Developing an Internal Physician Advisory Program: Our Experience at University Hospitals |
The Physician Advisor as a “Quarterback” in Managing Silos |
Adult COVID-19 Patients Do Not Get Hypoxic-Ischemic Encephalopathy (HIE)
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Analysis of March 2021 Observation Cases
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This Month’s Observation Cases from the ACPA Observation Committee
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Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI
Member, ACPA Advisory Board
Editor, ACPA Update
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Well, the hope was that the widespread availability of COVID-19 vaccine and rapid uptake would lead to a rapid drop in cases all over the country. But as I write this, hospitals in part of the country are once again cancelling medically necessary but less-time-sensitive surgeries (my terminology for “elective” surgery). There was an unconfirmed Twitter post stating that one Michigan hospital was “running out of ventilators.” The variants seem to spread rapidly and affect younger people more than the initial virus. If there is any consolation, it is that most health care workers are vaccinated and at much lower risk of infection. We lost thousands of colleagues and let’s hope we see no more.
As much as I would love to opine on my stance that one day inpatient surgical admissions are perfectly appropriate if the Medicare rules are followed and the physician’s rationale documented, I won’t. But I would ask you to read the article from Denise Wilson on how auditors are inappropriately applying coding rules to obesity. Like me, Denise professes that the rules should be followed, even if the auditors are likely to misinterpret them.
Dr. Anthony Muni provides us an outline of the development of their internal physician advisor program at University Hospitals in Ohio. His review includes some startling numbers about the financial effects of their work. What a smart thing to start from the beginning tracking so many data points which now can be used in a myriad of ways, especially to provide insurers feedback on their performance. How cool would that be to give them a quality score???
In the next article, Dr. Erica Remer discusses how terminology which has been applied to a complication of COVID-19 is complicating the coding of claims. We all urge our physicians to document accurately and completely, but in this case, the use of the “correct” terminology may lead to the application of the wrong code to a claim. What a mess!
Dr. John Zelem talk discusses what has to be one of the biggest pet peeve of most physician advisors- the many silos in our hospitals. Not to dwell on surgical status, but it is a great example of how silos can harm you. In one health system, the PA was able to partner with the revenue cycle team and realized that for one major payer, they were paid more if one surgery was done as outpatient than as inpatient. Of course, this led to a 180 degree change in strategy when getting prior authorization from that payer. Breaking down those silos works. Let me note here that both Dr. Zelem’s and Dr. Remer’s article first appeared online on RACmonitor.com and ICD10monitor.com, respectively. I’d always prefer original contributions but there are times when the topics discussed are worth repeating so I chose to include these two articles.
Finally, the Observation Committee was busy and gives us the results of the cases that were in the March newsletter. And once again there is little agreement on the cases. They also provide two new cases in the GI realm. Be sure to read the cases carefully and answer the questions. As a bonus, as I prepared the first GI case, one thing about the case really stood out to me and it was not about status. I won’t tell you what it is but those of you who read my comments on RAC Relief may figure it out. If you have a guess, email me at signaturedoc@gmail.com.
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Developing an Internal Physician Advisory Program: Our Experience at University Hospitals |
Anthony Muni, MD
Member, ACPA
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University Hospitals (UH) is located in Northeast Ohio and is comprised of 11 community hospitals and a large academic medical center in Cleveland. Prior to September of 2019, all of these hospitals had a different way to approach utilization management (UM) and had a wide variety of workflows and processes. They utilized Executive Health Resources (EHR) for admission status decision support but their services were only used for Traditional Medicare and Managed Medicare products. For several years, the cost of EHR far exceeded the budgeted amount as the UM team would rely on their input and send many more cases than what was predicted. The UM team did not fully embrace the Center for Medicare and Medicaid Services (CMS) Two Midnight Rule and payer peer to peers were left to the attending physicians who had varying levels of engagement and success.
