3 rd Annual Association of Clinical Documentation Improvement Specialists Conference

Kathleen A. Bower, DNSc, RN, FAAN Arinda F. Kennedy, RN, CCDS The Center for Case Management Wellesley, MA Creating a Point-of-Entry Clinical Documentation Specialist/Case Manager

Today’s environment of increasing scrutiny (or, they’re here and there are more on the way)

Oversight of enforcement efforts Monitors integrity activities – Medicare & Medicaid reimbursement – HIPPA security – Stark Law Conducts Medicare and Medicaid Investigations Enforcement of anti- kickback statute Issue compliance program guidance U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) Centers for Medicare & Medicaid Services (CMS)

OIG and CMS oversight Recovery Audit Contractors (RAC) – Detect past improper payments Medicare Administrative Contractors (MAC) – Prevent future improper payments Quality Improvement Organizations (QIO) – DRG reviews/quality Zone Program Integrity Contractors (ZPIC) – Focus on patterns that constitute fraud Medicaid Integrity Contractors (MIC) – Focus on Medicaid claims Office of Audit Services (OAS) – Focus on payments Office of Investigation (OI) – Criminal and civil referrals to DOJ Office of Counsel to IG (OCIG) – Focus on anti-kickback, quality Office of Evaluation and Inspections (OEI) – Focus on policy and systems Medicaid Fraud Control Units (MFCU) – Medicaid fraud Providers

Today’s increasing audit environment OIG QIO MIP – Medical review – PSCs – CERT – MEDICs – Medi-Medi – PERM MAC MFCU MIG – MIP – MIC ZPIC RAC

Office of Inspector General Current Inspector General: Daniel R. Levinson OIG combats fraud, waste, and abuse in Medicare and Medicaid Nonpartisan agency committed to protecting the integrity of the more than 300 programs administered by the U.S. Department of Health and Human Services (HHS) Approximately 80% of the OIG’s resources are dedicated to promoting efficiency and effectiveness of the Medicare and Medicaid programs

Medicare Fraud Control Units The MFCUs, created by Congress in 1977, are federal- and state-funded law enforcement entities that investigate and prosecute provider fraud and violations of state law pertaining to fraud in the administration of the Medicaid program In addition, the MFCUs are required to review complaints of resident abuse or neglect in nursing homes and other healthcare facilities

Quality Improvement Organizations Core functions: – Improve quality of care for beneficiaries – Ensure that Medicare pays only for services that are reasonable, necessary, and provided in the most appropriate setting – Protect beneficiaries by expeditiously addressing individual complaints and provider-based notice appeals Conduct individual case reviews for specific categories

Medicare Integrity Programs Medical review: Involves analysis of claims data for aberrances, pre-payment reviews triggered by system edits, and post-payment reviews, all of which involve claims data and therefore ICD codes. Program Safeguard Contractors (PSC): Investigate Medicare fraud, waste and abuse within Medicare Parts A and B. Investigations are based on FFS claims data obtained from CMS claims processing systems and thus involve ICD codes.

MIP (cont.) Comprehensive Error Rate Testing Program (CERT): Estimates payment error rates and monitors the accuracy of Medicare’s fee-for-service payments within Medicare Part A and B Medicare Drug Integrity Contractors (MEDIC): Investigate fraud, waste, and abuse in the Medicare Part D program

MIP (cont.) Medi-Medi program: Investigates fraud, waste, and abuse of services and payments rendered on behalf of Medicare and Medicaid dual- eligible beneficiaries. Payment Error Rate Measurement (PERM): Measures improper payments in the Medicaid program and the State’s Children Health Insurance Program (SCHIP). The PERM process estimates payment error rates for the fee-for-service and managed care components of both the Medicaid program and the SCHIP program.

Medicaid Integrity Group Medicaid Integrity Contractors (MIC) – Audit Medicaid claims – Identify overpayments – Educate providers and others about payment integrity and quality of care – Deter those who would exploit the program Medicaid Integrity Program

ZPIC 7 Zone Program Integrity Contractors to replace PSCs & MEDICs – PSCs work with MACs to handle fraud and abuse issues in their jurisdiction – MEDICs investigates fraud, waste, and abuse in the Medicare Part D program Responsibilities: – Look for fraud and abuse in Medicare Parts A, B, C, D, home health, DME, hospice – Utilize data analysis in searching for outliers and unusual patterns Zone Program Integrity Contractors

