HIM Briefings

Those who regularly attend the annual AHIMA Convention and Exhibit no doubt have seen the exceptional quilt created each year by AHIMA member Katy Sheehy, MPA, RHIA, and sponsored by the Dames of Distinction to be bid at auction. The quilt is auctioned in support of the Linda Culp Memorial Scholarship fund, which was established in memory of the late Linda Culp, a former HIM professional, hospital chief executive officer, and AHIMA member. If you have seen the quilt, you have probably asked yourself, "Who are these people?"

The healthcare industry is focused on the triple aim: reducing healthcare costs, improving patient experience, and improving the health outcomes of populations. Healthcare organizations will no longer be paid based on the volume of services provided but rather on the value of care delivery. 

The following case study examples illustrate various aspects of utilization review and patient status.

The new modifier -PO (services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments [PBD]) and the alternative payment provisions under the Bipartisan Budget Act Section 603 are both related to off-campus PBDs but define "off-campus PBD" slightly differently.

CMS recently published FAQs on modifier -PO, giving providers valuable guidance on how the modifier will apply to hospital services. Last week, CMS also indicated that it will wait until the CY 2017 OPPS proposed rule provides further guidance on Section 603. Nevertheless, some of the guidance related to modifier -PO seems to indicate that CMS is trying to bring the requirements in line with off-campus PBDs covered by Section 603, rather than simply relying on preexisting regulatory definitions of off-campus departments.

Modifier -PO was adopted January 1, 2015, with a required use date of January 1, 2016. It was originally adopted as a modifier to track statistics and information related to hospitals' off-campus PBDs. The modifier nominally applies to all items and services provided in an off-campus PBD, according to the Medicare Claims Processing Manual, but there are some significant exceptions.

The recent FAQs make it clear that modifier -PO does not apply to non-OPPS services. These services include therapy and a few other services still paid on other fee schedules, noted with a status indicator A under the OPPS, as well as dialysis, which is paid under the ESRD PPS. This guidance would dovetail with Section 603, which arguably only applies to services that would otherwise be payable under OPPS, exempting them from OPPS and providing alternative payment. Additionally, because critical access hospital (CAH) services are not paid under the OPPS, the modifier will also not apply to any services at PBDs of a CAH.

Similarly, the FAQs and other guidance indicate modifier -PO is not used for off-campus emergency departments. This guidance is in line with Section 603, which excludes the off-campus alternative payment methodology from items and services furnished at dedicated emergency departments.

Q: The emergency department (ED) at the hospital where I work often becomes so busy that we do not have enough rooms for all of our patients. This occurred last weekend, which meant that several patients were brought into the ED on stretchers to be evaluated but could not be placed in a room. I witnessed a nurse perform a physical/abdominal examination on a patient who was on a stretcher in the ED hallway and discuss medical history and current treatment options with the patient in this open space where plenty of patients and staff members could see/hear the encounter. Is this a HIPAA violation?

A: What you are describing is an incidental disclosure, not necessarily a HIPAA violation. Organizations must take steps to limit incidental disclosures and mitigate the risks to the patient’s privacy and the security of information. In the case you describe, for instance, could a screen have been erected to protect the patient’s privacy even if circumstances led to no choice but to perform the exam in the hallway? Could a white noise machine have been brought over to reduce the chance of being overheard? Could the gurney have been moved to a private area (or even a slightly more private one) when the exam had to take place? Could the exam have been postponed until a more private space was available, or was it necessary to do it right then? These are the questions staff should ask themselves in these situations. 

Editor's note: Simons is the director of health information and privacy officer of Maine General Medical Center in Augusta. She is also an HIMB advisory board member. This information does not constitute legal advice. Consult legal counsel for answers to specific privacy and security questions. Send your questions related to HIPAA compliance to Editor Jaclyn Fitzgerald at jfitzgerald@hcpro.com.

Accurate patient matching within the EMR should not be a concern limited to HIM professionals. Ensuring that medical record data is correct and complete and that duplicate records are not created is key to various healthcare initiatives, including population health management, analytics, information governance, patient-centric care, health information exchanges, and finance. It all starts with the patient's record. Reducing the number of duplicate records at a hospital and being able to effectively match records is critical to ensuring that these healthcare initiatives are successful, says Lesley Kadlec, MA, RHIA, CHDA, director of HIM practice excellence for AHIMA.