Many physician advisors and hospital leaders reading this can probably relate and wonder how a large and respected institution could have such broad variability and inefficiencies. Many questions needed to be answered. Why does one hospital have a certain workflow and another hospital in the same system has something different? Why is the CMS two midnight rule not being applied when this framework has been around for many years? Why is a third party vendor paid to render an opinion but the hospital accepts the fact that they cannot back up their opinion with a peer to peer? With hospital margins so thin, why is so much money being left on the table? So with unsatisfactory answers to those questions, the team at UH set out find solutions to our problems.
There was only one solution and it was evident: to create an in-house physician advisory program that would handle all inpatient vs observation status questions in addition to reviewing all medical necessity denials and perform all peer to peers. Forming this program de novo was a daunting task but there was confidence that with the resources and talent at UH, it could be accomplished. Without going into the details regarding technologies, communications and processes, the UH team was able to stand the program up in about three months. Fourteen highly respected and efficient hospitalists and emergency physicians from across the system were identified, recruited and trained in all of the nuances of utilization management. The work flow of every UM nurse in the system was significantly changed.
The University Hospital’s Physician Advisor Program officially started on January 6th, 2020 and the first full year was recently completed. Combined UM and financial data determined an expected return on investment of about $6.8 million. The graph demonstrates that the program was able to overturn 868 medical necessity denials (blue bar) via peer to peer with an expected reimbursement of $10,579,800 (green line). At the time of this publication, we have actually collected $8,740,402 (red line) but expect this number to increase over time.
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The expected reimbursement is offset by what would likely get reimbursed if these denied cases were paid as observation (yellow line) and by labor cost for the advisors (appox. $750,000). There were no specified goals going into this endeavor but this return far exceeded expectations. Many of you may astutely point out a significant percentage of these cases likely would have been overturned on appeal, which is probably true. However, when a denial is reversed via a peer to peer, the institution is getting paid within days as opposed to months compared to the appeals process. This front end denial intervention also saved countless of man-hours on the back end.
What this return on investment does not capture is the difficult to quantify volume increase of patients that were billed inpatient that was approved in addition to all of the inpatients captured by proper utilization of the CMS Two Midnight rule. University Hospital’s observation rate decreased in 2020 while our medical necessity denials have remained stable. The financial pick up from these process changes likely dwarf the direct contribution to the overturned denials due to peer to peers.
An amazing byproduct of the UH Physician Advisor Program is the incredible amount of data that has been collected. The UH physician advisors review approximately 70 cases per day and perform 7 peer to peers per day on average. Each case review captures a dozen pertinent data points including demographics, DRG, length of stay and insurance company. Over the course of the first year, nearly 400,000 discrete data items were captured and hopefully that helps make more informed decisions in the future. The next step is to work with artificial intelligence software and data scientists to use this information for physician advisor decision support. There are also plans to use this data to go back to the payers and show them how inefficient some of their utilization management techniques are. For example, payers have been identified who have a high first pass denial percentage but then overturn a high percentage of denials on peer to peer. All parties involved will probably agree that this inefficiency is causing many hours of lost productitvity.
This story about University Hospital’s Physician Advisor program exemplifies how healthcare systems can improve processes, at a lower cost, with better results and with more institutional engagement. If any of your institutions are struggling with unacceptable UM variation or a costly farmed out solution, this story will hopefully provide inspiration and encouragement.
Anthony Muni, MD is Chief Medical Officer, Utilization Management & Clinical Documentation Integrity at University Hospitals in Cleveland, Ohio
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The Physician Advisor as a “Quarterback” in Managing Silos
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John Zelem, MD, FACS
Member, ACPA
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There are silos in all aspects of life but most of the time we associate them with farming as the classic pictures are of grain silos. The term is often used in the business world, but “silo” is not really an exclusively business or project management term. Yet it is often used. For example, “when you say that the teams on a project work in silos, … it means that each and every individual team works independently of the other team, and the teams don't know anything about each other's work.”1 The use of the term even extends into the healthcare industry in many aspects such as their departments and even physicians. Department silos will be discussed further on, but I suspect that one never thought of physician practice as silos. Yet if you look again at the quote above, it may apply. There are many specialties in the practice of medicine such as cardiology, GI, GU, infectious disease, and many more. Why do hospitalists, internists, and other general practice physicians get consults, sometimes numerous during a single admission? Because they need the expertise of that specialty as they really don't know in detail about each other's area of practice or specialty. As a matter of fact, it has pretty much become the standard of care to get these consults, but does it contribute to the efficiency of care delivery? Most of the time, it may not.