ZPIC (cont.) Seven zones: – Zone 1: California, Nevada, Hawaii, American Samoa, Guam, and the Mariana Islands – Zone 2: Alaska, Washington, Oregon, Montana, Idaho, Wyoming, Utah, Arizona – Zone 3: Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, and Kentucky – Zone 4: Texas, Oklahoma, Colorado, and New Mexico (awarded to Health Integrity, LLC) – Zone 5: West Virginia, Virginia, North Carolina, South Carolina, Georgia, Alabama, Mississippi, Tennessee, Arkansas, and Louisiana (awarded to AdvanceMed Corp.) – Zone 6: Pennsylvania, New York, Maryland, Washington DC, Delaware, Maine, Massachusetts, New Jersey, Connecticut, Rhode Island, New Hampshire, and Vermont – Zone 7: Florida, Puerto Rico, and the U.S. Virgin Islands (awarded to Safeguard Services, LLC)

MAC Medicare Administrative Contractors: – Medicare will move from a network of Part A fiscal intermediaries (FI) and Part B carriers to the MACs – 19 MAC contracts awarded – Implementation phase from 2005 to 2011 Responsibilities: – Process claims for Part A and Part B – Serve as point of contact for healthcare providers for the receipt, processing, and payment of claims

A/B MAC jurisdictions map

RAC Objective is to identify and correct past overpayments and underpayments in the Medicare fee-for-service program Implement actions that will prevent future improper payments: – Improve provider compliance with existing rules – Identify fraud in the system – Ensure the longevity of the Medicare Trust Program Recovery Audit Contractors

RAC demonstration project 3-year Medicare RAC demonstration project lasted from March 2005 through March 2008 – Phase : California, Florida, New York – Phase : South Carolina, Arizona, Massachusetts, and Mutual of Omaha fiscal intermediary hospitals in any of the six demonstration states

Results of the RAC demonstration program Overpayment collected: $992.7m Less underpayments repaid -($37.8m) Less $ overturned on appeal -($46.0m) Less PRG IRF re-review -($14.0m) Less cost to run the demo -($201.3m) BACK TO TRUST FUND ▬►$693.6m Report available at 3/27/05–3/27/08 (Claims & MSP RACs)

Overpayment by provider type

Overpayment by error type

Today’s reality Issue: – Increased number of government contractors actively trying to identify Medicare and Medicaid overpayments and potential fraud – Hospitals are held to strict criteria to determine medical necessity for admission level of care

Focus on admission status Compliance – CMS – false claims and RAC program – Documentation requirements to change the status – Lack of medical necessity sited as the largest reason for overpayment – RAC

Physician documentation Physician documentation accounts for 80% of DRG billing errors* (*per OIG) Due to incomplete documentation, lack of medical necessity.

Current process Patient is admitted to the hospital Hospital is required to review the case and determine the medical necessity of the case; particularly important for Medicare/Medicaid – Inpatient – Observation Medical necessity review is done by case manager/ utilization review manager using: – InterQual – Milliman – MCAP – Other screening criteria Possibly a secondary review if hospital has process outlined

Medical necessity screening Hospitals require case manager/utilization manager to screen all admissions with tools that all have disclaimers about their criteria NOT being applicable to ALL patients

Disclaimer (Insert name here) Criteria reflect clinical interpretations and analyses and cannot alone either resolve medial ambiguities of particular situations or provide the sole basis for definitive decisions. The criteria are intended solely for use as screening guidelines with respect to the medical appropriateness of healthcare services and not for final clinical or payment determinations concerning the type or level of medical care provided, or proposed to be provided, to a patient. Licensee acknowledges that the criteria are not a substitute for physician judgment regarding patient care decisions and that (insert name here) has no control over licensee’s use of the criteria or over any patient care decisions made by or on behalf of licensee based upon such use …

Observation problems Overuse or underuse of observation status – Revenue: APC vs. DRG – LOS artificially low or high – Patient copays – Outpatient outliers

Observation problems (cont.) Many patients placed in observation status could meet inpatient criteria with improved clinical documentation by the physician Many patients admitted to inpatient status do not meet medical necessity for this level of care, but could with additional physician documentation Case/utilization managers are typically not trained in clinical documentation improvement

Observation problems (cont.) Solution: – Hospitals need effective processes to facilitate proactive strategies to manage today’s increasing rules and regulations without swinging too far in the opposite direction and losing reimbursement for which they are compliantly entitled to receive

A new role Point-of-entry clinical documentation specialist cross-trained in utilization review? Point-of-entry case/utilization manager cross-trained in clinical documentation improvement? Access managers?

A hybrid role is needed Access managers (would include ED case managers) – Clinical documentation specialist and case manager roles combined – Placed at all points of entry into facility Admission department ED Or one access manager who floats/covers all admissions Hours – Best case scenario 24/7 – Realistic scenario 10–12 hours daily, 7 days/week 10 a.m.–10 p.m. – Stark reality: Whatever administration is willing to support

Basic responsibilities Following CMS guidelines, review all admissions to hospital for medical necessity/documentation improvement opportunities Intervene with physicians for complete and accurate documentation of: – Working clinical diagnoses – Comorbid conditions – Physician’s impressions/clinical judgment – Physician’s plan of treatment/medical decision-making (orders) – Appropriate level of care Deliver admission/preadmission HINN or ABN when necessary Communicate effectively with care coordination team Education of staff and physicians

Focus points for the access manager Is there missing documentation that would impact the acuity of this case? Are all the physician’s concerns from a clinical perspective documented? Do all medications ordered have a corresponding clinical condition documented? Are all tests ordered pertinent to the reason(s) for admission?

