In this Update:

Editor's Note

Ronald Hirsch, MD, FACP

Editor, ACPA Update

Member, ACPA Advisory Board

Let me start with a belated Happy Birthday to the Two Midnight Rule. On October 1^st, it turned 10 years old. I don’t know how many of you were around back then to follow the saga but like any rule, CMS first released the proposal as part of the 2014 Inpatient Proposed Rule on April 26, 2013. And boy was it a blockbuster. Counting midnights? Were they crazy? Who is awake at midnight? Why midnight? What if the patient presented at 11:55 pm? Or 12:05 am? It seemed so arbitrary. 

But as with many things they propose, CMS stuck by it and all of us have learned to live within its confines, and of course now that it has made it through the first 10 years, it will soon apply to the MA plans. If you were not there back in 2013 and 2014 as I was with other soon-to-be members of ACPA, we graciously accept your thanks for all the work we did with CMS to get clarity on how to apply this rule and to get the certification rule that accompanied the rule eliminated. 

Now go ahead and read the many fine articles in this month’s newsletter. I am so proud to be a member of ACPA. Nowhere else can you find content like this written by members, for members, at no additional cost. 

Remember, ACPA is here for you. Tell us what you want, what you need, and what you can contribute. You can always contact me at signaturedoc@gmail.com. 

Accountability: Taking Your Influence as Physician Advisor to the Next Level

Alistair Aaronson, MD, MHA, FACP

Member, ACPA

Few Physician Advisors like to confront their physician colleagues when their performance lags, and even fewer like holding them accountable. This can be for a number of reasons:

1. It is uncomfortable.
2. It is perceived as out of scope for the role and more of a “CMO thing.”
3. There is the notion that it casts you as the “bad guy”, which is not as appealing as being seen as the supporter, the advocate, the ally.
4. It may be perceived as eroding the effective working relationship that you have spent so much time and effort to build. 

However, while this thinking is natural and common, it is also misplaced, and it actually stifles our effectiveness as Physician Advisors, and as leaders. 

In fact, when you set clear boundaries and expectations, and then hold someone accountable when they cross those boundaries or do not meet those expectations, it engenders trust. It promotes respect. And it builds a safe space of bidirectional, honest, and transparent conversation that hallmarks effective communication.

As Medical Director for Care Management and Clinical Documentation Improvement (CDI) for the South Division at Providence, I oversee the Physician Advising program at 17 hospitals in California, which comprises dozens of Physician Advisors, each of whom has a different background, skillset, and approach to accountability when it comes to engaging with physicians who do not respond to CDI queries, hold on to patients beyond the point of any medical necessity, or refuse to communicate with Care Managers or Utilization Management nurses.

From my personal experience as a Physician Advisor, as well as through my experience working with and leading a team of Physician Advisors, some key patterns have emerged that seem to consistently yield great results when it comes to holding physicians accountable:

1. Be Direct: 

Physician Advisors who succeed at these challenging conversations are direct. They stipulate the expectations, and they then indicate that the physician is not meeting those expectations. No emotion attached to the conversation, just stating facts.

2. Show Data: 

After verbalizing the expectations are not met, it is critical to show data that led to this conclusion. Again, declarative, not judgmental. Facts are facts, and the physician performance is simply not meeting expectations.

3. Toe the line: 

At this point, Physician Advisors must engage in their most challenging test. Do they simply state the facts and then hope for the best? Or do they use that as a springboard for holding the physician accountable for their performance? And if the latter, how do they maintain their relationship while not capitulating to and therefore enabling the behavior they are seeking to change? 

I have found that the most effective Physician Advisors are those who still cast themselves as supporter and advocate while simultaneously saying that things need to change with a sense of detached urgency. They do this deftly by indicating that external pressures or forcing their hand, whether that be hospital policies and bylaws, or CMS regulations, or an insurance company’s policies. The Physician Advisor by telling a physician that they need to change their behavior is therefore seen as simply doing so in order to protect them and ensure they are not subject to reprimand or suspension by the Medical Executive Committee, the recipient of a fraud charge by CMS, or the cause of a costly denial. 

4. Collaboration

Finally, the Physician Advisors who are most successful at holding their physician colleagues accountable do so by collaborating closely with their CMO, Chief of Staff, as well as other hospital leaders. This is because the teeth in accountability lie within actual policies and processes, which CMS and insurance companies have in spades, but that are not always or even often present in the hospital. 