Where Does Silo Thinking Originate?
The reality is that silos are everywhere, and they are not necessarily totally bad, but where does that silo mentality come from? Surprisingly, the silo concept gets implanted in our minds very early on in life which may be a surprise to most of us. It was to me. Remembering back to our childhood days, grammar school tended to be one teacher, multiple subjects, all in the same classroom. The silo process starts in the upper grades with each subject having its own teacher, with different styles, different rooms, homework assignments, and allotted times. In addition, most of the time each student had their own desk, their own locker, books, and equipment. This was the beginning of compartmentalization or, more simply stated, silos. Each subject was independent of all the others.2 This concept is subliminally implanted in our minds, so why would we not carry it through to our work environment including healthcare.
What exactly is subliminal? It has been defined as “existing or operating below the threshold of consciousness; being or employing stimuli insufficiently intense to produce a discrete sensation but often being or designed to be intense enough to influence the mental processes or the behavior of the individual.”3
Clinical Revenue Cycle
There tend to be numerous silos in healthcare but let’s focus on the Clinical Revenue Cycle (CRC) area from a holistic point of view. Utilizing this holistic approach where no one component is more important than the whole, the components of utilization review (UR), case management (CM), clinical documentation integrity (CDI), the Physician Advisor (PA), and coding all funnel into CRC. There is a common link between all of these components and that is they are all looking at the same documentation, the medical record, but through their own lens. Hence they tend to function as a collection of sealed off departments with few perceived links between them where critical information may be trapped, inaccessible, or sequestered. There may actually be a sixth component to this – revenue integrity, but is it a silo or a solution? To learn more about this component please refer to the following article:
The PA may not actually be a silo, but a “quarterback”, as they tend to work with the other components, UR, CM, CDI, but not that often with coding. With this unintentional silo concept each of these components generally work independently, and each really doesn't know much about the other's work or role. Working in silos can obstruct communication, hinder productivity, lead to resentment and animosity, and generally just makes work a lot more painful than it needs to be.
Types of Business Silos
According to Corey Moseley4 there are three types of silos he discusses:
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Organizational – this is division within the department according to different types of people and skill sets often making them operationally autonomous entities focusing on specific goals leading to little interaction and information sharing.
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Information – this can be secondary to #1 where information remains trapped within the department
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Silos of the mind – these are ingrained thought patterns that influence everyday decision-making within teams. They’re the result of departmental biases and information hoarding
These are all found in clinical revenue cycle.
What is a Physician Advisor?
There really are no exact definitions of a PA. They can be onsite or there are remote services and are typically associated with second level medical necessity reviews in the UR arena. As this specialty has progressed and grown, the functions have increased to many different areas including, but not exclusive of, appeal of denials with peer to peers, length of stay management, participation in the UR committee, physician education including physician documentation improvement, collaboration with UR, CDI, case management, and maybe even coding. Many times, PA’s are considered the liaison between physicians and leadership and in essence, they must primarily integrate with the utilization staff, physicians, and executive level. They become regulatory and subject matter experts. There are probably many other roles that have not been included here but they will appropriately vary from facility to facility.
Since physician advisors are a key component of clinical revenue cycle and, using the holistic approach where no one part is more important than the whole, the effect to be achieved in managing those silos is collaboration and knowledge sharing. The PA is perfectly positioned to play a major role in helping this to occur as “boots on the ground” along with executive levels. In order to accomplish it is important to understand how these silos originate in the business world. There are overall common etiologies and there will be some specific to the healthcare organization.
How do Silos Originate in Business?
