Note: This is your last issue of the TMF Review & HPMP Update.
Because the Centers for Medicare & Medicaid Services (CMS) has eliminated the Hospital Payment Monitoring Program (HPMP) from the QIO’s next contract, which begins in August 2008, TMF regrets that we will no longer be providing this free newsletter to you. (See article below, “Hospital Payment Monitoring Program (HPMP) Excluded from New CMS QIO Contract.”) TMF will still be conducting case review work and quality improvement initiatives for CMS and we hope to have the opportunity to continue our relationship with those of you who work in these areas now and in the years ahead.
We have enjoyed working with you—the compliance officers, utilization reviewers, case managers, health information management professionals, coders and other health care professionals at the over 390 Texas hospitals we serve throughout Texas—and hope that you will continue the important work of reducing Medicare payment errors to help preserve the Medicare trust fund for future generations and to help keep the health care institutions that we all serve healthy and viable organizations. Best wishes for a rewarding and successful future!
PLEASE NOTE: Other than recorded training programs, none of the information currently on TMF Health Quality Institute’s HPMP Web site will be available after July 31, 2008. Training programs will be accessible using your current username and password through December 31, 2008.
In This Newsletter:
1. Hospital Payment Monitoring Program (HPMP) Excluded from New CMS QIO Contract
2. Septicemia/Sepsis Coding Worksheet Makes a Difficult Job Easier
3. Free DRG Coding Training and AHIMA CEUs
4. Announcements
– Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) Have Changed for FY 2008
– Read About Requirements of the New CMS Contract That Will Impact Medicare Hospitals
– Use Free Prompter Cards to Help Reduce Payment Errors
– Journal Article Gives Tips on Reducing Unnecessary One-Day Medicare Hospital Stays
5. New & Notable Online
– The HPMP Compliance Workbook Has Been Updated
– Use Correct Patient Discharge Status Codes to Avoid Claim Rejection or Cancellation
6. Utilization Matters
– Questions Clarifying Inpatient vs. Outpatient Observation Billing Errors
– Questions on Kyphoplasty as Inpatient or Outpatient Procedure
7. Coders Corner
– How are coders affected by the new FY 2008 IPPS MS-DRG MCC/CC list?
1. Hospital Payment Monitoring Program (HPMP) Excluded from New CMS QIO Contract
Effective August 1, 2008, with the beginning of the 9th Scope of Work (SOW)—the quality improvement contract for work with the Centers for Medicare & Medicaid Services (CMS)—state Quality Improvement Organizations (QIOs) such as TMF will no longer be responsible for implementing the Hospital Payment Monitoring Program.
2. Septicemia/Sepsis Coding Worksheet Makes a Difficult Job Easier
The Report on Medicare Compliance published in its March 17, 2008 issue TMF’s Septicemia/Sepsis Coding Worksheet, useful for auditing your sepsis records. Catching coding or DRG assignment problems or monitoring improvement becomes a smoother process using this helpful tool. With the aid of this worksheet for either post-payment or pre-payment medical record review, coders can learn to recognize problems more easily and recommend corrective action, if needed. The worksheet is now available on the TMF Web site.
Choose “Septicemia/Sepsis Coding Worksheet” from the HPMP Tools list at:
3. Free DRG Coding Training and AHIMA CEUs
The Centers for Medicare & Medicaid Services is closely monitoring data on diagnosis related groups (DRGs) and DRG payment errors. To address DRGs and coding issues commonly associated with Medicare payment errors in Texas, TMF Health Quality Institute is now offering three new recorded educational sessions on coding.
· Coding III: Coding Issues for Cellulitis and Excisional Debridement
· Coding IV: Coding Issues for Diabetes and Red Blood Cell Disorders
· Coding V: Coding Issues for Syncope and Collapse, Circulatory System Diagnoses, and Gastrointestinal Hemorrhage
Each of these programs has been approved for 2 continuing education units for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA).
