Clinical Documentation Improvement as a Response to Federal Recoupment Initiatives

1. Clinical DocumentationImprovement as a Response to Federal Recoupment Initiatives Barry S. Herrin, JD, CHPS, FACHE Smith Moore Leatherwood LLP Atlanta GA GHA Compliance Officers’ Roundtable – March 2013

2. Overview • What We Will NOT Cover • How to Respond to a RAC Audit • The “Alphabet Soup” of New Program Auditors

3. Overview • What We WILL Cover • Compliance Reasons that Correct Clinical Documentation is Important • Action Items for Improving Clinical Documentation and Compliance • The Ten Ironclad Rules of Medicare

4. Attitudes About Health Care Delivery Are Changing…

5. …But Attitudes About Compliance Aren’t

6. “Low Hanging Fruit” • RAC audits reveal that coding errors and lack of sufficient clinical documentation to support medical necessity are the highest areas of recoupment activity • Renal and urinary tract disorders • Surgical cardiovascular procedures • Acute inpatient admission neurological disorders • Outpatient services billed as inpatient

7. “Low Hanging Fruit” Medicare improper payment rate (not adjusted for appeals in RAC audits) is 8.6% Medicaid improper payment rate is 8.1% However, about 75% of this (or 6+%) can be recovered by the provider Nevertheless, if your facility is 60% government beneficiary revenue, could you afford to give back 1.25% of your margin every year?

8. “Low Hanging Fruit” • Traditional consultant-driven internal “projects” to improve “revenue cycle management” focus on tightly defined “silos” of activity • CFOs want to see ROI for consulting fees expended • Do not address systemic issues of clinical documentation or decision-making • Do not permanently change institutional behavior

9. PPACA is a Game Changer Section 6402 of PPACA (42 USC Section 1320a-7k(d)) creates an affirmative obligation on a provider to return an “overpayment” within 60 days of its “identification”

10. PPACA is a Game Changer • No clarification of what constitutes “identification” • Does the 60 days run from a suspicion of an overpayment? • Does the 60 days run from the precise determination of the overpayment amount? • Can you notify of the circumstances of the overpayment and send payment later?

11. PPACA is a Game Changer • The False Claims Act (31 U.S.C. Section 3729 et seq.) • $5,500 to $11,000 penalty PER False Claim, PLUS • 3x the amount claimed, PLUS • Attorneys’ Fees, if it is a qui tam suit

12. PPACA is a Game Changer • Liability if : • “Knowingly” submitted, or caused to be submitted a false claim for payment or approval by the Government; OR • “Knowingly” and improperly avoids or decreases an “obligation” to pay or transmit money to the Government • Knowingly = Reckless Disregard • Obligation = An established duty . . . arising from the retention of an overpayment • Standard of Proof = Preponderance of the Evidence

13. Medicare Conditions of Participation • 42 CFR Section 482.30 • Hospital must have in effect a utilization review (UR) plan that reviews services furnished to Medicare/Medicaid beneficiaries by hospital AND medical staff • Hospital must have UR committee composed of practitioners with at least 2 physician members • UR committee member may not be involved in a review if the member was professionally involved in the care under review • UR plan must review medical necessity of admission, length of stay, and services furnished

14. Medicare Conditions of Participation • 42 CFR Section 482.30 • UR admission review may be pre-admission, post-admission, or concurrent • UR length of stay and service reviews may be limited to outliers • This review is NOT THE SAME as the quality assessment and performance improvement reviews required under 42 CFR Section 482.21

15. Medicare Conditions of Participation • CMS issued Transmittal 299 (Change Request 3444) on September 10, 2004, implementing new section 50.3 in Chapter 1 of the Medicare Claims Processing Manual • Describes when and how a hospital may change a patient’s status from inpatient to outpatient • “The change in patient status from inpatient to outpatient is made prior to discharge or release, while the beneficiary is still a patient of the hospital;” • Establishes the necessity for Admission Review to be completed before patient discharge

16. Medicare Conditions of Participation • Section 1879(a) of the Social Security Act (Limitation on Liability) provides where: “(1) a determination is made that… payment may not be made under part A or part B of this title for any expenses incurred for items or services furnished an individual by a provider of services …, and (2) both such individual and such provider of services…did not know, and could not reasonably have been expected to know, that payment would not be made for such items or services under such part A or part B, then to the extent permitted by this title, payment shall…be made…as though the coverage denial…had not occurred.”

17. Medicare Conditions of Participation • 42 CFR §411.406(e) provides “that a provider that furnishes services that are not reasonable and necessary is considered to have known that the services were not covered if it is clear that the provider could have been expected to have known that the services were excluded from coverage on the basis of notification of PRO screening criteria specific to the condition of the beneficiary for whom the furnished services are at issue or its knowledge of what are considered acceptable standards of practice by the local medical community.” • The only way the provider could not be expected to know that payment for services would be denied was if it conducted an Admission Review process to certify medical necessity for ALL beneficiaries.