It’s already been stated that silos are subliminally implanted in our behavior from childhood. It becomes part of adult behavior as it is already quite prevalent in nature. Take for example the male lion that has his own “pride”, group of females, and a male comes along challenging that position. It can lead to a battle to the death. Luckily, that shouldn’t happen in the human environment. Silos are not necessarily bad, intentional, nor the work of any one person but they must be managed appropriately. You may have seen some examples of that behavior when it gets carried to an extreme on an individual basis in the form of territorialism. It’s like “marking my territory”:
- “That’s my chair”
- Hiding stuff so no one else can use it
- “That’s my staff, they only work for me”
That type of individual thinking and behavior taken to the departmental level can be so destructive especially by making decisions on what’s best for them, not the overall goal or vision, not the overall team. In the business and healthcare world there is a tendency to cluster expertise into specific departments by functions and employees tend to mimic what they see in management. One can recognize that a silo has or is developing when information or other business resources that would be beneficial to the organization are being kept by an individual or specific group.
What Role Can the PA Play?
Once again, the onsite PA interacts with many of the components of Clinical Revenue Cycle on a daily basis. Can the PA play a role in managing these silos? Here is a list of several suggested areas that can be addressed by PA’s as they may have detailed knowledge of each component’s processes:
Learn what are common goals and visions and educate all involved.
The PA should have the advantage of knowing and understanding what the common goals and visions are for their institution. Increasing revenue is certainly number one but it needs to be sustainable revenue. The PA should meet with management to learn and validate what these goals and visions are. Once that is established, and since the PA would have working knowledge of each component, there needs to be inter-compartmental education at a high level. Team empowerment will play a significant role as they are the ones in the trenches, not management. Management needs to reduce bottlenecks and constraints to make the teams successful. The PA can be the liaison between the teams and management.
With team empowerment the IKEA effect can be utilized. “The IKEA effect is a cognitive bias in which consumers place a disproportionately high value on products they partially created. The name refers to Swedish manufacturer and furniture retailer IKEA, which sells many items of furniture that require assembly.”5 As you may know, many IKEA products require some degree of assembly. The basic theory is that people place more value, ownership, in something that they have participated in building and/or creating. It goes back to the old question, as a child, what bike did you treat better, the one someone bought for you or the one you paid for? One must be careful that the value or ownership does not turn into hoarding and non-sharing. Product development is a perfect example, as they create a new product or service, but they must eventually “let go” of the ownership and relinquish it out to sales and implementation.
Help to Build the Puzzle
Look at where your components of CRC are and know where you want them to be. This is different than vision and goals but has to deal with knowing what is the proper process and functions of each component. One might consider this a gap analysis analogy, and this is where the puzzle concept comes into play. One knows what the completed puzzle should look like based on the picture on the box or an enlarged provided picture but starts with a bunch of pieces. There are a couple of ways to build a puzzle:
- Build the edges first and then fill in the inside – edges are identified easily but filling in can be a daunting task
- Lay out all the pieces and start looking for those that match. This can be very challenging with a high number of pieces
- Build smaller sections of the puzzle, get them into their right places, and then fill in the connecting sections, the rest
Even though management should know what the proper function of a department or team should be, they are not in the trenches. The PA knows what the functions, roles, and team members are for each of the components. Without being intimately involved in the details of daily functions, they can provide the needed education of regulations, standards, and compliant practices to all components and physicians. Following #3 building technique above, the PA can help them fit into the overall picture while leadership and management fills in to connect the sections. There may be meetings, conferences, such as multi-disciplinary rounds where the PA can serve as a facilitator for all components.