4. Announcements
Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) Have Changed for FY 2008
Effective October 1, 2007, Medicare severity (MS) diagnosis related groups (DRGs) replaced CMS DRGs. The target areas included in PEPPER have been revised to reflect the new MS-DRGs, and, where possible, have been constructed to be analogous with the CMS DRG target areas so that data can be trended over time. Please note these and other revisions that have been made to PEPPER for FY 2008. Refer to the PEPPER User's Guides for more information.
Click here for story...
Read About Requirements of the New CMS Contract That Will Impact Medicare Hospitals
Click the link below to read “Progressing Toward the 9th SOW” in the March 2008 issue of QIO News, about the next CMS three-year contract with QIOs which begins August 1. Activities currently under the CMS hospital quality improvement umbrella and changes to those activities will be moving to the “Patient Safety” theme, which will be called the CMS National Patient Safety Initiative (NPSI). A brief summary of this theme is included in the newsletter appendix. Medicare's QIO News is a quarterly e-newsletter from the office of Barry M. Straube, MD, CMS chief medical officer and director of the office of clinical standards and quality.
Click on “QIO News March 2008” in the “Download Now” box on left ...
Use Free Prompter Cards to Help Reduce Payment Errors
As a service to Texas Medicare hospitals, TMF Health Quality Institute’s Hospital Payment Monitoring Program has offered free tools and information to help reduce payment errors. TMF currently has a small number of our most popular tool, the credit-card-sized “Physician Documentation Prompter Cards,” still available. If you’ve run out or didn’t order yours last winter, this is your last chance to order. Use these prompter cards to:
● Remind admitting physicians what to document
● Provide physicians with information on documenting “Present on Admission”
● Help physicians determine when outpatient observation is appropriate
TMF’s reserve supply will be distributed on a first-come-first-served basis. Once these cards are gone, we will not be printing more.
To order your free prompter cards, e-mail your request along with mailing address and quantities needed to Virginia Newell at vnewell@txqio.sdps.org.
Journal Article Gives Tips on Reducing Unnecessary One-Day Medicare Hospital Stays
The March/April issue of the Journal of Health Care Compliance includes an article written by Judi McCabe, director of the TMF Health Quality Institute hospital payment monitoring program, and Debra Holsinger, TMF hospital payment monitoring specialist. The article, "Special Project Focusing on One-Day Stays Achieves Breakthrough Results," describes an initiative unusual in that it used The Breakthrough Series: IHI's Collaborative Model for Achieving Breakthrough Improvement for achieving quality improvement in the health care utilization arena. Results described include reducing unnecessary one-day Medicare hospital admissions by 19 percent, far exceeding the project's goal of a three to five percent reduction.
5. New & Notable Online
The HPMP Compliance Workbook Has Been Updated
The HPMP Compliance Workbook has been updated and posted to www.hpmpresources.org. This workbook offers practical guidance and helpful tools for identifying and improving hospital compliance program structures and processes that contribute to payment error outcomes.
Access the workbook directly at the following link:
Use Correct Patient Discharge Status Codes to Avoid Claim Rejection or Cancellation
The Centers for Medicare & Medicaid Services (CMS) requires patient discharge status codes for many hospital inpatient claims, skilled nursing claims and outpatient hospital services, as well as all hospice and home health claims. Assigning the correct patient discharge status code is as important as assigning any other coding when filing a claim. Omitting a code or submitting an incorrect code is a claim billing error and could result in the provider’s claim being rejected or cancelled and payment being taken back. Choose the correct patient discharge status code to avoid claim errors and help receive payment sooner.
Read the complete CMS Medicare Learning Network article …
6. Utilization Matters
Questions Clarifying Inpatient vs. Outpatient Observation Billing Errors
Q. We have a patient who was admitted as inpatient who did not meet inpatient criteria. An order was later written to change the status to observation but this was not caught until after the patient was discharged. How should this be handled?
