis

October 8, 2013 http://www.justcoding.com/297100/clinical-information-queries-help-reduce-confusion-when-coding-sepsis

210

ORGAN SYSTEMS Liver function: acute hepatic necrosis,

elevated levels of serum bilirubin, alkaline phosphatase, cholestatic jaundice

Clotting mechanism: disseminated intravascular coagulopathy often associated with thrombocytopenia

211

CODING TIPS Know how to apply sequencing guidelines Wait for the discharge summary If a physician documents a diagnosis as

probable, suspected, likely, questionable, possible, or still to be ruled out at the time of discharge, coders can report the condition as if it existed or was established

Seven savvy tips for coding sepsis and SIRS May 22, 2012

212

CODING CONCEPTS All coding is based on physician documentation Do not code on the basis of laboratory or radiological

findings alone ICD-9-CM code assignment issues related to

inconsistent, missing, conflicting or unclear documentation must be resolved by the provider

Whenever there are concerns about a diagnosis and/or treatment, query the physician

Coding Septicemia, SIRS, and Sepsis Copyright 2008 American Health Information Management Association. All rights reserved

213

SEPSIS W/ UNDERLYING INFECTION

Diagnosis DRG Sepsis due to Cellulitis 872

SIRS criteria met due to infectious process.

Clarify to determine whether sepsis actually POA (present

on admission), but not documented on admission. Were SIRS criteria present

on admission?

Cellulitis w/ Sepsis (sepsis not POA)

602

Sepsis due to Urinary Track Infection

872

UTI w/ Sepsis (sepsis not POA)

689

Sepsis due to Pneumonia (any type)

871

Complex Pneumonia w/ Sepsis (sepsis not POA)

177

Simple Pneumonia w/ Sepsis (sepsis not POA)

193

214

SEPSIS AS COMPLICATION Diagnosis DRG

Sepsis from Postoperative Infection 862

Physician documentation must

link infection and device or

identify postoperative infection

Postoperative Infection (not identified as sepsis) 863

Sepsis from Enterostomy / Colostomy Infection 393

Enterostomy / Colostomy infection (not identified as sepsis)

395

Sepsis due to UTI from Foley 698

UTI from Foley (not identified as sepsis) 700

UTI from Foley w/ Sepsis (sepsis not POA) 698

Sepsis due to Ventricular Assist Device or Central Venous Catheter

314

Ventricular Assist Device or Central Venous Catheter Infection (not identified as sepsis)

316

215

VENT PATIENTS

Diagnosis DRG

Respiratory Dx on Mechanical Vent 96+ hrs

207

Carefully count vent times —

includes weaning time

Respiratory Dx on Mechanical Vent <96 hrs

208

Sepsis on Mechanical Vent 96+ hrs

870

Sepsis due to Pneumonia (or other MCC) on Mechanical

Vent <96 hrs

871

Sepsis due to non-MCC condition on Mechanical

Vent <96 hrs

872

MS-DRG News. Administrative Consultant Services, LLC. Issue date January 2, 2013. http://www.acsteam.net/sites/acs/uploads/documents/newsletters/sepsis_newsletter_FY13.pdf

216

DRG 459-460

Spinal Fusion

217

DRG 459-460 CERT DATA

PART A (INPATIENT HOSPITAL PPS) Type of

Service

Nat

iona

l Im

prop

er

Pay

men

t R

ate

J11

Pro

ject

ed

Err

or R

ate

J11

Pro

ject

ed

Impr

oper

P

aym

ent

Spinal Fusion Except Cervical (459, 460)

7.8% 13.6% $20,420,264

218

DRG 460

$91,990,598 dollars at risk Dollars at risk per claim are $19,788

219

DRG 460 NC


Claims Denied 90 Dollars Denied $2,246,323.73


Error(s):

Need for service/item is not medically necessary – 98.6% Information submitted does not support dates of service

billed – 1.4 %

220

DRG 460 VA/WV

DRG 293 DRG 460 VA/WV

Claims Reviewed 114

Claims Denied 78

Dollars Denied $1,895,448.24

CDR 65%



No orders for inpatient admission – 0.6% Information submitted does not support

dates of service billed – 0.6 %

221

SPINAL FUSION Spinal fusion is a surgical procedure

used to correct problems with the small bones in the spine (vertebrae)