Facilitate Communication
All five components of CRC are dealing in some manner with the patient story and the care in order to facilitate proper level of care placement, proper treatment and care transition, proper documentation, and compliant billing. Think about it this way: there is a football team whose players never block, won’t tackle unless it is the man they are covering, receivers that run out for a reception only when it will be to them, and focus only on actions that will run up their statistics. This is another form of silos and the chances of this team winning are next to nil. This can and does occur in individual healthcare teams and overall clinical revenue cycle and resentment and disgruntlement will start to build. In reality, there is a huddle before each play, that is run by the quarterback who lays out the play and options. This is a great form of “communication”. Everyone on the team knows what the intended play is and the options for change. The PA can serve as a “quarterback”
Just as a few examples, do the team members, components, know:
- The financial consequences to the beneficiary for being in the wrong level of care
- The challenges of getting a patient transferred to a SNF
- The extent of documentation that doesn’t support the acuity of the patient
- Trying to get a physician to change the level of care order
- What are the processes and consequences of condition code 44 and trying to notify the patient, the physician, and the facility
- What are the consequences of up coding
- Why are there so many denials and how do you appeal them
- And so much more?
One may say why does each member and component need to know this? Well, they don’t need to know the intimate details, but an overall knowledge base can provide some insight to getting the right results and outcomes for the patient and the facility resulting in sustainable revenue and maintaining hospital existence. Therefore, that’s where communication and education plays a role, a role that the PA can be part of in managing silos. The physician advisor can provide this communication on a one on one basis or overall education.
Summary
The role that the Physician Advisor provides as communicator, facilitator, subject matter expert, and “quarterback” is invaluable. In just performing their intended duties, working with teams and management, managing the silos within Clinical Revenue Cycle can occur.
Dr. John Zelem is president of Streamline Solutions Consulting, Inc.
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Adult COVID-19 Patients Do Not Get Hypoxic-Ischemic Encephalopathy (HIE)
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Erica E. Remer, MD, FACEP, CCDS
Member, ACPA Board of Directors
Co-Chair, ACPA Clinical Documentation Integrity Committee
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The issue I am about to detail to you exemplifies the problem of coding-clinical disconnect that arises from clinicians not understanding the constraints of ICD-10-CM (the International Classification of Diseases, 10th revision, Clinical Modification – the coding set in the United States). As physician advisors, you can be the bridge between the clinician and the coder. Sometimes you need to train the coder; sometimes you need to educate the provider. This issue may require both.
There was an article published in Neurocritical Care, March 16, 2021, by Frontera, Melmed, Fang, et al., titled Toxic-Metabolic Encephalopathy in Hospitalized Patients with COVID-19. When I read the article, alarm bells started blaring in my brain. I could foresee a serious coding-clinical disconnect with the potential to wreak havoc on coders.
The article presented the fact that many patients with COVID-19 experience encephalopathy. Their retrospective, multi-center, observational study showed that nearly one in eight patients had encephalopathy not attributable to the effects of sedative medications. Encephalopathy in COVID-19 imparted an increased risk of mortality of 24 percent. It was also associated with a longer length of stay and an increased likelihood of not being discharged to home.
There is no dispute with the substance of the article. The issue is with the terminology and the coding implications.
The National Institute of Neurological Disorders and Strokes (NINDS) defines encephalopathy as a term for any diffuse disease of the brain that alters function or structure. It has myriad causes, including infection, metabolic or mitochondrial dysfunction, toxins, trauma, poor nutrition, hypoxia, or hypoperfusion of the brain. The hallmark is altered mental status, either in level of consciousness or impaired cognition.
As a review, there are different types of encephalopathy:
Metabolic encephalopathy is the most common pathway. Encephalopathy from sepsis is categorized as metabolic. It is not caused by an infectious agent directly compromising brain tissue – that would be considered an encephalitis.
Also landing in this bucket are electrolyte disturbances, hypoglycemia, hypoxia, and mitochondrial dysfunction. Hypoperfusion and increased intracranial pressure are also metabolic-based.
Metabolic encephalopathy is a major comorbid condition or complication (MCC).
Toxic encephalopathy and toxic-metabolic encephalopathy (for the clinically indecisive) include exposure to drugs, such as overdoses; toxins, such as heavy metals; solvents, chemicals, and uremia. Most of the time, another code is necessary to identify the culprit medication or toxic agent.
If a medication is appropriately dosed and the intention is depressed level of consciousness, that would not be considered toxic encephalopathy. In that case, the alteration of consciousness is integral to the medication administration.