Physician Advisors who lead from the front do so by working with their CMO, Chief of Staff, and other hospital leaders to develop and implement internal processes for accountability such as incentivizing physicians through contractual terms as well as through celebrations, developing a peer review process vis a vis LOS performance, conducting 1:1 meetings with physicians at a routine cadence to address performance shortfalls, and tie key performance metrics to credentialing through rules and regulations and bylaws to name a few.

Finally, know that as Physician Advisors who take their game to the next level by holding physician colleagues accountable, you have a support system among your Physician Advisor peers through the ACPA to provide guidance, to hear and share in your frustrations, and to create a community of high performing physician leaders who don’t shy away from challenging conversations but rather embrace them as opportunities not only for personal and professional growth, but also as an engine to improve performance at your hospital in all areas of CDI, utilization management, and care management. 

Dr. Alistair Aaronson is Division Medical Director of Care Management and CDI for the South Division of Providence, comprising 17 hospitals in California.

Hospice Conundrums (Part 1): Demystifying GIP, Ensuring Appropriate Use, Documentation, and Payment

Erin Boyd, MD

Member, ACPA

General inpatient hospice (GIP) is a Medicare benefit also covered by many Medicaid and commercial insurances that is frequently misunderstood by physicians, hospitals, and families. The use of GIP varies widely across hospices, and the Office of Inspector General just recently announced in June 2023 that GIP is a priority audit area. Given this, understanding the key components of GIP, appropriate use, reimbursement, and documentation is essential. 

Importantly, although the pneumonic GIP is for “general inpatient hospice,” GIP is an entirely different service than inpatient level of care. GIP is actually one of four types of benefits that all hospice agencies must provide for patients enrolled in hospice including: 1.routine home care, 2.continuous home care, 3.general inpatient care (GIP), and 4.inpatient respite care for relief of the patient’s caregivers. GIP can be offered in a Medicare participating hospital, skilled nursing facility, or hospice inpatient facility, and the purpose of GIP is to provide short term relief of uncontrolled symptoms that cannot be managed in an alternative setting. Examples of when GIP may be appropriate include aggressive treatment for pain control, uncontrolled nausea/vomiting, frequent seizures, severe agitation/anxiety related to end stage process, and symptom management that requires frequent skilled nursing observation or intervention. GIP is not intended for respite care/caregiver relief, to be automatically used when end-of-life care is needed for the imminently dying patient (the patient must have clear need for skilled nursing), or for patients on hospice who need more general supervision for reasons other than aggressive symptom management (falls, safety). 

Given GIP is an entirely different level of care than inpatient level of care, the two-midnight rule does not apply, and neither do other notices such as the Important Message from Medicare (IMM) or HINN letters. GIP also does not pay by DRG but rather per diem. Interestingly, though it is not considered “inpatient” care, GIP midnights in a hospital DO count towards the “3 midnights” needed for SNF per the Medicare Benefit Policy Manual Chapter 9 should a patient initially receiving GIP ultimately revoke hospice and need to be discharged to SNF. 

To initiate GIP services, a patient must already be enrolled in hospice. The hospice physician employed by or under contract with the hospice is responsible for evaluating the patient, ensuring that medical necessity for GIP is met, and ensuring that there is daily documentation supporting why ongoing GIP care is needed. The desire of a non-hospice attending to “Admit to GIP” is not sufficient to begin GIP services as the hospice and managing team must agree that GIP is needed. Specifically, documentation should include the circumstances that led to the need for GIP (failed attempts to achieve symptom control), and daily updates regarding what symptoms are being addressed, the patient’s response to intervention, progression towards goals, discharge planning, and why the symptoms cannot be addressed in a different setting (home, respite care, etc.). Documentation of “why” interventions being performed cannot occur in a lower acuity setting is critical and may relate to frequent medication adjustment clearly requiring constant nursing supervision to assess response. 

With regards to payment and billing for GIP, a hospice pays the hospital for GIP services after the hospice submits a claim directly to Medicare part A with code 0656 and the hospice agency gets paid. Per the final rule for fiscal year 2024 (CMS-1787-F), base payment rate per diem for GIP for fiscal Year 2024 is $1142.20, and the absolute dollar cap a hospice can receive cannot be greater than the total number of Medicare patients cared for by the hospice multiplied by $33,494.01. If documentation does not support the need for GIP level of care, hospices could be subject to adverse audit outcomes or receive payments at a non-GIP rate and have difficulty paying the hospital. Additionally, should there be a case where a patient was appropriate for GIP but now does not meet requirements and family is declining an appropriate alternative level of care, an ABN could be issued. 