It is essentially a "welding" process The basic idea is to fuse together the

painful vertebrae so that they heal into a single, solid bone

222

STRATEGIES TO IMPROVE DOCUMENTATION The following strategies could reduce audit errors

caused solely by information missing from the hospital record: Hospitals may proactively obtain previous

diagnostic and therapeutic records from the surgeon and other practitioners

These records may include pertinent: Physical assessment of condition, including pain

level Physician history and physical

223

STRATEGIES TO IMPROVE DOCUMENTATION

– Progress notes – “Consultations” – Physical and occupational therapist evaluations

and therapy notes – Radiology reports – Therapeutic procedure notes, such as joint

injections • Practitioners should either create clinically

meaningful inpatient records or supply the hospital with relevant documents from their outpatient records

224

STRATEGIES TO IMPROVE DOCUMENTATION

This list contains examples of documentation that, if clearly documented, may help support payment for spinal fusion-related hospital care Previous non-surgical treatment, including, but not limited

to:

Physical therapy Occupational therapy Joint injections Analgesia Assistive devices

225

STRATEGIES TO IMPROVE DOCUMENTATION • Physical examination clearly documenting the

progression of any: – Neurological deficits – Upper or lower extremity strength – Activity modification – Pain levels

• Diagnostic test results and interpretations, such as Magnetic Resonance Imaging (MRI)

226

DOCUMENTATION EXAMPLE

Date: 12/15/20XX Chief complaint: Low back pain radiating

down legs History: Patient has spondylolisthesis,

gradually progressing with increased spinal stenosis over the past 5–7 years. Most recent MRI (11/2/11) shows spondylolisthesis at L3-L4 and L4-L5 with moderately severe stenosis at both levels

227

DOCUMENTATION EXAMPLE Patient has been treated as follows:

– Ibuprofen 400 mg QID since January (allergic to codeine); PT 3 x week from 6/15/11 to 9/30/11

– Epidural steroid injections in October and facet joint injections in November gave only minor temporary improvement

– Pain is now constant at level 5/10 when sitting, but 9/10 on rising or ambulation and radiates down both legs

– Is slightly better with water therapy – The pain keeps patient awake at night with severe

stabbing, throbbing and aching

228

DOCUMENTATION EXAMPLE (CON’T)

Physical exam: Patient has limited lumbar range of motion and

severe pain on palpation Knee and ankle reflexes are reduced to 1+ (they

were 2+ in October) Patient has diminished sensation in lower legs, but

strength and pulses are within normal limits The patient has positive sitting root and leg raises

bilaterally Faber Four is negative bilaterally

229

DOCUMENTATION EXAMPLE (CON’T) Impression: Worsening pain, deteriorating reflexes and

significant interference with function Current therapy ineffective Lumbar fusion is only option for pain

control Orders: Admit to inpatient care for L3-L4 and L4-

L5 lumbar fusion

230

TELL A GOOD STORY

Documentation should: Tell a good story that anyone can

understand substantiating the medical necessity of the procedure for that particular patient

Suppose the physician has treated the patient for two years for back pain and leg problems, but medication and injections aren’t working Spinal Fusion Is New PEPPER Target, With Focus on Medical Necessity of Procedures . Report on Medicare Compliance February 6, 2012. Copyright © 2012 by Atlantic Information Services, Inc.

231

TELL A GOOD STORY The physician knows why the patient requires

surgery and the procedure is legitimate, but the physician may not incorporate the outpatient notes into the inpatient record

So the documentation is thin and the reviewer is left wondering why the patient needed surgery

232

DOCUMENTATION

By far the most common reason for denial has been a lack of specific information about conservative care before the surgical intervention

233

LACK OF DOCUMENTATION Statements such as:

“Failed outpatient therapy, admit for spinal fusion,” are simply not sufficient evidence of medical necessity for the admission or the surgery

234

LACK OF DOCUMENTATION History of illness from onset to decision

for surgery Prior courses of treatment and results Current symptoms and functional

limitations Physical exam detailing objective

findings supporting history of illness Results of special tests

Lumbar Fusion procedures and RAC Audits: What you need to Know Christopher P Kauffman Spine line March-April 2013

235

NEED FOR SERVICES NOT MEDICALLY AND REASONABLY NECESSARY

No documentation of pain impacting the functional ability of beneficiary

No documentation of conservative measures/treatments failed (without specific interventions given) or neurological impairment-spinal stenosis

No X-ray, CT or MRI results submitted detailing mechanical instability, deformity of the lumbar spine or neural compression

