The social determinants of health. We all know about them. Every day most of us face a patient with inadequate housing, inability to afford medications, lack of family support, exposure to abusive environments. And every day you and your team try to work out the best plan for that patient. And the social worker and case manager likely documented these factors in their notes. But did the ICD-10-CM codes for those determinants get placed on the claim? If not, how do you expect researchers to understand why that patient’s length of stay was 2 days longer than the GMLOS for their DRG?  

Yes, the SDoH (not SDOH) codes have been available in ICD-10 since day one but in 2019 less than 2% of Medicare beneficiaries had an SDoH codes on their claim. Why? Most likely because there is no money attached to it. Capture that acute kidney injury and the DRG changes. Code that the patient is homeless and the hospital does not get paid one additional penny. 

But that may be changing soon, and not because CMS is finally listening to me but because the MA plans are now all in on getting those codes captured. Some say it is so they can get a better profile of their enrolled population but the glass half empty me says it is because they are also pushing to have these same codes added to the HCC weighing system and that means they get a higher RAF score and more money from CMS for these patients.  

Either way, it is critical that we start capturing these diagnoses. Check what is happening at your hospital and see how you can help push it along. 

I hope you will read this month’s articles. We have two Observation themed articles- Dr. Caponi follows up on the ACPA Town Hall on Observation Units and the Observation Committee has a tricky case for us. Dr. Banerjee provides a nice respite to all the regulatory talk with a little dreaming. And Dr. Brundage talks about surgical punctures. Ooops, the surgeon did it again and now how are you going to code it? 

And just to see if you are paying attention, in this month’s Observation case, they note that “the hospitalist entered an observation order 5.4.22 at 8:46 AM and notified a different hospitalist to see the patient.” There is a specific Medicare billing rule that applies here. The first two people who email me at signaturedoc@gmail.com with the rule and how it affects this situation will get a gift card from me for an unrevealed value to an unrevealed merchant. Start looking!  

Have you thought about submitting an article for the ACPA newsletter? Email me at signaturedoc@gmail.com for the submission guidelines. I accept articles of any length and on any topic. 

Imagine 

Deb K. Banerjee, MD, FACP, CHCQM, MBA/HCM 

Member, ACPA Government Affairs Committee   

Imagine you were in a perfect world of healthcare delivery. No restrictions for your hospital, physicians, nursing homes, investigations or site of surgery. No cap on home health agencies, or the type of medication to take. No silo between mental and physical health, no restrictions to choose your own physician, or a health aide.  

Imagine as a physician you are free to practice evidence-based medicine. You did not order tests out of fear of being sued. You were able to treat the patient as a whole and not only the kidney, lungs, heart and brain or the abnormal lab tests. Imagine if there was a mutual respect and understanding between patients, physicians, families and the plethora of all the care givers. 

Imagine that there was never a queue for the MRI or an interventional radiology procedure. A test ordered just to identify zebras upfront. Admissions were not done for the convenience of the doctor or the patient but because it was the right thing to do for that patient at that time.  

Imagine if the patient was not “stuck” in the hospital due to lack of insurance coverage or authorization, or that every single patient required to be evaluated by a physical therapist. That safety was paramount and everyone took ownership of their respective duties and performed them with compassion and human kindness. The ER physician did not admit the patient to the hospital because there was no other option to care for the patient. 

Imagine as a physician your bills were paid on time for the services rendered and as an insurance company there was no fraudulent billing. Imagine there was no surprise billing at the back end. Imagine if everyone accepted their own mortality and limited lifespan. That palliative care was not ordered to just not care for the sick patient and not perceived as a “dump” but a thoughtful and compassionate decision made to improve the quality of life of another human.  

So my fellow colleagues, let your imagination run free and work towards parts of it to come to fruition. Maybe with time and effort we shall soon be in a Utopia to let us practice our work in a noble and humble fashion. 

Inspired by John Lennon

Dr. Banerjee is Physician Advisor at Mercy Gilbert Hospital, a part of CommonSpirit Health.

Patient Safety Indicator 15 (PSI 15): Abdominopelvic Accidental Puncture or Laceration Rate

Timothy Brundage, MD, CCDS 

Co-Chair, ACPA CDI Committee

Introduction 

The following case study examines complication coding and quality tracking through PSI 15. This is an interesting case that dissects the complicated relationship between clinical medicine, quality metrics and coding compliance.  