Further noted is that GIP services (as with all other hospice services) for Medicare part C beneficiaries (Medicare Advantage), are always paid for by Medicare part A per 42 CFR Part 417.585, Subpart P. Billing for hospice/GIP to Part A for either a Medicare FFS or a Medicare Advantage recipient starts with a notification of election filled within 5 days of hospice election assuming the patient clearly meets hospice enrollment eligibility with a documented life expectancy of 6 months or less. A hospice beneficiary can change hospices once per benefit period (either the initial 90-day or subsequent 60-day periods) or revoke hospice at any time. When hospice is revoked, a patient who had been on Medicare Advantage coverage prior to enrolling in hospice is still covered by Medicare A/B rather than the Medicare Advantage plan until the end of the month, after which Medicare Advantage would assume responsibility for payment. 

In sum, understanding the nuances of GIP with regards to appropriateness of use and required documentation is becoming increasingly important as GIP comes under increased auditor scrutiny. Remembering that GIP is entirely separate from inpatient care despite “inpatient” being in its name, and that Medicare Advantage hospice benefits including GIP are paid just like Medicare FFS through part A is critical. Stay tuned for further hospice/end-of-life conundrums related to patients needing services not related to hospice, revocation of hospice, and impact of GIP/care of end of life patients on quality metrics in further newsletters!

Dr Boyd is Associate Chief Medical Officer at Sound Advisory Services

I Want a SNF Please…

Dr Maria Johar, MD

Member, ACPA Government Affairs Committee

75 year old patient with Medicare Advantage came to the hospital for a procedure. Post-operatively the family states they are unable to care for the patient and both family and patient desire placement in a skilled nursing facility for rehabilitation. Social workers get the paperwork together for submission after a choice for an in-network facility has been made. Physical therapy and occupational therapy provide assessments and recommend a SNF as well. 

Therapy Assessment:

Ambulation

Surface: Level surface

Device: Rolling walker

Distance: 100 feet x2, 15 feet x2

Activity: Within Room; Within Unit

Activity Comments: Patient ambulation to bathroom back into room and then ambulation in hallway

Additional Factors: Set-up; Verbal cues; Hand placement cues

Assistance Level: Contact guard assist

Gait Deviations: Slow cadence; Decreased step length bilateral; Decreased weight shift bilateral; Decreased heel strike right; Decreased heel strike left; Path deviations.

During the second ambulation had patient verbalize colors to promote a more natural ambulation and increase step size, however limited carry over.

Social worker sends paperwork to MA Plan for approval on Monday, it is reviewed on Wednesday and denied, Peer to Peer is offered by 12pm on Thursday. Attending is busy so seeks the physician advisor’s help.

As a physician advisor the first step is to review the case:

1. What is the denial for?
2. Why are they seeking a SNF or any other post-acute destination?
3. Is it the correct place for a safe discharge?
4. Do we have all the information to do the peer to peer?
5. If on review there are other suggestions you can offer, how do you communicate this to the attending and the bedside team?
6. Can you prevent avoidable delays in discharge by educating the team?

Let’s tackle these one by one.

If recommending home with home health, the patient must be homebound. To leave their home, they must need help, including the help of another person, crutches, a walker, a wheelchair, or special transportation. Patients must need skilled nursing care on intermittent basis. Patients must need physical, speech-language, or occupational therapy or nursing services on an intermittent basis.

Home health care makes sense when the patient is recovering from an injury or illness and doesn’t need 24-hour care. It also makes sense when the type of care required is custodial, although custodial care is not covered. Home health care is most often provided by a visiting nurse, therapist, or home health aide. Often, several visits to the home are made each week to provide the appropriate care. Home health care can include a wide range of services, including, but not limited to, respiratory therapy, cleaning and bandaging of wounds, monitoring health, and assistance with bathing and dressing.

If recommending a skilled nursing facility, this is usually a short term placement with the goal of allowing the patient to return home at baseline. The change between baseline and current state generally needs to have an expectation of improvement. Clear and current information needs to be sent to the payor for approval.

Skilled nursing is typically used for short-term rehabilitation to allow patients to improve their functioning and regain independence. It can also help patients learn how to better take care of themselves in the face of their ongoing health challenges or prevent decline with some chronic conditions. The best skilled nursing programs take a well-rounded and integrative approach to care. Overall, a patient who requires daily care for any health condition is qualified for skilled nursing care. Individuals who require ongoing medical care after an injury, rehabilitation or other highly effective medical treatment qualify for skilled nursing care. Those recovering from a stroke, a surgery, an accident, or significant illness are typical skilled nursing facility patients. Patients in need of intensive wound care or those requiring physical and occupational therapy also qualify for skilled nursing facilities.