A. This should be billed provider liable. Billing under Condition Code 44 is not an option because to use Condition Code 44, all four of the conditions it lists must be met, one of which is that the patient must still be in the hospital so that he or she can be notified of the change. Because the patient's stay was not medically necessary, it is not possible to bill for an inpatient stay and so billing provider liable is the only option.
Q. A patient was admitted as an inpatient and did meet criteria. An order was later written to change the status to observation, but this was not caught until after discharge. How would this be billed?
A. If the patient meets inpatient criteria and has an order for inpatient admission it is appropriate to bill as inpatient.
Q. A patient came in for an inpatient-only procedure. After the procedure the physician checked “observation order” although the patient met inpatient criteria. This was not caught until after discharge. With the observation order following the inpatient-only procedure, how should that be billed?
A. It depends. If there is an inpatient order prior to the procedure, showing that the procedure was done inpatient, bill the claim as inpatient.
If there is no inpatient order prior to the procedure and there is an observation order, then you would submit an outpatient claim. However, know that the procedure will be denied because the patient must be inpatient at the time the procedure is performed in order to be paid for it.
Questions on Kyphoplasty as Inpatient or Outpatient Procedure
Q. Is kyphoplasty an inpatient or outpatient procedure?
A. Kyphoplasty is not on the Medicare “Inpatient Only” list and is therefore routinely considered an outpatient procedure. If the physician determines that it is medically necessary for an individual patient to be inpatient for the kyphoplasty, the physician must fully document the rationale to support the medical necessity for the admission.
Q. If a patient is admitted inpatient for pain control secondary to a compression fracture and kyphoplasty is scheduled for the following day, is it appropriate to perform the kyphoplasty as an inpatient?
A. In the case cited, it does not appear that the admission meets criteria for an inpatient admission. Uncomplicated compression fracture (i.e., without ileus or significant neurological deficit) is specifically excluded from InterQual admission criteria. Intractable pain requiring parenteral analgesics meets InterQual criteria for outpatient observation. When a patient is treated in observation, the rule regarding procedures not on the Medicare “Inpatient Only” list applies.
If a patient meets medical necessity for inpatient admission and a procedure is performed during the hospital stay to treat the patient's medical condition, the procedure is considered part of the inpatient stay.
7. Coders Corner
Q. How are coders affected by the new FY 2008 IPPS MS-DRG MCC/CC list?
A. The FY 2008 IPPS MS-DRG reimbursement system introduced major revisions to the complications/comorbidities (CC) list for the first time in over 20 years. Since the implementation of the IPPS, the CC list lost much of its capacity to discriminate hospital resource use, so Medicare medical officers deleted many nonspecific conditions, symptoms and chronic low-severity conditions. They also added a new high-severity category, Major CCs (MCCs).
These changes impact coders primarily in two ways. First, coding productivity is expected to decrease initially as coders become acquainted with the new list. Chronic conditions familiar to coders as CCs such as emphysema, chronic obstructive pulmonary disease (COPD) and chronic blood loss anemia are no longer on the CC list. Second, it is important for coders to acquaint themselves with the CC/MCC list to enable coding at the appropriate level of specificity. Knowledge of the CC/MCC list equips coders to search for clues about specific diseases throughout the record, and to query physicians if necessary.
For example, congestive heart failure (CHF) unspecified, 428.0, is no longer a CC; however, documentation including type and acuity of heart failure can lead to a CC or MCC. Note that increased pressure on coders to code at high levels of specificity cannot overshadow the need for supporting documentation in the choice of any code as outlined in the ICD-9-CM Official Guidelines for Coding and Reporting.
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TMF Review & HPMP Update is not copyrighted. You may copy and distribute this publication in whole or in part. If you reprint any of the content, please include the credit "Reprinted with permission of TMF Health Quality Institute."
This material was prepared by 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. The contents presented do not necessarily reflect CMS policy. 8SOW-TX-HPPE-08-05.