Background 

• The patient is an 84-year-old female who presented to the hospital with abdominal pain associated with nausea and vomiting. She was diagnosed with acute cholecystitis but was deemed high risk for surgery. She underwent a percutaneous cholecystostomy tube by IR followed by a laparoscopic sub-total cholecystectomy. During the surgery, she was noted to have a serosal tear during the extensive lysis of adhesions. The tear was repaired during the surgery.  
• The surgeon noted the following: "During her lysis of adhesions a 3mm serosal tear was created in the mid jejunum. This was carefully indicated using a 3-0 silk suture. It took approximately 90 minutes to satisfactorily clear the anterior abdominal wall in the right upper quadrant so that we could appropriately visualize the liver. This lysis of adhesions was beyond what would be expected in a standard cholecystectomy."​ 

Question 

Is this a PSI 15? Will a complication code be reported?   

• PSI 15 inclusion is designed to capture and report inadvertent cuts, punctures, perforations or lacerations on patients who have undergone an abdominopelvic procedure, in which a second abdominopelvic procedure follows one or more days after an index abdominopelvic procedure. 
• The appropriate coding of a serosal tear in a case like this is complicated, and guidance exists from both Coding Clinic and coding guidelines that are relevant.  

Applicable Guidance 

• From the FY 2022 Coding Guidelines Section 1.B.16​ 
• Documentation of Complications of Care​ 
• Code assignment is based on the provider’s documentation of the relationship between the condition and the care or procedure, unless otherwise instructed by the classification. The guideline extends to any complications of care, regardless of the chapter the code is located in. It is important to note that not all conditions that occur during or following medical care or surgery are classified as complications. There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. Query the provider for clarification, if the complication is not clearly documented.​ 

• Coding Clinic noted the following:​ 
• ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2022 Pages: 50-51​ 
• Reporting for documentation of complication of care (1.B.16.) since a cause-and-effect relationship was documented between the surgery and the serosal tear. This guideline was not intended to mean that the surgeon must specifically document the term "complication." The surgeon's documentation of the serosal tear and the subsequent procedure for repairing the tear is sufficient documentation to report a complication code.  
• Furthermore, the term "complication" does not imply inappropriate/inadequate care, and/or an unplanned outcome. Some issues or conditions occurring as a result of surgery are classified by ICD-10-CM as a complication whether stated or not.  
• Although the surgeon stated that the serosal tear was unavoidable, it does not mean that the tear is not a surgical complication. For example, a serosal tear can range from a small nick requiring no treatment at all, to a major tear requiring removal of a portion of the small intestine.  
• Serosal tears alone do not qualify as reportable diagnoses. If, however, the degree of a serosal tear alters the course of the surgery as supported by the medical record documentation, then the tear should be reported.​ 

• Further Guidance 
• In addition, there is a Coding Clinic from AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2018 Issue 4​. 
• When there is a discrepancy between the conventions in the classification, the guidelines and/or advice published in Coding Clinic, coding professionals should adhere to the following hierarchy: Conventions in the ICD-10-CM and ICD-10-PCS classification take precedence over the Official Guidelines for Coding and Reporting, and both the classification and guidelines take precedence over Coding Clinic advice.​ 

• We noted conflicting guidance between the most recent Coding Clinic and the coding guidelines.  
• The coding guidelines indicate there must be a cause-and-effect relationship AND an indication in the documentation that it is a complication. This conflicts with the most recent guidance from Coding Clinic.  
• As noted in the Coding Clinic guidance from 2018, when there is a discrepancy between Coding Clinic and the coding guidelines, the coding guidelines take precedence. There should be clear documentation that the condition is a complication to warrant coding it as such.  
• In addition, the most recent Coding Clinic guidance notes the serosal tear should alter the course of the surgery as supported by the documentation to be considered a complication. A serosal tear in a complex cholecystectomy that took 90 minutes to clear the abdominal wall is expected and did not alter the course of the surgery. This is corroborated by the surgeon who answered the query as follows: "Serosal tear documented in the operative note was unavoidable due to the density of the adhesions."​ 

Physician Advisor Opinion 

• This will not be tracked as a PSI 15. 
• This serosal tear is not coded using a complication code. 

Dr. Brundage is CEO of the Brundage Group.