 If recommending long-term care services, we are seeking care for someone who is at baseline and needs full care which is not possible elsewhere. Medicare and Medicare Advantage do not cover long term care.

Services that include medical and non-medical care for people with chronic illnesses or disability. Long-term care helps meet health or personal needs. Most long-term care services assists people with Activities of Daily Living, such as dressing, bathing, and using the bathroom. Long-term care can be provided at home, in the community, or in a facility. For purposes of Medicaid eligibility and payment, long-term care services are those provided to an individual who requires a level of care equivalent to that received in a nursing facility.

Medicaid: Does pay for the largest share of long-term care services, but to qualify, your income must be below a certain level, and you must meet minimum state eligibility requirements.

Some other options are also available:

Adult Day Care

Adult day-care centers provide care in a group setting for aged or disabled people who live at home, and/or may need help with the basic activities of daily living due to physical or mental impairment. Often, these people live with a relative who works and cannot take care of them during the day. Adult day-care centers usually provide an elderly person with social interaction, therapeutic activities, preventive health services, and nutritional meals.

Hospice Care

Hospice care is quality compassionate care for those terminally ill patients nearing their end of life. Hospice can take place in a care facility that provides comfort and care, or it can be administered in the home.

Respite Care

Respite care provides some time off for the caregiver (usually a relative) who regularly provides care for an elderly or disabled person. It can be offered in a local community center, nursing home or at home through the services of a home health aide.

Case Follow-up: This 75 year old Medicare Advantage patient wants a short term SNF, however pt does NOT qualify for a short term SNF because the pt is able to walk household distances. Typically, pts walking 50 -75 ft are not eligible for care at a SNF. We would communicate with the treating doctor and ancillary team to find a suitable discharge option. In this case the team had provided multiple options to the patient and family and the patient finally agreed to go home with home health. Payor did approve home health services.

How Physician advisors Can Assist:

Participating in regular rounds or having a great line of communication with the bedside team will assist in identifying the right discharge destination for the patients in need.

Contacting the treating physician and having a dialogue with them on the possibilities and assisting them with an optimal discharge will help in the recognition of the physician advisor as a valuable member of the team. The hospital administrators and leaders see the value of a well-informed physician advisor as they prevent avoidable delays by helping with the right discharge disposition with complex cases.

Performing peer to peers for any discharge denial is another feature that can prove very valuable for the hospitals if they have a strong physician advisor.

Reducing length of stay, educating the team of case managers, social services, physical therapists to seek the right disposition is key to ensure appropriate utilization of healthcare resources.

Tips to remember:

1. Discharge planning begins on admission.
2. Ensure education regarding discharge dispositions.
3. Capture avoidable delays and educate, educate, and educate.
4. Patients not participating in therapy are also not going to qualify as they will not gain strength or benefit due to non-adherence to physical therapy etc.
5. Escalation processes should be in place and used if needed.
6. If you feel strongly about the denial, you can certainly do a peer to peer and if needed an expedited appeal as well.

Dr Maria Johar is Lead Physician Advisor for Ensemble Health Partners

Observation Rate – Shooting for a Standard

Dr. Russell Firman, MD, FACEP, CHCQM, FABQAURP–PHYSADV

Member, ACPA Observation Committee

After reading RAC Monitor’s “The Right Observation Rate - I have the numbers sort of…” by Ronald Hirsch MD, it dawned on me that the observation rate discussion is never going to stop. How can a metric that is so flawed continue to be a benchmark Physician Advisors are held accountable for? If it won’t go away, then how can we make it work for us instead of against us?

I looked for other articles with a standard definition to apply across all platforms but none of them were truly apples to apples. Even ACPA has no recommendation on how to define the observation rate. The only consistent theme was how inconsistent the reporting was due to different numerator and denominator definitions not accounting for certain exclusions and endless variable exceptions not considered. 

For sports enthusiasts, a shot off the post in hockey is not considered a shot on goal while in lacrosse it is considered a shot on goal. If you had to come up with a save rate for sports goalies in general, you would have different definitions for numerators and denominators. What do you do with shootouts, or penalty shots, or empty net goals when the goalie is pulled for an extra attacker? These seem hardly fair to apply to overall sports save rate since each sport has their own unique set of rules.