Focus points for the access manager What provisional diagnoses are likely in the physician’s clinical judgment and impressions but are not included in the documented clinical impressions? What is needed to substantiate the need for inpatient admission? Are there any abnormal lab or diagnostic results available at the time of admission? Are they addressed in the physician’s clinical impression or provisional diagnoses?

Access manager role Education/background – RN – Excellent communication skills – Preferred clinical background in ED or ICU (willing to interview nurses with background in other areas requiring a broad clinical knowledge base) – Best-case scenario: Expert in clinical documentation improvement and utilization review – Realistic but hopeful scenario: Expert in utilization review or clinical documentation improvement and willing to learn the other role – Probable scenario: RN with the right clinical experience who is willing to take on this role

Benefits of merging the roles Improved physician documentation at the point of entry, or before it Increased compliance with CMS rules and regulations, Conditions of Participation, etc. – Documentation of medical necessity up front – If medical necessity is not present, HINN or ABN would be given – Decreasing hospital’s audit risks Decreased RAC/MAC/MIC/ZPIC … audit risks More accurate reflection of patient’s severity of illness and risk of mortality – Potential to improve staffing ratios Improved hospital and physician profiles Increased compliant reimbursement Decreased risk of litigation

Potential barriers How many super nurses are out there? Once you get them trained and they realize how much they are worth to your facility, could you afford to pay them? Are consulting agencies scouting these conferences looking for these experts right now? Are you thinking you need to look into this new field ASAP?

Real potential barriers Training has to be tailored to the needs of this role – Expert clinical documentation specialist Physician documentation improvement – Expert case manager/utilization review manager Medical necessity Time required to become expert in this combined role Keeping up with CMS changes Keeping up with commercial payer contracts Physician buy-in

Process Identify your facility’s top medical necessity or observation admission targets Using your medical necessity criteria tool (InterQual, Milliman, etc.), develop strategies to identify patients who could meet inpatient criteria with additional documentation Using these same criteria, develop educational material (including improving physician documentation to meet medical necessity) around your top problematic areas Educate your access management staff Educate your physician advisors or secondary reviewers We also recommend that you educate your clinical denial analysts in both

Process (cont.) Track your interventions Track your responses Track your improvements Demonstrating your influence on the hospital’s revenue cycle = more staff Policies and procedures reflect new role Recognize lasting change is not achieved overnight Adoption of consistent processes is key to compliance and billing accuracy

Typical medical necessity targets 1, 2, and 3 day stays Symptom diagnoses – chest pain, syncope, weakness, change in mental status High-cost procedures with short hospital stays – cardiac procedures (PCI stent, ICD placement, pacemakers) High-risk MS-DRGs – Heart failure and shock – Kidney and urinary tract infections or procedures – Simple pneumonia – COPD – Diabetes

Risk adjustments Multiple comorbid conditions 12 or more medications Lives alone Frequent readmissions – 3rd admission in 6 months is a red flag Cultural issues New diagnosis of ongoing disease Inability to manage disease(s) Barriers to care – Disabilities – Educational level – Poverty – Language Some patients are high risk before they get sick. Completing documentation of these risks is key to accurate MS-DRG assignment and reimbursement, and it also impacts severity of illness, risk of mortality, and level of care.

Physician education Communication with physician staff is critical Link education on improved documentation of medical necessity with how it can benefit the physician’s practice (WIIFM) – Reduced administrative hassles – Increased business success – Decreased denials Certain physicians need targeted and ongoing education: – ED physicians – Hospitalists – Residents/fellows and attending physician staff – Physician advisors – Chief medical officers

Emergency department ED primary access point for most patients entering hospitals Daily demands of patient care responsibilities (often life-and-death issues) are a priority Designation of a patient’s observation or admission status is not a priority ED physicians practice defensive medicine Access manager position is critical in this area – Access management may be done by ED case managers if cross-trained

Discussion Chest pain – Unstable angina? R/O AMI? Syncope – History of CAD? Telemetry monitoring? Cardiac workup? Cardiac procedure – Comorbid conditions or risk factors present that would support inpatient level of care?

Conclusion The complexity of observation service versus admission status coupled with the increasing need to get the status compliantly correct the first time has become a major issue for hospitals This is an area that could be positively affected with clinical documentation improvement by physicians Preparation including point-of-entry access managers, policies and procedures, focused education, and ongoing reviews are critical to your facility surviving in today’s high-risk arena

Questions?