The American Hospital Association asked CMS to clarify some aspects of its new outpatient notification requirement, Notice of Observation Treatment and Implication for Care Eligibility Act, which is supposed to go into effect in the summer of 2016.
Is your hospital in one of the 67 geographic areas defined by CMS as a metropolitan statistical area (MSA) and one that CMS has identified to participate in the Comprehensive Care for Joint Replacement (CJR) Model? If so, is your case management department ready? Does your department have the processes and procedures in place for how it will participate in this retrospective bundled payment innovative project for Medicare fee-for-service beneficiaries?
When the Quality Improvement Organizations (QIO) took over the role of education and enforcement for the 2-midnight rule on October 1, 2015, many anticipated that their reviews would only look at records from that date forward. But in an unpleasant turn of events, some hospitals have reported QIO record requests zeroing in on cases as far back as May 2015, says Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group for AccretivePAS in Chicago.
"It caught everybody off guard. No one expected them to audit any earlier than October 1," he says. "But audits are starting hot and heavy, and it's important for organizations to understand that it's permitted and that the QIOs can request charts going back six months."
According to a fact sheet, CMS is specifically using "Beneficiary and Family Centered Care (BFCC) QIOs, rather than MACs or Recovery Auditors, to conduct the initial medical reviews of providers who submit claims for short-stay inpatient admissions on October 1, 2015. Beginning in 2016, BFCC-QIOs will begin reviewing inpatient cases under the revised Two Midnight Rule being announced today." (For more information, visit www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30-4.html.)
Another surprise? BFCC-QIOs are requesting charts for inpatient-only surgeries, something they weren't supposed to do, says Hirsch.
by Shannon Newell, RHIA, CCS, AHIMA-approved ICD-10-CM/PCS trainer
Approximately 800 hospitals across the country that perform inpatient total hip and knee joint replacements will be required to participate in the latest value-based payment initiative launched by CMS, the Comprehensive Care for Joint Replacement (CJR) model, which becomes effective April 1.
A recent Healthcare Financial Management Association webinar on the CJR noted it as one of the biggest Medicare changes since the implementation of diagnosis-related groups (DRG). Not surprisingly, various impacted parties continue to push for delays in implementation of the model. The CJR model holds participant hospitals financially accountable for the cost and quality of an episode of care and incentivizes increased coordination of care among hospitals, physicians, and postacute care providers.
The assignment of ICD-10 codes on both inpatient and outpatient claims impacts these outcomes by triggering which discharges are included in the program, the actual (or observed) complication rates for these patients, and?equally important but often overlooked?their risk-adjusted expected complication rates. If ever there was an opportunity for clinical documentation improvement (CDI) programs to step up to support their organizations with documentation that impacts both quality and financial outcomes, this is it!
In celebration of our 30th year of delivering you the latest in HIM, we continue to reflect on what HIM was like 30 years ago, examine today's HIM landscape, and look to the future.