The observation rate changes depending on whether you measure it during a hospitalization at the front end. (ER, direct admit), the middle of a hospitalization (snapshot), or at the back end (discharge final status). So, how many observation rates are there, and which is best to use? Let's consider the possibilities.

1) ED Observation rate: this considers all “observation” eligible patients hospitalized through the ER and measures how your ED case management is doing. This has been defined previously by Steven Meyerson MD and his definition includes any patient with ED charges with HCPS code G0378/G0379 (can include direct admits) in the numerator, with the denominator including the numerator plus all current inpatients with ED charges. This is probably the only measure that can be standardized and easily measured across all hospital systems with a clear numerator and denominator. If you are with me so far, what did you do with your surgical cases here in the numerator and denominator? Do you include or exclude appendectomies and cholecystectomies going directly to the OR? Do you include Inpatient only list procedures? Is this your correct observation rate you tell your CFO when many of these patients are converted to inpatient later? Is this the correct observation rate?

2) Spot daily observation rate - a daily report of number of patients in observation status divided by total observation plus inpatient at a moment in time as measured by your hospital. This is usually a daily report manufactured within your institution where all the observation cases are in the numerator, and anything is fair game in the denominator. This is usually “very high” at 6 am and much better at 4pm so make sure it is reported out to daily huddles with the 4pm number. Overnight observation cases pileup overnight. If a hockey goalie has a great second period with 15 saves and no goals allowed but allows 9 goals on 10 shots in the 1st and 3rd periods, and loses the hockey game, I am not sure how this data tracking helps the overall goal of the organization. Is this the right observation rate?

3) Discharge observation rate - measures how many people are discharged in observation status (numerator) over total observation plus inpatients (denominator), upon discharge. This measure accounts for the conversions made during the stay. If your hospital continues observation cases after procedures your observation rate will be high. Once a patient has a procedure, changing the status to outpatient with extended recovery gets the discharge final status of observation off your numerator and lowers your observation rate. This work yields you no financial benefit, but you get a warm and fuzzy about reducing your overall observation number. If a soccer player kicks the ball back to his own goalie, is it a boost to his/her save percentage? Is this the right observation rate?

4) Specialty line observation rate - different rules unique to each specialty would make this plausible but nearly impossible. Did you know a hockey goalie making a save on a shot going wide of the net does not receive credit for that shot on goal?

5) Hospital random reported observation rate - Are you stuck with a daily observation percentage report at your hospital but you have no idea what the numerator or denominator is? I have determined that someone in IT at your hospital has a formula for the observation rate they obtained from someone in finance. It is time you took this over!

Let's look at the problems that need to be addressed so we can try to begin to make the observation rate number standardized and meaningful for all of us and our hospital partners.

1) How do you compare a hospital with a very high inpatient denial rate (possibly lower observation rate) with another hospital with a lower inpatient denial rate (possibly higher observation rate)? One hospital will look great to the CFO, or will it? Should we always look at the observation rate next to the denial rate / overturn rate? This reminds me of a sports team that plays terrible defense but allows a lot of shots on goal or vice versa.

2) Do you exclude OB/GYN, psych, pediatrics? What is this supposed to include exactly with varying definitions? For example, an overdose that is cleared in the ER for psychiatry, but because there are no psych beds, is placed in a medical bed overnight with observation, would this count? Is this applied nationally at all hospitals? What about 22-week pregnant vaginal bleed directly sent to observation on L&D? Ectopic ruled out in obs. Does this count? Is peds age standardized across all hospitals? Do emancipated minors count? Why exclude pediatrics? Are they considered the hockey goal post? 

3) Are your nursing homes sending cases to the ER with minor falls and weakness when they are struggling with staffing? Are your observation cases really outpatient in a bed that have no medical necessity?

4) Are your ED and admitting physicians in a highly litigious county of your state that requires more hospitalizations in observation for risk management purposes?

5) Does a patient’s primary care physician send patients to the ER to be admitted that may not need to be admitted?

6) Are surgeons sending elective cases to the ER as an end around due to difficult scheduling or the need for medical clearance and they start out errantly as observation?

7) Are you an accepting tertiary care center making it easy and accessible for referring hospitals to send a patient population that are placed in observation, even when these procedures are routinely done in the outpatient setting? Do you do 20 cardiac caths every day on transfers all in observation that should be in a surgical outpatient status?