Toxic encephalopathy also risk-adjusts as an MCC.
There are specific types, such as hypertensive, hepatic, or Wernicke’s encephalopathies. There is no rhyme or reason as to why those are only comorbid conditions or complications (CCs).
Unspecified and other encephalopathy were downgraded to CCs a few years ago.
As usual, the crux of the matter is in the details. The article uses two terms that must be discussed further.
They bundled all encephalopathy into toxic-metabolic encephalopathy (TME). The code used for “toxic-metabolic encephalopathy” is G92, Toxic encephalopathy. There is an instruction to code first, if applicable, the drug or toxin that is inducing the encephalopathy.
The prevalence of different etiologies of TME is found in Figure 2 of the article. A total of 28 percent of the 559 patients with encephalopathy in this study had uremia listed as the etiology (uremia is often referred to by providers as causing a TME), and 6.2 percent had formal toxic encephalopathy (supratherapeutic, intoxication, withdrawal, poisoning). The vast majority of patients (61.8 percent) had metabolic encephalopathy with etiologies such as sepsis, hypoxia, hypo/hypernatremia, fever, acidosis, hyper/hypoglycemia, and hypothermia.
The especially problematic term the authors used was hypoxic-ischemic encephalopathy (HIE), which they defined as a global cerebral insult due to oxygen deprivation to the brain or lack of perfusion to the brain caused by systemic hypoxemia, hypotension, or cardiac arrest. This does accurately describe the mechanism of injury. The issue is that there is a specific neonatal entity known by this name and referred to as HIE. The ICD-10-CM code for HIE is P91.6-, subdivided by severity. Perinatal codes are to be used in the first 28 days of life. A condition that arises in adulthood is never coded with a P code. Although “hypoxic-ischemic” describes the mechanism of how the encephalopathy arises in these patients, it will result in a nightmare dilemma for the coders.
This is not just semantics. COVID-19 patients land in the Respiratory Infections and Inflammations MS-DRG. Toxic or metabolic encephalopathy serves as an MCC and elevates the encounter to the highest tier. This article lends credence to these patients belonging in the highest tier, demonstrating an increased consumption of resources by having a longer length of stay and an increased risk of in-hospital mortality. The problem is that If providers read this article and adopt the terminology promulgated in it, coders are going to have to query repeatedly to get codable verbiage. HIE will not be acceptable in this patient population, and the claims will be rejected before they go anywhere. Coders will incessantly querying, and providers will be confused, frustrated, and irritated.
Furthermore, if the TME verbiage predominates, payors may start rejecting the diagnosis because there is no toxin/medication code coded first. There will be an epidemic of payor denials trying to remove the (possible sole) risk-adjusting, tier-elevating MCC from the diagnosis list.
If your providers read the Neurocritical Care article and jump on the TME/HIE bandwagon, here is my advice. Have them read this article so they understand the implications. Then, let’s give them verbiage that makes sense to them.
- If the final pathway to the encephalopathy is metabolic, use the term “metabolic encephalopathy.” Conditions that lead to metabolic encephalopathy are decreased perfusion, hypoxia, electrolyte or glucose disturbances, and sepsis. Many conditions take this common pathway.
- If toxins or medications are a factor, document which medication or toxin is causative and whether it is an excess, underdosing, or just an undesirable adverse effect of the compound. If there is no toxin or medication, reconsider whether TME is the correct terminology. It is probably metabolic encephalopathy instead.
- I recommend that providers who want to use the expression “hypoxic-ischemic encephalopathy” in an adult COVID-19 patient resist the urge and document “metabolic encephalopathy due to hypoxia” (or ischemia, whichever is your intent).
- If your electronic medical record has the functionality to do this, design an acronym expansion that takes “HIE” and “hypoxic-ischemic encephalopathy” to “metabolic encephalopathy due to hypoxia and/or ischemia” in adult patients. If the patient is 28 days old or younger, documented “HIE” should go to P91.6-. Patients who have perinatal conditions that persist beyond the neonatal period may be coded with the perinatal code regardless of age, so if HIE is documented in the pediatric population beyond 28 days, the coder/CDI professional should assess for clinical validity. If HIE causes cerebral palsy (CP), HIE often falls off the clinician’s list, and the specified CP is documented and captured instead.