"Patient matching is really the underpinning of all the strategic initiatives that are going on in healthcare," Kadlec says. "You have to have accurate patient information to have accurate patient care. Ensuring that you have the right patient and the right information at the right time is really what drives the physicians' and clinicians' ability to actually provide that patient with care."

More than half of HIM professionals work with mitigating duplicate patient records, and of that group, 72% do so on a weekly basis, according to a recent survey of AHIMA members. Unfortunately, less than half of all respondents have quality assurance in place for their registration or post-registration processes. (A summary of the data is available in the Journal of AHIMA.)

"The challenge is having the staff to be able to dedicate to making the corrections, doing the matching, and ensuring that everything is getting put back together," Kadlec says.

Patient matching and duplicate records are a major issue right now because hospitals are using so many different systems and there is often a lack of information governance across those systems, says Megan Munns, RHIA, identity manager at Just Associates, Inc., based in Denver.

Over the past couple months, HIMB has had audits on the brain. We covered the progress of the 2-midnight audits and walked you through the pass-fail meaningful use audits in detail. Now it's time to get a bird's-eye view of the 2016 audit landscape to ensure you're prepared for whatever comes your way this year.

Recovery Auditors

With 2-midnight rule audits shifting to the BFCC-QIOs, Crump predicts the Recovery Auditors will likely spend 2016 focusing on diagnosis-related group (DRG) audits and medical necessity reviews. These audits will likely focus on reviewing medical necessity for procedures, tests, and treatments in relation to what the Payment Integrity Manual states should be captured in the health information. Records that do not capture information related to local and national coverage determinations will likely be the low-hanging fruit if the Recovery Auditors are approved to focus on these reviews, says Dawn Crump, MA, SSBB, CHC, vice president of audit management solutions for CIOX Health in Alpharetta, Georgia.

To prepare for the Recovery Auditors, HIM professionals should focus on analyzing the risk at their facility. In addition, they should ensure there is a continuous feedback loop not only within the department but outside of it as well. Coding, compliance, and medical staff should be in the loop too, Crump says. Solid communication and education can go a long way in ensuring everyone is well prepared for an audit.

Establishing good quality checks, especially with EMRs, can also help a hospital bolster its audit preparation. HIM should be involved in checking that the information in the record tells the patient's complete story, Crump says.

"Records are evolving and EMRs are evolving, so I think status quo needs to be checked on a regular basis," she says.

For example, EMRs don't always capture all of the needed information. As local and national coverage determinations change for high-risk procedures and admissions, HIM and coding should be involved in the process of ensuring the EMR captures the latest changes and meets the new requirements; this way, the hospital will be ready to present information in the event of an audit, Crump says.

In our last article, I provided an overview of the Comprehensive Care for Joint Replacement (CJR) model, described in a recent Healthcare Financial Management Association webinar as one of the biggest Medicare changes since the implementation of DRGs.

Under the CJR, which began April 1, acute care hospitals in selected geographic areas assume quality and payment accountability for retrospectively calculated bundled payments for lower extremity joint replacement (LEJR) episodes.

The impact of CDI on CJR patient selection

A Medicare fee-for-service beneficiary is included in the CJR model when a claim is submitted for an inpatient encounter assigned MS-DRGs 469 or 470. These surgical MS-DRGs include total hip and knee replacements, ankle arthroplasties, partial hip replacements, lower leg, ankle and thigh reattachments, and hip resurfacing procedures. In the CJR final rule, CMS noted that the majority of the procedures in these MS-DRGs are total and partial hip replacements, and total knee replacements (see Figure 1 on p. 5).

The key CDI vulnerability associated with CJR patient selection is inaccurate MS-DRG assignment. The included MS-DRGs are replacement—not revision—procedures. Joint revision procedures are more complex, have higher costs, and are therefore assigned to different MS-DRGs (466-468, revision of hip or knee replacement with or without MCC).

If the coder omits assignment of the ICD-10-PCS code for the removal of the original device and only codes the replacement procedure, a patient with a revision—who should be assigned to MS-DRGs 466-468—will instead be misclassified into MS-DRGs 469 or 470, and will skew CJR clinical and cost outcomes.