Key Considerations in Developing an Observation Unit  

Bartho Caponi, MD 

Member, ACPA Observation Committee

The recent ACPA Observation Committee Town Hall on Observation Units answered many questions about how to set up such a unit, how billing works in an observation unit, and discussed many different models for a unit. I wanted to follow up on what I consider to be a few key points that were not addressed in detail. 

It is important to identify exactly who and/or what cause your Observation Unit serves. Besides questions during the Town Hall, a colleague at another organization reached out to me because a consultant firm reported that his organization’s observation rate was “too high,” and that an observation unit was not only necessary, but the only way to solve the issue. I counseled caution.   

As we have heard before, there is no global benchmark for observation. When you are deciding on an appropriate hospitalization status, you must be guided by the patient-specific situation and the payor-specific policies you are subject to—Medicare’s Two-Midnight Policy, for example, or your state’s Medicaid policies, or managed/commercial payor contracts. Social determinants of health (SDOH) are also important when considering use of observation services—impoverished patients with poor access to care are placed under hospital observation more frequently and are more likely to be re-observed. In my colleague’s case, his organization serves a large proportion of Medicaid-eligible patients, and we can surmise that a higher number of observation stays appear necessary to the clinicians, driven by access to care issues and payor policies. 

Would a dedicated observation unit solve this problem? That also depends on many factors. Patient selection and adequate resourcing of an Observation Unit are critical to its success, and a unit is not automatically a solution to “lots of observation patients”. I identify two specific populations of patients who get hospital observation care. The first group consists of patients with specific, often straightforward presenting conditions where a shorter period of further monitoring, an expedited, protocolized evaluation, or a limited period of targeted therapy is most appropriate. That population of patients benefits from structured, cohorted, properly resourced specialist observation care, and a dedicated observation unit is likely to benefit them (and the organization caring for them). The second group of observation patients consists of those patients who do not meet payor criteria for inpatient status and are not subject to time-based determinations like the 2-Midnight Policy. That second group may be older and more chronically ill than the first group and may require prolonged hospitalization regardless of status or medical acuity. While ostensibly receiving observation services, these patients are less likely to present with straightforward, medically acute issues that would benefit from expedited evaluation and are more likely to need extended stays. Many of us remember the pre-Two Midnight Policy era, when patients with medical needs who required hospital care but did not satisfy a commercial tool’s determination of inpatient status languished in observation for extended periods, never qualifying for rehab benefits but unable to leave a care setting. While Medicare Fee-for-Service beneficiaries are now much better off in that regard, Medicare Advantage, Medicaid/Managed Medicaid, and Commercial patients are not, and those commercial plans, generally administered by for-profit corporations, have a decided financial incentive to push patients towards hospitalized observation status. 

Another issue identified during the Town Hall was management of post-procedure patients in an observation unit. Again, one must consider what purpose the Observation Unit serves when deciding what patients are appropriately placed there. Observation services are provided to hospital outpatients while prospective evaluation and management is ongoing, leading to a medical decision point—discharge, or admission for further care. Extended recovery cares provided to an outpatient surgical patient are not the same as observation services and should neither be considered nor billed as such. Sometimes deciding whether a patient should be observation with a procedure or a surgical patient with extended recovery is not perfectly clear, but if the patient’s stay is expected to require a longer period, or they need therapy assessments or assistance with ambulation, they are not likely observation-unit appropriate. Though both may be “observation” based on payor criteria, there is a world of difference between a healthy 20-year-old Managed Medicaid patient with uncomplicated appendicitis and a 90-year-old Medicare Advantage patient with spinal compression fractures for whom someone is considering vertebroplasty pending response to medical management (a scenario posed during the Town Hall). 

In summary, a dedicated Observation Unit can be a powerful tool to help you get the right care to the right patient at the right time. With proper patient selection, an appropriately resourced Observation Unit can increase efficiency in care delivery and increase throughput, and even effectively increase your capacity. However, not all hospitalized outpatients are suitable for dedicated observation units, and only ongoing national advocacy and pressure on payors hold any hope of positively addressing the second type of observation patients. 

Dr. Caponi is Medical Director for Utilization Review and Case Management at UWHealth in Madison, WI. 

June 2022 Observation Case

This month’s case is tricky. It has a couple of variations for you to consider. You will need to read the whole case carefully to properly answer the question. 