236

NEED FOR SERVICES NOT MEDICALLY AND REASONABLY NECESSARY

There were no biopsy or LP results submitted showing significant infection that would require this type of procedure

The operative procedure was not included in the documentation submitted (Thoracic, Lumbar, Sacral Fusion)

237

PARTNERS IN COMPLIANCE

238

COMPLIANCE COMMITMENT

Palmetto GBA is diligent to provide education on CMS program safeguards through: Publications Customer service Compliance initiatives Website

239

COMPLIANCE COMMITMENT Ensures an understanding of the importance

of being compliant with: Documenting their services correctly Filing claims properly with correct

information Adhere to program guidelines and coverage

policies

240

COMPLIANCE COMMITMENT All these efforts help ensure Medicare contractors

and providers uphold and continue to work toward Paying it right the first time, every time!

Eliminates the appeals process!

Increases staff productivity by working on billing new claims as opposed to completing redetermination request forms and pulling medical records

Increases provider cash flow by having claim paid right the first time it is submitted to Palmetto GBA

241

COMPLIANCE – ANALYSIS CMS Division of Data Analysis activities

include: Program for Evaluating Payment Patterns

Electronic Report (PEPPER) First-Look Analysis Tool for Hospital

Outlier Monitoring (FATHOM) Comparative Billing Report (CBR)

242

COMPLIANCE - PEPPER

Comparative data report provides hospital specific Medicare data statistics for discharges vulnerable to improper payments Support a hospital’s compliance efforts by

identifying where it’s an outlier for risk areas

Data helps identify potential overpayments and underpayments

243

COMPLIANCE - PEPPER

• Created by TMF Health Quality Institute to: – Prioritize hospital specific findings – Provide guidance on areas in which a hospital may

want to focus auditing/monitoring efforts – Identifies areas of potential over/under coding – Questionable medical necessity of admission

• Pepper Resources are available at:

http://www.pepperresources.org/

244

http://www.pepperresources.org/

COMPLIANCE - FATHOM CMS provides each State with hospital-

specific Medicare claims data statistics Identify areas having high payment errors Statistics serve as relative indicators of payment

errors FATHOM reports include:

Short-Term acute care inpatient PPS hospitals Long-term acute care inpatient PPS hospitals CAHs, IRFs and IPF

FATHOM articles at: www.palmettogba.com

245

http://www.palmettogba.com/

COMPLIANCE – AVOID ERRORS

Be proactive rather than reactive! By reviewing errors after claim submission

Staff struggles to deal with errors leading to bill holds, rebilling, coding problems, and denials

Shift responsibility from after submission to before - while patient is being treated Focus on preventing errors in first place through proper

and appropriate documentation

246

COMPLIANCE – AVOID ERRORS Core of billing compliance is that each and

every physician service performed : Meets criteria for being reasonable and medically

necessary Must be supported by appropriate documentation that

leads to proper coding

It is critical to have complete and accurate medical records!

247

WHAT ARE CBRS?

• CBR letters are intended to show providers how their billing patterns compare to their peers

• Not intended to be punitive or sent as an indication of fraud

• Intended to be a proactive statement that will help the provider identify potential errors in their billing practice

• The last CBR letters Provider Outreach & Education sent out were for Evaluation & Management services

248

TWO TYPES OF CBRS

• CMS contractor issued CBRs – developed and disseminated under contract by eGlobalTech, a Federal services firm based in Arlington, VA.

• Palmetto GBA issued CBRs – developed and disseminated by Palmetto GBA

249

IF YOU RECEIVE EITHER TYPE OF CBR

• Evaluate your agency’s billing patterns to ensure the claims are billed accurately

• Examine the issue identified in the report to see if there are reasons your agency is an outlier in the data

• Evaluate the CPT/HCPCS/ICD-CM codes used related to the issue in the report to verify the most appropriate code is used

250

HOW ARE CBRS USED?

• Contains peer comparisons which can be used to provide helpful insights into their coding and billing practices

251

HOW CAN CBRS HELP PROVIDERS?

• The information provided is designed to help the provider prevent improper billing and payment

252

CBR RESOURCES

http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/pim83c03.pdf

253

CMS IOM Publication Program Integrity Manual,

Chapter 3, Section 3.7.2









RESCUE YOUR RESOURCES

254

OUR GOAL IS YOUR GOAL

• Reduce errors • Get claims processed and paid with the first

submittal • Reduce appeals • Reduce all errors including reducing the CERT error

rate • Save money!

