3/7/2012 Hospitalists with a Capital H How to Keep them and Your Facility out of HOT WATER Sheryl Spohn, RHIA, CHC AVP Compliance Kim Heibel CPC Manager WellStar Health System Professional Services Coding Assurance Objectives • Improving ED Metrics with Compliant Admissions • Utilizing Hospitalists on the Observation Unit • Utilizing Midlevels Effectively—Risks & Benefits • Educating on Clinical Documentation Improvement • Informing on Post Discharge Reviews • Communicating effectively 2012 Compliance Institute 1 3/7/2012 Appropriate Use of Observation • Outpatient care, although rendered in a hospital bed • Intended for short‐term monitoring & decision making • Documentation is critical. – Initial order, severity of illness/intensity of service 2012 Compliance Institute Defining Observation Services • Observation care begins at the time documented by the observation unit's admitting nurse. • Observation care ends at the time documented on the physician's discharge order or when the appropriate person signs off on the physician's discharge order. • Patients can be admitted to an inpatient unit from the observation unit. In such cases, payment for the observation services will fall under the DRG payment. • Patients cannot be placed in the observation unit following inpatient status. 2012 Compliance Institute 2 3/7/2012 Further Defining Observation Services • Patients must be under the care of a physician while receiving observation care. • Emergency department visits must be reported in conjunction with the bill for observation services. • Patients directly admitted to the observation unit, a physician must be present to initiate observation services. 2012 Compliance Institute CDU‐Benefits • Clinical Decision Making Unit – A bed in an area of the hospital where a patient may be evaluated or treated for up to 24 hours to determine the need for admission • CDUs are one model of care designed to strengthen the gatekeeper role of Emergency Departments • CDU Case Study 2012 Compliance Institute 3 3/7/2012 CDU‐Responsibility • Who “owns” the CDU? – ED versus Hospitalist? • Fiscal Responsibility – Understanding the differences in admission types – Understanding the difference in reimbursement for top diagnoses in the unit • Full Potential • Improvements realized – ED Door‐to‐Floor – Decrease in Inpatient 1‐day stays – Decreased Inpatient readmissions 2012 Compliance Institute Differences in Documentation Requirements & Reimbursement • Documentation requirements with associated visit codes – Observation Admission • H&P—Initial Outpatient Visit • Progress Note‐‐Subsequent visit • Observation Discharge – Codes used for observation/outpatient physician visits dependant upon “attending” physician – Inpatient Admission • H&P—Initial Inpatient Visit • Progress Note‐‐Subsequent visit • Discharge Summary/Discharge visit 2012 Compliance Institute 4 3/7/2012 Advance Practitioners Scope • In states where NPs are supervised by physicians, hospital patients who require a diagnosis must be seen daily by a physician. If a hospitalist NP is the provider designated to see a patient, an MD often sees the patient briefly and writes a short note or adds a comment. 2012 Compliance Institute Advance Practitioners Scope • The extent of involvement for the advance practitioner will depend on the degree of complexity and experience of the practitioner. Duties may include: – Admitting/Discharging patients; – Managing the care of patients with simple to complex acute health problems – Managing patients on an observation/CUD unit. 2012 Compliance Institute 5 3/7/2012 Reimbursement for Advance Practitioner Services Risks vs. Benefits • Individual services – 85% of the physician fee schedule • Shared services – 100% of the physician fee schedule • Documentation challenges – Documentation of a face‐to‐face visit – Pitfalls 2012 Compliance Institute Looking at a Hosptialist Mixed Model • Employment • Reporting • Metrics • Compliance responsibility • Continued Opportunities for Improvement 2012 Compliance Institute 6 3/7/2012 Documentation / Coding / Billing Compliance • Evaluation of current auditing/monitoring methodology • Electronic Health Record (EHR) and coding nuances • Accuracy rate (what is “good enough”) • Sample Size/Selection Process • Result: Point based model • True Risk Potential 2012 