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
Top Related