8) Has your CFO signed a contract that all patients must stay three days before the payer will consider inpatient status (you are stuck with payer short stay policies)?

9) Is your EMR easier for your medical staff to place observation orders instead of inpatient or hospital outpatient?

10) Are there errors in preauthorized outpatient procedure orders, being mistakenly placed in observation, such as infusion center encounters? Does the same thing happen for pre-authorized outpatient surgeries that the surgeon placed an observation order out of habit?

11) Are denials for observation services by payers considered in your final data collection? Do you consider counting patients who spend less than eight hours in observation since you won’t get paid for observation?

12) What do you do with a patient that was discharged as an inpatient, but after P2P there is mutual agreement that observation was more appropriate? We know that with some payers they allow you to go ahead and collect a similar amount of money, but the patient order is not officially changed to observation. 

13) How would you consider counting an inpatient denial that is lost on written appeal and 12 months later is finally overturned? Your high observation rate from a year ago now is better. 

14) How do you account for a third-party denial for an appropriate inpatient stay three years later that cannot be overturned on written appeal and they recoup the money? Now your data will look worse. Do Medicare self-denials fit here as well? Who adjusts your observation rate? 

15) How do you account for certain J1 and T procedures that do not allow you to receive reimbursement for observation services for that visit? Was this patient counted in your observation percentage when in some cases observation services pay more than the procedure?

16) How do you define a patient who is placed in observation on day one, attending switched to inpatient day 2, but UM recommends switching back to observation but patient elopes prior to order being placed? I would argue this patient could be both an inpatient or an observation statistic depending on how your IT department defines the data. 

17) How do you account for a patient that is in an appropriate observation status from the ER with abdominal pain and after a day is determined to need a laparoscopic cholecystectomy. The patient is changed to an outpatient status commonly referred to as extended care to recover. The patient has an APC for observation and for the procedure. Since the observation APC is not paid, should it be counted? It had to be reported, so why not? Off the hockey post for sure here, no save counted!

18) How do we count the patient in observation for 7 hours, changes to inpatient for 12 hours before undergoing a non-emergent lap cholecystectomy (code 44) and discharged as an outpatient with extended care before 2nd midnight? 

Let’s define the term once and for all and not let it continue to be inaccurately used. Let’s standardize the data collection and reporting in a way that is reliable and trusted and clear up the variable exceptions. At professional sporting events there are officials whose sole job is to count shots on goal. I propose these referees are Physician Advisors at hospitals. Unfortunately, we have allowed others to do this for us. Last month, I presented my frustration to the observation committee who pledged to define and standardize the rate with guidance in the coming months. I appreciate the observation committee “skating to where the puck is going, not where it has been” in the words of Wayne Gretzky.

How do you think Observation rate should be defined? Go to this link to give us your thoughts and suggestions. (Add a survey monkey link for comments)

Also, keep an eye out for the formal announcement and date for ACPA Observation Committee Townhall in Feb 2023 “Observation Metrics 101.”

 Reference - What is Your Real Observation Rate? What Should It Be? at https://www.acpadvisors.org/content.aspx?page_id=5&club_id=90610&item_id=61692&search=1

Dr. Firman is board certified Emergency Medicine and practices clinically for US Acute Care Solutions, and is currently full time as a Physician Advisor with Saint Joseph’s Health/Trinity in Syracuse, New York.

The Role of Clinical Documentation Integrity in the Hospital Readmissions Reduction Program as it Relates to Same-Day Acute Care Readmissions and the 3-Day Payment Window

Waldo Herrera, MD, MBA, MSc, FACP, SFHM

Vice Chair, ACPA CDI Committee

The Hospital Readmissions Reduction Program (HRRP) is a Medicare value-based purchasing initiative that aims to reduce avoidable readmissions by encouraging better communication and care coordination post-discharge. By linking payment to the quality of hospital care, this program seeks to improve the health care of American patients. The Centers for Medicare & Medicaid Services (CMS) includes acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, coronary artery bypass graft surgery, and elective primary total hip arthroplasty and/or total knee arthroplasty as the 30-day risk-standardized unplanned readmission measures for this program. The payment reduction for each hospital depends on its performance during a rolling period, and it uses a payment adjustment factor to decrease the hospital compensation. The reimbursement reductions apply to all Medicare fee-for-service base operating diagnosis-related group (DRG) payments during the fiscal year (October 1 to September 30), and this payment reduction caps at three percent.