255

TOTAL J11 PART A CLAIMS RECEIVED

Part A Claims Workload

(June, 2013 – May 2014)

TOTAL 13,577,460

256

How many claims did you submit last year?

NON CERT APPEALS

Part A Appeal

Requests Redetermination

Receipts Reopening Receipts Total

Total 88,748 858 89,606

257

How many appeals did you submit last year?

CERT APPEALS

J11 Part A CERT Appeals

Year State

Total CERT Appeals

Completed Total

Overturned Reversal % at 1st level of Appeal Overturned at higher level

2013 WV 26 7 26.92% 4

VA 46 15 32.61% 1

SC 243 83 34.16% 6

NC 73 31 42.47% 6

Total 388 136 35.05% 17

2014 WV 4 2 50.0% 0

VA 10 1 10.00% 0

SC 50 15 30.00% 0

NC 23 4 17.39% 0

Total 87 22 25.29% 0

258

A CALL TO ACTION!

259

A CALL TO ACTION! • Use the HISC and DMAIC processes • Develop and implement policies, procedures, and

practices designed to ensure compliance • Take advantage of educational opportunities • Utilize our website resources to enhance your

Medicare knowledge • Perform a complete and prompt review of medical

records requests • Deliver documentation within the time frame

requested • Be proactive and ensure the provider billing staff are

responsible for completing pre bill audits

260

EDUCATIONAL RESOURCES

261

E-MAIL UPDATES

Please be sure that you register for e-mail updates from Palmetto GBA

The ListServ messages are free The only requirement is that you register You may choose the type of updates you

receive Link to register is located on the

Palmetto GBA Part A website at the top of the page under “Email Updates”

262

EDUCATIONAL RESOURCES Gateway to customized learning!

Medicare Advisory and Articles Frequently Asked Questions (FAQs) Ask the Contractor Teleconference (ACT) Listserv E-Mail Updates Workshops and teleconferences Online courses via ON24 Web chat is available Monday – Wednesday

10:30 a.m. – 12:00 p.m. and 2:00 p.m. – 3:00 p.m.

263

EDUCATIONAL RESOURCES Provider Outreach & Education (POE)

Education Requests Requested educational sessions provide

education targeted to meet particular needs Complete the form found under Forms link

on J11 Part A website

264

ONLINE PROVIDER SERVICES (OPS) Online Provider Services (OPS) Free Internet-based, self-service portal

Real-time information Web access for: Eligibility Claim Status Remittance Advices (RAs) Financial Information (Showing the last 3 Checks on the Payment Floor)

265

OPS Eligible to participate in OPS if you have a

signed EDI Enrollment Agreement on file If you already submit claims electronically,

you do not need to submit new agreement OPS application is user-friendly and easy-to-

use Help buttons available on each page link to

Frequently Asked Questions (FAQs) and other helpful information

266

OPS

Enhanced benefits for providers: e-Check e-Offset Ability to file an appeal online

using OPS

267

GOING BEYOND DIAGNOSIS Palmetto GBA is addressing the need to

improve the quality of health care records by incorporating the concepts of the International Classification of Functioning, Disability and Health (ICF) into health care policy and education

Harry Feliciano, M.D. our Senior Part A Medical Director, is at the forefront of this process

268

GOING BEYOND DIAGNOSIS To learn more about Going Beyond

Diagnosis and how to communicate better with Palmetto GBA and other third-party payers more efficiently, visit the Going Beyond Diagnosis blog www.palmettogba.com/goingbeyonddi

agnosisblog

269

GOING BEYOND DIAGNOSIS BLOG

Palmetto GBA and Provider DMAIC activities are posted on GBD blog:

http://palmgba.com/gbd/category/dmaic/ Twitter@BeyondDx

270

http://palmgba.com/gbd/category/dmaic/

http://palmgba.com/gbd/category/dmaic/

SOCIAL NETWORKING

Ways to Stay Connected

271

TIME FOR QUESTIONS

272

Thank you for attending.

Please take a few moments to complete the post test and

evaluation.

Post Test Evaluation

273

Documents

2014 Medicare Partnership Tour: Partnering to Reduce Errors · 2014-07-17 · LCDs Organizational Process Improvement Coaching Project (OPICP) Medicare Providers Improve the relevant