© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use.

Chapter 2 Hospital-Based Care

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Learning Objectives Describe types of care provided by hospitals. Explain regulatory and accreditation standards that apply to hospital-based care. Discuss documentation issues in hospital-based care. 3 (continues)

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Learning Objectives (continued) Describe reimbursement methods for hospital-based care. Identify coding and classification systems used in hospital-based care Describe data sets utilized for hospital- based care. 4 (continues)

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Learning Objectives (continued) Cite factors in avoiding legal risk in hospital-based care. Define roles of the health information management professional in hospital- based care. 5

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Types of Settings Examples of Hospital Inpatient Settings –Hospital Inpatient Unit –Intensive Care Unit Examples of Hospital Outpatient Settings –Hospital Outpatient Unit –Hospital Outpatient Clinic –Hospital Emergency Unit –Hospital Observation Services 6

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Types of Settings (continued) Examples of Hospital Outpatient Settings (continued) –Hospital Ambulatory Surgery Unit –Partial hospitalization program (PHP) Long-Term Acute Care Hospital 7

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Types of Patients Hospital inpatients Hospital outpatients –Clinic outpatient –Referred hospital outpatient –Emergency outpatient Long-Term Acute Care Hospital Patients 8

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Types of Caregivers Many types, including physicians, nurses, physical therapists, occupational therapists, clinical laboratory scientists, pharmacists, and others Hospitalists 9

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Regulatory Issues Licensure: Each state determines requirements Federal Regulations: Medicare’s Conditions of Participation for Hospitals or “deemed” status by virtue of accreditation Accreditation: Voluntary program through –The Joint Commission –Healthcare Facilities Accreditation Program (HFAP), American Osteopathic Association –NIAHO program of DNV Healthcare, Inc. 10

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Documentation Good documentation is important to the hospital to… –Meet accrediting and regulatory guidelines –Provide high-quality care –Demonstrate appropriateness of payments Type and extent of documentation depends on nature of services performed, e.g., surgery, critical care, outpatient care 11

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Joint Commission and Documentation Standards affecting health information services are found in various sections, e.g. –Information Management –Record of Care, Treatment, and Services –Provision of Care, Treatment, and Services Elements of performance (EPs) address specific issues 12

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Physician Reimbursement and Documentation Level of service billed by physician determined by documentation in record Resident’s services not billed to Medicare (Indirect medical education allowances fund resident’s Medicare services.) Teaching physician may bill Medicare when documentation indicates his or her presence and participation 13

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Charge Description Master (CDM) or Chargemaster CDM (or chargemaster) is a data file containing codes for hospital services with corresponding charges for those services CDM automatically assigns codes for billing when the charge is entered CDM maintenance is important to hospital’s financial health 14

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Hospital Reimbursement Medicare –Medicare Administrative Contractor (MACs) replace Part A: Fiscal Intermediary Part B: Medicare carrier –Hospital Inpatient Prospective Payment System (IPPS) –Hospital Outpatient Prospective Payment System (OPPS) 15

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Hospital IPPS Medicare-Severity Diagnosis Related Groups (MS-DRGs) are the basis for Medicare payment Each MS-DRG has a relative weight that determines the payment amount for the patient stay 16

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Seventy-Two-Hour Window Outpatient services related to inpatient admission within subsequent 72 hours must be billed with inpatient charges, resulting in a single DRG payment for both outpatient and inpatient services Failure to bundle outpatient and inpatient codes on same bill can result in financial penalties for the hospital 17

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Hospital OPPS Ambulatory Payment Classifications (APCs) are the basis for Medicare payment under hospital OPPS Multiple APCs per visit are possible for outpatients. In contrast, only one DRG per stay is paid for inpatients. Status indicators Composite APCs 18

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Hospital OPPS (continued) Observation services Pass-through payments Provider-based clinics 19

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Long-Term Care Hospital PPS Medicare severity long-term care diagnosis related groups (MS-LTC-DRGs) –Similar in structure to MS-DRGs –Different relative weights –Different lengths of stay Other Medicare payment mechanisms for interrupted stays and certain types of transfers 20

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Other Reimbursement Issues Other payers Billing forms –UB-04 (or HCFA 1450) used by hospitals –HCFA 1500 used by physicians Electronic claims submission is the norm 21

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Coding and Classification ICD –Diagnosis coding for inpatients and outpatients –Procedure coding for inpatients only HCPCS –Procedure coding for hospital outpatients Revenue codes Coding edits (MCE, OCE, NCCI) 22

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Data and Information Flow Registration Master patient index Documentation of assessments, diagnostic procedures, treatments, etc., added to record as completed Record must be readily available when patient presents for care in any location of the hospital 23

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Electronic Health Records and Computer Systems Early systems related to billing functions Clinical information systems began to receive more attention in the 1990s Electronic health records –ARRA’s financial incentives for meaningful use of electronic health records –Advantages to patients and clinicians 24

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Data Sets Uniform Hospital Discharge Data Set Uniform Ambulatory Care Data Set Data Elements for Emergency Department Systems HIPAA designated standards maintenance organizations Medicare common working file (CWF) combines claims data from Part A and Part B claims 25

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Quality Assessment and Performance Improvement Joint Commission DNV Healthcare CMS –Hospital Inpatient Quality Reporting –Hospital Outpatient Quality Data Reporting 26

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Utilization Management (UM) Appropriateness, efficiency, and cost- effectiveness of health care PPS and managed care provide incentive for effective UM programs Team effort required to operate efficiently, reduce repetitive testing, etc. 27

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Risk Management & Legal Issues Potentially compensable events (PCEs) – may result in litigation or payments to an injured party Occurrence (or incident) reporting systems may be paper-based or electronic Legible, complete documentation Documentation of telephone contacts Telephone calls should be HIPAA compliant 28

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. EMTALA-Emergency Medical Treatment and Active Labor Act “Anti-dumping” legislation Legal duty to screen and stabilize Cannot delay screening to check insurance status Must stabilize before transfer Stabilization for woman in labor generally means delivery of infant before transfer 29

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Role of Health Information Management Professional Health Information Services Compliance Officer Revenue Cycle Other Roles 30

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Trends Increasing complexity of services Increasing numbers of hospitalists Long-term acute care Quality and reimbursement linkage Electronic health records Auditing initiatives 31

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Summary Broad range of services and many types of caregivers Licensure and accreditation Documentation issues Reimbursement issues Coding and classification Data and information flow 32

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Summary (continued) Data sets Quality assessment and improvement Utilization management Risk management Role of the health information professional Trends 33

© 2012 Cengage Learning. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a license distributed with a certain product or service or otherwise on a password-protected website for classroom use. Web Activity Health Care Compliance Association CHC certification –HCCB handbook content outline –Content areas and health information management training 34