Here is the background: A Medicare FFS patient with schizophrenia and seizure disorder presented to the ER on 5.3.22 at 2200 hours. The ED doctor saw that patient soon after arrival.  Documented noted progressive weakness, fatigue and lethargy. Physical examination noted a patient in moderate distress who was "ill-appearing" with a "listless level of consciousness".  Sodium was 121 and potassium 2.6. 

The ER physician placed an “admit to inpatient” order on behalf of a private physician at 22:34 on 5.3.22.  On 5.4.22 at 7:23 AM the private physician voided the admission order and changed the patient to a hospitalist service.  The hospitalist entered an observation order 5.4.22 at 8:46 AM and notified a different hospitalist to see the patient.  

The H&P stated, “Justification for Hospitalization – Patient is admitted for hyponatremia.  He will require > 2 MN stay for IV fluid hydration, serial lab monitoring and nephrology consultation.  

The patient was discharged on 5/5/22 without an inpatient order after receiving 2 midnights of medically necessary care. The physician advisor was called.  

Now go to the survey, read carefully, and answer the questions: https://www.surveymonkey.com/r/XCZVRCB   

ACPA Letter to CMS about the 2022 OIG Report on MAOs

In reaction to the recent OIG report about Medicare Advantage plans routinely denying Medicare beneficiaries care and hospitals reimbursement, the ACPA Government Affairs Committee - led by Chairs Dr. Carolyn Dutton and Dr. Brian Moore - created the following comment letter to the Centers for Medicare and Medicaid Services (CMS). With a special thanks to Dr. Ronald Hirsch for his authorship. This work is truly a reflection of the manner in which we and our members have a finger on the pulse of these regulatory and quality issues and hopefully, will prove to be an effective catalyst for future discussions with leadership at CMS.  

June 9, 2022 

The Honorable Chiquita Brooks-LaSure  

Administrator  

Centers for Medicare and Medicaid Services  

7500 Security Boulevard  

Baltimore, MD 21244  

Dear Administrator Brooks-LaSure: 

The American College of Physician Advisors is a national organization comprised of more than 1,000 physicians, case management, and utilization review professionals who work every day at hospitals on issues related to medical necessity, level of care, Medicare Advantage (MA) plan coverage, length of stay, and many other issues related to acute and post-acute care. On behalf of our members, I would like to ask the Centers for Medicare and Medicaid Services (CMS) to engage with us to improve the care provided to Medicare patients. 

In the recent report issued by the Office of the Inspector General of the Department of Health and Human Services (OIG), OEI-09-18-00260, the OIG indicated that the MA plans are routinely denying Medicare-covered care and payment, resulting in adverse outcomes for Medicare beneficiaries who have elected to enroll with MA plans. Given the rapidly increasing enrollment numbers in MA plans, we are gravely concerned for the future health of aging Americans.  

The findings that the MA plans are gaming the rules is not a new discovery. In 2021, the OIG issued OEI-03-17-00474, titled, “Some Medicare Advantage Companies Leverage Chart Reviews and Health Risk Assessments to Disproportionately Drive Payments” which found that MA plans routinely added non-substantiated diagnoses to their reporting with the intent to increase the patient’s risk score and therefore obtain higher payment from CMS.  

In 2018, the OIG also reported in OEI-09-16-00410, titled, “Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials” that 75% of MA denials were overturned by the plans themselves on appeal. Interestingly, in the most recent OIG audit, 23% of MA plan denials were reversed by MA plans as soon as the OIG requested the records, even without the OIG determining the appropriateness of the denial. That speaks volumes about how MA plans are systematically denying care without regard for medical necessity or Medicare rules. 

In addition, in early May 2022, CMS made public the database of all Qualified Independent Contractor (QIC) decisions on appeals of part C denials. In several determinations, such as QIC22-435352, the QIC made it clear that MA plans are obligated to follow Medicare rules and pay for care if that care would have been covered by traditional Medicare. 

While one can argue that MA plan overbilling and inappropriate denial of claims for services already provided is “only money,” in many of the cases outlined by the OIG, Medicare beneficiaries were deprived of medically necessary care that they would have received if they had traditional Medicare, including access to Inpatient Rehabilitation Facilities and Long-Term Acute Care Hospital care. The MA plans’ prior authorization processes, especially for time-sensitive care such as post-acute care, are inefficient.  They often extend hospital stays by days to even weeks if the plan decides to downgrade an expedited request or if the plan determines need for additional information. These delays result in potentially harmful outcomes and loss of ability for the patient to achieve a full recovery. 