Compliance Institute The Case for Clinical Documentation Improvement • Defining signs & symptoms into “probable” and “possible” diagnoses • Consistent coverage – Consistent documentation • Completion of Non‐leading Query – i.e. Is this type of congestive heart failure acute or chronic, systolic or diastolic • Linking the stay in the discharge summary 2012 Compliance Institute 7 3/7/2012 Coding and Reimbursement • DRG 143 ‐ Chest pain – Inpatient Services Place of service: Inpatient hospital Reimbursement: Approximately $1,300 Length of stay: Open • APC 0339 ‐ Observation services Place of service: Observation unit Reimbursement: About $425 Duration of service: Eight hours to 48 hours. CMS reimburses for the first 24 hours of service. • Patient Out‐of‐Pocket Effects 2012 Compliance Institute The Campaign for CDIP • Obtain buy‐in! If not fully committed to CDIP may become low priority • Provide reports regarding areas of documentation needing improvement • Present at hospitalist staff meetings. • Consider morning huddles • Summarize improved reimbursement • Should not be the sole focus in communicating with the physicians 2012 Compliance Institute 8 3/7/2012 Things to Remember • Hospitalist time constraints • Must balance different coding systems— the ICD‐9‐CM/ICD‐10, as well as CPT and Evaluation and Management coding for their own billing • Buy‐in occurs when metrics are built into Hospitalist metrics 2012 Compliance Institute Measure the Success Internal Medicine SOI Level Trends 50.00% 45.00% SOI 1 40.00% 35.00% SOI 2 30.00% 25.00% SOI 3 20.00% 15.00% SOI 4 10.00% 5.00% 0.00% 2009 Q2 2009 Q3 2009 Q4 2010 Q1 2010 Q2 2010 Q3 2010 Q4 2011 Q1 2011 Q2 2011 Q3 2012 Compliance Institute 9 3/7/2012 Measure the Success Internal Medicine ROM Level Trends 0.45 0.4 ROM 1 0.35 0.3 ROM 2 0.25 0.2 ROM 3 0.15 0.1 ROM 4 0.05 0 2009 Q2 2009 Q3 2009 Q4 2010 Q1 2010 Q2 2010 Q3 2010 Q4 2011 Q1 2011 Q2 2011 Q3 2012 Compliance Institute Measure the Success • Defining what to measure – Case Mix Index – CC/MCC Capture Rate – Length of Stay – Query rate – Physician response rate • Provide feedback and engage the physicians on improving the program effectiveness 2012 Compliance Institute 10 3/7/2012 External Regulatory Focus • OIG Workplan Item – Short stay inpatients – Long observation stays • RAC Reviews – 1‐day stay inpatients—CP, Syncope, Back Pain, Esophagitis • MAC Prepayment Reviews – 1‐day stay inpatients—CP, Syncope 2012 Compliance Institute External Regulatory Focus‐‐RACs • The RACs are targeting: – Incorrect coding excisional debridement; – Confusion between septicemia/urosepsis; – Respiratory failure claims with incorrect sequencing of principal diagnosis, e.g., respiratory failure vs. sepsis; – Severity of patient's anemia failing to meet medical necessity for blood transfusion – Inadequate intensivist documentation for level of care provided in the ICU. 2012 Compliance Institute 11 3/7/2012 The Hospitalist Role • Hospitalist documentation is essential in appropriate coding, DRG assignment, supporting medical necessity and defining severity/quality indexes • Defense from costly overpayments • Documentation of patient diagnoses, not just symptoms (e.g., syncope suspected due to cardiac arrhythmia, chest pain suspected to be angina). • Post‐discharge Planning—CMS requiring documentation certifying Home Health, DME, etc. 2012 Compliance Institute The Hospitalist Types & External Drivers NP Hospitalists Observationalists OB Hospitalists (OB triage area) Neuro Hospitalists (Trauma Program) Medicare priorities and financial incentives of hospitals and physicians • Acute Care Episode (ACE) Demonstration Project (hospital‐physician bundled payments) • Accountable Care Organizations (ACOs) • • • • • 2012 Compliance Institute 12 3/7/2012 Effective Communication • • • • E&M Cards Department Meetings Lunch and Learns Physician Portal 2012 Compliance Institute E&M Template Review See Handout 2012 Compliance Institute 13 3/7/2012 2012 Compliance Institute Recap • Improving ED Metrics with Compliant Admissions • Utilizing Hospitalists on the Observation Unit • Utilizing Midlevels Effectively—Risks & Benefits • Educating on Clinical Documentation Improvement • Informing on Post Discharge Reviews • Communicating effectively 2012 Compliance Institute 14 3/7/2012 Questions Thank you 15