18. What We’re Seeing Today • UR absorbed into case management • Confusing appropriateness of classification with approval for stay by commercial payors • Standards are NOT the same • Preadmission reviews missing

19. What We’re Seeing Today • Workarounds for physician satisfaction • No monitoring of recidivist admitters • Preauthorization for physician charges now permitted, but no FTEs added for workload

20. Present on Admission Indicators • Incomplete physician H&Ps lead to queries by • Nursing staff – hardly ever • Coders – routinely • Incomplete nursing assessments lead to queries by • Physicians – never • Coders – routinely

21. Present on Admission Indicators • Incomplete documentation of catheter placement/removal leads to queries by • Clinical staff – hardly ever • Coders – routinely if UTI present in the chart

22. What We’re Seeing Today • Problems with the Solutions • Leading questions by coders • Coders adding clinical information to medical records • Joint Commission Standard IM.6.10 Problem? • Nonlicensed personnel making clinical entries in the chart?

23. What We’re Seeing Today • Problems with the Solutions • Coders assuming POA absent physician lack of concurrence • Can’t assume like this with physician attestation being the key to record completion and reimbursement • Coders assuming that conflicting documentation means POA rather than the reverse

24. What We’re Seeing Today • Problems with the Solutions • Physicians know that the only reason these questions are being asked is to increase hospital revenues • Physicians therefore want to know “What’s in it for me?”

25. POA Queries: Check the Box

26. POA: Leading Question Notice:  This query is an attempt to gather more information for accurate and specific coding.  No particular response is expected or desired.  We may add an addendum to your discharge summary depending on your response to this query.  You should review this addendum carefully before signing the discharge summary.  If there is a discrepancy, please contact the coding supervisor. Dr ________________: Patient with acute viral gastroenteritis was treated with fluids, dehydration documented on admission orders. Was the patient treated for dehydration?  Sincerely, Coding Department

27. POA: Clinical Documentation by Coders Dr. _______________, In review of the record of your patient listed above, it was documented in the Progress Notes three days post admission that the patient had a catheter-associated UTI. There was not adequate information to determine if this was POA. I marked it YES for POA – if you disagree please document in the Progress Notes and sign and date.

28. Action Items • Focus on “Revenue Integrity” • Means not increases in billing, but keeping more of what you do bill • Right coding may mean lower initial reimbursement but more certainty in your revenue picture • Who wants to create an 8% reserve for potential recoupment?

29. Action Items • Focus on “Revenue Integrity” • Create a team of internal experts • HIM (supervising coding) • Case Management • Nursing • Medical Staff • Billing • Corporate Compliance

30. Action Items • Focus on “Revenue Integrity” • Review billing and coding for high revenue and high volume procedures more frequently than annually • Conduct regular audits of clinical documentation, billing and coding – use the RAC and other auditor work plans as a guide – “shadow audits”

31. Action Items • Training, Training, Training • Teach physicians the basics of coding • Not so physicians can code, but so they understand the impact of clinical documentation on coding

32. Action Items • Training, Training, Training • Teach coders about clinical documentation processes • They can ask better questions if records are incomplete • They can interpret records better if the clinical context is understood

33. Action Items • Get clinical documentation specialists involved in reviewing charts for content on the floor during episodes of care • Their intervention can train physicians to provide better documentation • Their intervention can prevent coders from asking clinical questions to complete the chart

34. Why the Focus on Coding? • At its root, coding is an HIM function, not a business office function • If properly implemented, coding serves as a summary of diagnoses and procedures • Coding is not simply the pathway to receive revenue from patient treatment • If that were so, there would be more than a 10% change in reimbursement from ICD-9 vs. ICD-10

35. The Ten Ironclad Rules of Medicare Courtesy of Larry Oday, Federal Affairs Network Meeting, June 7, 2000 • Just because you have a code doesn't mean it's covered. • Just because it's covered doesn't mean you can bill for it. • Just because you can bill for it doesn't mean you'll get paid.

36. The Ten Ironclad Rules of Medicare Just because you've been paid doesn't mean you can keep the money. Just because you've been paid once doesn't mean you'll get paid again. Just because you've been paid in one state doesn't mean you'll get paid in another state.

37. The Ten Ironclad Rules of Medicare You'll never know all the rules. Not knowing the rules can get you in jail. There's always someone who doesn't get the message. There's always someone who gets the message and ignores it.

38. Contact Information Barry S. Herrin, JD, CHPS, FACHE 877-404-7466 x1027 barry.herrin@smithmoorelaw.com www.legalhimformation.com www.facebook.com/legalhimformation