This week’s Medicare updates include a transmittal recurring update notification describing changes to and billing instructions for various payment policies implemented in the October 2016 OPPS update; news about CMS once again allowing some providers to settle inpatient status claims in appeals; an OIG report regarding the improper payment of millions of dollars for unlawfully present beneficiaries; and more!
I recently heard of a local long-term care hospital (LTCH, also known as LTACH) that was unwilling to accept military veterans who were cared for at her facility or any Veterans Affairs hospitals even though they would otherwise qualify for LTCH care. The reason the LTCH would not accept these patients was because they did not have a preceding visit in a “regular” hospital. What's the solution?
One year following the official implementation of ICD-10, the coding industry is beginning to report valid results regarding accuracy, productivity, and denial trends. While some of these facts and figures are self-reported by HIM directors and anecdotal in nature, other findings are grounded in hard, fast coding performance data. Such is the case with the results from Central Learning (www.centrallearning.com), a web-based system that electronically assesses coder knowledge using real medical record cases and expert-verified answer keys.
This article summarizes coder performance data as measured across 50 health systems and 300 coders as of June 30, 2016. It compares these findings with other industry reports and extrapolates key findings for HIM directors and revenue cycle executives. Since coding and diagnosis-related group (DRG) assignment are the major drivers behind health system revenue streams, consistent data analysis helps to ensure accurate coding and reimbursement.
According to Central Learning data, coding accuracy is slightly increasing after nine months under ICD-10 for both experienced coders and coders-in-training. While the industry overall still lags behind the 95% accuracy benchmark achieved in ICD-9, we're getting closer in all three major patient types: inpatient, outpatient, and emergency services.
Fifty health systems are represented in the data, providing a broad-based assessment. We compared coder accuracy from Q1 (January 1?March 31) with Q2 (April 1?June 30) to identify recent, timely trends in code quality. The figure on p. 13 lists the most current benchmark of our status through June 30, 2016.
Hospitals got a last-minute reprieve from the MOON notification requirement, which was set to go into effect August 6. Citing the need for additional time to revise the standardized notification form that hospitals will need to use to notify patients about the financial implications of being assigned to observation services, CMS moved back the start date for the requirement in the 2017 Inpatient Prospective Payment System (IPPS) final rule to "no later than 90 days," after the final version of the form is approved.
When CMS decided to postpone the MOON notification requirement a few days before the scheduled implementation date of August 6, it provided a welcome reprieve for many hospital staff members who were scrambling to get ready.
"We were almost ready to go, however, plans are actually now on hold until the final draft is approved, in probably January," says Frantzie Firmin, MS, RN, director, utilization management and care coordination of Brigham & Women's Hospital in Boston.
The hospital's preparations included development of a process to deliver the notification to patients who needed it.
"Our organization, Partners Healthcare System, has decided to address the MOON implementation systemwide. As a result, we set up a case management expert panel, which is a collaborative practice committee that meets regularly to address and develop a plan that will ensure regulatory compliance across the system," she says.
The group worked with the electronic medical system team to develop an automated workflow directly within the system. "Each hospital has its own work queue set up," says Firmin. "The Medicare patients in the work queue are only those in observation status that have been there 12 hours or more."
Care coordinators and insurance support nurses have access to the work queue, which allows them to identify their observation patients. "Furthermore, we have also added functionality in [our electronic system] to document that the notice has been given," she says. Staff members are able to check off the status and date of receipt for each patient, and then the patient's name moves out of the work queue.
The system also allows the insurance support nurse or care coordinator to print the form and provide a copy to the patient before discharge.
Other organizations had taken similar steps.
RWJ Barnabas Health in Toms River, New Jersey, also formed a small task force to ensure compliance with MOON, says Shawna Grossman Kates, MSW, MBA, LSW, CMA, the organization's case and bed management director. But while MOON is new to them, this type of observation notification requirement is not. New Jersey hospitals have already been subject to an even more restrictive patient notification requirement for several years, she says.
One of the topics raising the most questions in case management today is related to the MOON notification requirement. Hospitals were struggling this summer to comply with the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, which was signed by President Barack Obama August 6, requiring hospitals to provide a verbal and written notice of outpatient status to any patient in observation who has been in the hospital for more than 24 hours. Just prior to the August 6 implementation date, hospitals received word that the notification requirement would be delayed pending approval of modifications made to the government's notification form.
