Publication MO-13-06-CR December 2013This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy

Physician Reviewer Training:Utilization Appeals and HW-DRG

Reviews

Sharon Hoffarth, MD, MPH, FACPM

Chief Medical Director

Objectives

• Understand the distinctions between observation and

inpatient admissions

• Understand the beneficiary discharge appeals process

• Understand the basics of higher-weighted DRG (HW-DRG)

validation reviews

Publication MO-13-06-CR December 2013This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy

Hospital Admissions:Inpatient vs. Observation Status

The Fundamental Hospital Admission Decision: Inpatient vs. Observation

• Treatment longer than 24 hours expected

• Outpatient treatment has not been effective

• Inpatient-only procedure necessary

• Continuous monitoring necessary

• Points of Entry for Outpatient Observation

Inpatient Admission Considerations

• Severity of presenting signs and symptoms

• Predictability of the clinical course

• Existence of co-morbid conditions which may

negatively impact course

• Potential for complications

• Services required upon presentation

• Diagnostic procedures available

Inpatient Admission Documentation

• The physician’s admission order should:

-- specify inpatient vs. observation status

-- have the date and time

• Clinical documentation (e.g., in initial note or H&P)

is present to support medical necessity for inpatient

admission

• No “back-dating” is allowed

What are Observation Services?

• Services furnished by a hospital including:

− use of bed

− periodic monitoring by staff

− requires physician order

• Reasonable and necessary

− evaluate outpatient condition

− determine inpatient admission need

Why Observation Services?

• Determines need for inpatient admission

• Rapid response to treatment is expected

• Patient has unusually prolonged recovery period

following an OP procedure

Observation Documentation

• Observation admission order with date and time

• Assessment of patient risk to determine benefit from

observation care

• Timed and signed admission notes, progress notes

and discharge notes

Observation Services Not Reasonable When…

• Services not reasonable or necessary for

diagnosis or treatment of patient

• Services provided for convenience of patient,

family or physician

• Services covered under Part A

• Services that are part of another Part B service

• Standing orders for observation after OP

surgery

• Custodial care

Observation or Inpatient?

Hospitalization required?

No acute hospital care

No

Yes

24 hours adequate toevaluate, treat or

respond?

Yes

Observation

No Inpatient

• Premature discharge (PD)

− Subsequent re-admit to same hospital

• Re-admit

− Care not provided during 1st stay

• Inappropriate transfer

− PPS to PPS-exempt

− PPS-exempt to PPS

Circumvention of PPS (Prospective Payment System)

Procedure review

• Reasonable?

• Medically necessary?

− If unnecessary, then quality concern?

• Quality appropriate?

Appeals Review

• Two types

− Retrospective

− Concurrent

• Protection for beneficiary

− Determine whether care is covered or not

Retrospective Appeals Review

• Document medical basis for agreement or

disagreement

• Hospital should NOT issue if……

− Patient requires initial or continued care

− Patient requires SNF and no SNF bed available

Concurrent Appeals Review

• Settings for concurrent discharge appeals include:

hospital, skilled care, home health, hospice, outpatient

rehab

• 7 days/wk + holidays

• Hospital overnights or faxes record

• NPR contacts patient/family and hospital

• Immediate PR review (phone)

− Contact Attending Physician

• Voluntary PR schedule for interested PRs to cover

weekends and holidays

Concurrent Appeals Review Continued

• Physician review decision

• Non-Physician Reviewer at Primaris follows up with

hospital, attending physician and patient

− Immediate notification of decision by telephone

− Additional notification is also sent in writing

Reconsideration Reviews

• Second level of review (reconsideration) can be requested

by the beneficiary when the QIO has upheld the discharge

by the provider

• PR must not have been involved previously

• PR must be board certified or board eligible

Important Message from Medicare (IMM)

• Important Message from Medicare (IMM)

− Explains pt’s rights under Medicare

− Expedited QIO review when hospital or MA plan

determines acute care no longer necessary

• Given to pt TWICE during stay

− Upon admission (or w/in 48h of admit)

− No fewer than 48h prior to D/C

• Instructs how patient can contact QIO if disagrees with

discharge

Discharge Appeal -- Hospital and Concurrent: QIO Internal Process

• Accepts requests for review 24/7

• Provider must supply the medical record documentation

as requested by the QIO

• QIO Non-Physician Reviewer who is working the case

solicits additional input from

− The Patient or her representative

− Provider

− Medicare Advantage plan as applicable

− Attending physician (depending on the Physician

Reviewer’s preference)

Discharge Appeal -- Hospital and Concurrent: QIO Internal Process (continued)

• QIO must:

− Verify appropriateness and comprehensiveness of

Discharge Planning

− Complete review within 24 hours

− Notify beneficiary or representative immediately upon

completion of review

All Discharge Appeals Reviews –Physician Reviewer Responsibilities

• Based upon medical necessity of continued acute care

• At the time of facility intent to discharge and issuance of

the notice of non-coverage, did patient still require acute

care services?

− If NOT, then agree with the discharge

− If acute care is still required, disagree with the discharge

• Most importantly, the PR’s review must document the

medical basis for agreement or disagreement with the

discharge with a detailed rationale to support his

decision

All Discharge Appeals Reviews –Physician Reviewer Responsibilities (continued)

• The Physician Reviewer provides his decision to the

Primaris NPR

− Verbal or fax (your choice)

− No e-mail

− E-mail is not secure

• NPR will send

− Copy of decision for signature

− Invoice voucher for reimbursement

Concurrent Discharge Appeals Decisions:-- Financial Liability for the Patient

• QIO agrees with the provider’s decision to discharge the

patient

− Patient is financially liable if he chooses to stay

− Patient can request a Reconsideration

• QIO disagrees with the planned discharge

− Patient is not financially liable and can stay in acute care

− If QIO reverses the initial appeals decision (agreeing with

the discharge) the patient is not financially liable for

medical costs incurred during the reconsideration

Publication MO-13-06-CR December 2013This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy

Higher-Weighted Diagnosis Related Group Reviews (HW-DRG)

• Source of information:

-- The provider’s claim for services provided to a

beneficiary

-- The Medical Record

• Appropriate designation of the Principal Diagnosis

• Addition/Deletion of Secondary Diagnoses

• Confirmation of Procedures

Principles of HW-DRG Review

• Principal Diagnosis: “The condition that, after

study, is determined to have occasioned the

admission of the patient to the hospital for

care.”

• Secondary Diagnosis/Additional conditions

affecting patient care

− Clinical evaluation

− Diagnostic procedures

− Increased nursing care/monitoring

− Therapeutic Tx

− Extended LOS

HW-DRG Reviews – Medicare Definitions of Principal and Secondary Diagnoses

• Examine all available medical record information

− H&P

− Physician notes

− Hospital course

− Evaluation (lab, X-rays, etc.)

− Treatment

− Consultations

− Discharge summary

• Evaluate the information from a Clinical Perspective

− NOT expected to code

HW-DRG Reviews – Physician Reviewer’s Responsibilities

HW-DRG Reviews – Common Coding Guidelines

• NPR will ask specific question

• Guidelines assist in PR determination

• Use applicable clinical judgment

For questions and additional information, call Rita Ketterlin at 1-800-735-6776, ext. 153