Hospitals and health systems already face severe financial struggles with minimal profits and, more commonly, negative operating margins. As a result, many healthcare facilities track and incorporate readmission data in their scorecard, which gets providers' and administrator's attention and helps shift the focus to strategies that decrease avoidable readmissions. Clinical documentation integrity (CDI) specialists and CDI physician advisors are regularly tasked to help improve readmission data by ensuring the correct principal diagnosis is chosen, guaranteeing an accurate DRG assignment. In addition, the CDI team may participate in combining accounts when patients are readmitted on the same day of discharge.

The Medicare Claims Processing Manual instructs hospitals to merge admissions when a patient is readmitted on the same calendar day for a similar problem experienced in the index admission. They also allow hospitals to combine inpatient stays if a subsequent admission is expected or scheduled. In this second scenario, the beneficiary is placed on a leave of absence if the patient does not require a hospital level of care during the interim period. It is essential to clarify that if same-day readmission is for an unrelated condition, the accounts should not be combined, and the hospital needs to place condition code (CC) B4 on the readmitting claim for the subsequent readmission. The efforts to combine accounts on the same day of readmission are known as the Medicare Same-Day, Same-Provider Acute Care Readmissions, and they apply to patients discharged/transferred from an acute care Prospective Payment System (PPS) hospital and readmitted to the same acute care PPS hospital on the same day.

The CDI team is well-positioned to help in the above efforts. Still, its role is limited to help determine if the hospital stays are related when the coders and case management cannot make this determination. Ideally, the CDI specialist or physician advisor supporting these efforts should have broad clinical experience and deep knowledge of the CMS regulations about combining accounts. Some institutions might face challenges when establishing a process to combine accounts. On June 25, 2010, the "Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010" was made into law, and it regulates the payment of outpatient services provided on either the date of a patient's admission or during the three previous calendar days of an inpatient admission to a hospital subject to the inpatient prospective payment system (IPPS). The "3-payment window" guidance should not be confused with combining accounts on same-day readmissions. Under this law, the hospital must include on the inpatient claim all "the diagnoses, procedures, and charges for all outpatient diagnostic services and admission-related outpatient non-diagnostic services furnished to the beneficiary during the 3-day payment window". It is critical to clarify that for hospitals not paid under the IPPS (psychiatric hospitals and units, inpatient rehabilitation hospitals and units, long-term care hospitals, children's hospitals, and cancer hospitals), the statutory payment window is one day preceding the date of the patient's admission.

The policy explains that the payment window applies only to outpatient services billable under Medicare Part B and does not apply to nonhospital services that are generally covered under Part A and to critical access hospitals (CAHs). As a result, if the admitting hospital is a CAH, the payment window policy doesn't apply. While CMS provides clear guidance about combining inpatient admissions that occur on the same day and outpatient services that happen in the three-day payment window, they do not give guidance if hospitals should combine two admissions into one when the patient is readmitted after the same-day passed, even if the readmission is perceived as being the discharging hospital's fault. 

A review of the literature and of an article by Dr. Ronald Hirsch in October 2017 indicates that if two admissions do not occur on the same day or are planned, they should not be combined, and the hospital should not submit a no-pay claim if they feel the readmission was due to the suboptimal transition of care. At that time, Dr. Hirsh contacted the MAC representatives, who advised him to follow the regulations as written and bill two admissions accepting two payments.

As you can see, combining accounts can be complex and time-consuming. Supposing the CDI specialist or physician advisor is involved. In that case, they must understand CMS guidance and work closely with the utilization management and coding team to select the proper process. This effort will lead to doing the right thing and, ideally, decrease avoidable readmissions reported.

Dr. Herrera is the Senior Physician Advisor, Care Management and Documentation Integrity at NorthShore University HealthSystem

Observation Committee August 2023 Survey Results 

Provided by the Members of the ACPA Observation Committee

Q1: Seventy-five years old female with a history of hypertension and advanced arthritis who had total hip arthroplasty performed with CPT27130. While in the recovery room, a problem was noted in the first surgery, and the patient had to go back to the operating room for another surgery, coded under CPT 27134 as a revision. The patient remained hemodynamically stable post-op, and her pain was managed with oral narcotics. The patient was discharged home the following day with home health care and home physical therapy. What is the appropriate status for this case before the first procedure of total hip arthroplasty was performed?