Likewise, the MA plans’ frequent denial of inpatient admission payment to hospitals, under the guise of “not meeting criteria,” results in a significant loss of compliant revenue to hospitals for payments for IME and DSH, upon which hospitals depend to continue to provide care to their communities. Furthermore, this manipulation results in the payers being able to report falsely overly optimistic data on the care they are providing to their enrollees.  

Although NCQA and URAC standards are proprietary, there is also concern that MA plans are no longer meeting the conditions set to qualify as a deemed provider for CMS. For example, payers often report  “records were not received,” yet the provider has proof of delivery, suggesting that plans are not properly safeguarding patient information.  MA plans’ lack of consistency with  utilization review criteria requirements and dismissal of Peer-to-Peer obligations are other areas of concern.  We believe it would be beneficial for CMS to specifically clarify MA plan obligations in regard to Peer-to-Peer disccussions, overall. 

The leaders of the American College of Physician Advisors would be happy to meet members of your staff or you to discuss further the negative effect that current MA practices  can have on Medicare beneficiaries and hospital operations. We hope that such discussions might be of value in guiding clarification of current CMS rules and policy as well as future rulemaking.  We cannot understate the importance of the issue of current MA denial practices as they result in patient care and utilization issues that we, as physician advisors,  face on a daily basis. 

Thank you for your time and consideration. 

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV

(Pronouns: She/Her)

President, ACPA

June 2022

Equality. Diversity. Equity. Inclusion. Quality. This string of words might pique some of your interests but some of you might be sighing in exasperation. We at the American College of Physician Advisors have discussed on a regular basis the profound variability and diversity of our members’ roles at their hospitals and health systems and our members themselves, and last year I made the decision to broaden the conversation to include Pride Month.   

Otherwise known as June – as one individual wittily described on LinkedIn – I see this time as an annual opportunity to expose folks to concepts and challenges they might not otherwise consider regarding the LGBTQ+ community. Shining a light on just one small idea or connection can lead to a whole year of illumination. Last year, about a dozen people took the time to reach out and express their opinion about our brand-new ACPA Pride logo. One of the two which were not supportive, included how ACPA should stay out of social justice movements which are not related to the foundational clinical and regulatory focus of our organization and also, why was Pride featured in June but Mental Health or Stroke Awareness were not highlighted in May? 

Another asked why a group dedicated to advancing quality and efficiency in healthcare would feel it has anything to add to the discussion and likened it to a similar “not in our lane” topic as that of gun rights. In the member’s opinion, “ACPA shouldn’t endorse Pride Month any more than it should the NRA” [National Rifle Association]. Which actually brings up a good point…what is “our lane?” Do we, as a college, formulate a position on the fact that as of June 6th there have been 247 mass shootings* in the United States over the course of 2022? How about on the war in Ukraine? Or, the treatment of Uyghurs in China? Or state legislation limiting abortion? Our Board of Directors is in the process of considering this and I welcome your thoughts, too. 

The question about why we recognize Pride Month and not other months – like Black History Month in February – is another good one. My honest answer is, “baby steps.” But seriously, the baseline of what we are trying to foster is one of inclusion. So, for this topic, as well, I welcome all of our members’ opinions, thoughts, and suggestions on where we head in the future. 

Finally, mixed in among the dozens of likes and reshares and comments supporting our Pride logo last year, was a request to go further and feature articles or blog posts from members who are part of the LGBTQ+ community, or which highlight challenges faced by our patients within the LGBTQ+ community. Absolutely! Yes! Please send them in! There is no need to segregate such articles to a single month…please offer your expertise and experience by submitting articles for this newsletter YEAR-ROUND to our editor, Dr. Ronald Hirsch, at signaturedoc@gmail.com . Have thoughts you’d like to share which are more personal or reflective and less professional? The ACPA Community Blog is waiting for you! Send as many words as you wish to ACPAdvisorsSocialMedia@gmail.com for consideration. We are so looking forward to hearing from you! Happy Pride, everyone.   

#ProtectTransKids 

P.S. – Yes, we are working on those ACPA Pride logo lapel pins…perhaps you’ll see them at NPAC 2023 in Orlando next year??? 

* The definition of a “mass shooting” via the Gun Violence Archive (www.gunviolencearchive.org) is an incident involving a firearm where a minimum of four victims are shot, either injured or killed, not including the shooter.