This question focused on CPT code 27130, which is total hip arthroplasty. This CPT code was removed from the Medicare inpatient-only list in 2018. Other payers followed traditional Medicare and now considering this elective surgery an outpatient one. In the answer, 80.95% of the responders selected outpatient procedure status, 14.29% selected observation, and 4.76% selected inpatient. Since the question was asking about the appropriate status before the first procedure was performed, at that point, observation services cannot be selected in advance before the procedure is performed. As stated, this procedure is considered an outpatient procedure for most payers, which means selecting “admit to inpatient” is inappropriate based on how the first question was asked. Additionally, nothing in the question suggested that the surgeon expected the patient to stay beyond two midnights with medical necessity, which he could have supported inpatient status based on the two midnights role for traditional Medicare. One of the comments suggested that status cannot be answered correctly without knowing patient comorbidities, living situations, etc. This is a good point, as some total hip arthroplasty cases could qualify for inpatient status based on their high comorbidity, living conditions or risk for adverse events even with short stay.

Q2: What is the appropriate status for this case after the second procedure of hip revision with discharge in less than 2 midnights of hospital level care?

For this question, 65.08% selected admitted as inpatient despite the patient being discharged before two midnights. For traditional Medicare, the CPT code 27134 revision of total hip arthroplasty is in the Medicare inpatient-only list, qualifying the patient for admitted to inpatient status without needing to stay for two nights. 

Q3: The third question asked if this selection could change if the patient were under the Medicare Advantage plan and not traditional Medicare and 72.13% answered no. This situation is not as clear-cut as traditional Medicare as some Medicare Advantage plans follow the Medicare inpatient-only list, which makes this code appropriate for inpatients, while other payers don’t. In such scenario, additional factors will come into play, such as the contract language between provider and payer and if any specific guidelines or national criteria are used to decide such cases. Some national criteria support the option of admit to inpatient for revision cases.

However, CMS did codify the requirement for Medicare Advantage plans to follow the Inpatient-only list starting CY 2024. 

 Q4: The final question asked if the answer to question two would change if the patient was under a commercial plan. Again, the majority answered no but was a lower percentage when compared to Q3. Responders' comments again referenced contract language, which might have had more effect in commercial plans. Also, commercial plans usually do not follow the inpatient-only list. 

Some comments went as far as the impact of prior authorization. Usually, prior authorization impacts an elective procedure, however, and since the revision was urgent, prior authorization would not impact the second CPT code. 

Commercial plans might also consider that the patient underwent through two full surgeries within the same day, which adds significant complexity to the case and grant approval for inpatient status even with the short stay.

Reference 

Breaking News: Medicare Advantage Must Follow Two-Midnight Rule – RACmonitor (medlearn.com)

October 2023

This is my first “President’s Corner” as President of the American College of Physician Advisors and Dr. Juliet Ugarte Hopkins left me some very big shoes to fill. Dr. Ugarte Hopkins, Dr. Charles Locke, Dr. Edward Hu, and Dr. Ronald Rejzer have each made such significant contributions and I am so grateful for the time and energy they invested to get ACPA to this point. As only the 5th President, I cannot wait to see how ACPA, and the physician advisor profession, grows during my tenure. 

The Physician Advisor profession continues to expand. In many ways it reminds me of the early days of the Hospitalist explosion. In the beginning it was “why do we need hospitalists?” There was often confusion between on the part of patients and staff when they were expecting the primary physician to round and realizing that a hospitalist would be seeing this patient instead. Hospitalists then began taking over as the primary attending for patients who had previously been admitted by specialists. Almost overnight hospitalists became indispensable, and it is increasingly difficult to find a hospital operating without one. In the beginning there were similar questions about physician advisors. What is a physician advisor? What do they do anyway? Does my hospital need one? 

In physician advisor lifetime, I’ve seen job postings for physician advisors go from being almost impossible to fill to ultra-competitive. Every year ACPA membership grows. Each year the National Physician Advisor Conference (NPAC) gets better and better. Speaking of NPAC, mark your calendars now for NPAC 2024: Safeguarding Patients Amidst Shifting Currents of Healthcare happening April 15-18 in Coronado, CA. Keep an eye out for the Speaker Call. I know you all are doing great work and I can’t wait to hear about it. 

The success of one physician advisor is really a success for all of us. Personally, I love highlighting the achievements of others so if you’re doing something amazing, please let us know so we can help celebrate you! You can reach us through the usual channels or find us on social media. 

I am so looking forward to helping ACPA continue to grow! The fall Board retreat happens this month so check out the President’s Corner next month for updates on what’s happening next!  

Clarissa Barnes, MD

President, ACPA