I am completely supportive of the conclusion that encephalopathy is a big problem in hospitalized COVID-19 patients, and documenting that encephalopathy specifically and accurately is crucial. In fact, I think it will often be companion organ dysfunction to acute hypoxic respiratory failure heralding viral sepsis due to COVID-19. I just hope this Neurocritical Care article won’t cause a coding-clinical disconnect and result in payer denials and headaches for physician advisors.
Dr. Remer is the founder and president of Erica Remer, MD, Inc., icd10md.com
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Denise Wilson, MS, RN, RRT
Member, ACPA Advisory Board, Education Committee
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It’s well known that many folks may be in denial of the actual numbers on the bathroom scale, but this article isn’t about that. This article is about payers denying the ICD-10-CM code of obesity or severe obesity. This article is about a particular payer who employs a third party auditor who routinely denies the obesity codes and accompanying Body Mass Index (BMI) code even though the denials routinely are overturned during external review.
The coding of obesity follows a rather black and white rule. Per Coding Clinic guidelines, obesity is “always clinically significant and reportable when documented by the provider. In addition, the body mass index (BMI) code meets the requirement for clinical significance when obesity is documented.”i The rules around coding obesity and BMI were further explained in the Body Mass Index, Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2018 when the American Hospital Association Central Office published twelve question and answers around the coding of BMI and obesity. This Coding Clinic reinforced the guidance issued in 2011, that obesity and morbid obesity are always clinical significant and reportable when documented by the provider.
Despite this clear guidance, payers continue to audit and deny obesity and the associated BMI codes based on rationale that does not follow the coding rules. Here’s an example. A 40-year-old female who weighed 315 pounds with a BMI 60.5 presented to the hospital with abdominal pain and underwent a laparoscopic cholecystectomy. The third-party auditor employed by the payer reviewed the record and denied the obesity and BMI codes stating that “There was no evidence that the patient's weight was clinically evaluated, received treatment, increased the length of the hospital stay, or increased nursing care or monitoring. The codes for BMI and morbid obesity do not meet the criteria for secondary diagnosis coding per the 2019 ICD-10-CM Official Guidelines for Coding and Reporting, Section III. Reporting Additional Diagnoses.” However, coding rules do not require this criteria be met for the reporting of obesity and the associated BMI. After two levels of internal appeal back to the payer where the denial was upheld, the case was appealed externally to an Independent Review Organization (IRO) which overturned the denial. The IRO stated in their decision, “As per Coding Clinics 2011 and 2018, “Individuals who are overweight, obese or morbidly obsess are at an increased risk for certain medical conditions when compared to persons of normal weight. Therefore these conditions are always clinically significant and reportable when documented by the provider. In addition, the BMI code meets the requirement for clinical significance when obesity is documented. The hospital has correctly coded E66.01 and Z68.44.”
Here's another example. A 53-year-old male admitted for persistent pain following spinal surgery had a documented diagnosis from the provider of morbid obesity and a BMI of 43.7. The auditor stated in their review letter that a clinical validation review was performed which is a separate process from the coding process. It’s hard to fathom how a review of the obesity and BMI codes could fall into a clinical validation process. Yes, the CDC defines obesity and morbid obesity based on a BMI scale. But, coding rules do not. Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2018 States, “While the BMI is used as a screening tool for patients who are overweight or obese, there is no coding rule that defines what BMI values correspond to obesity or morbid obesity, since the conditions are coded only when diagnosed and documented by the provider or another physician involved in the patient's care.”1 It’s been made very clear that obesity and morbid obesity are always reportable when documented by the provider. There is no other clinical evidence required. Now, if physicians are documenting obesity in a patient with a BMI of 18, that’s an opportunity for clarification through a query.
In this denial, the auditor acknowledged the obesity and BMI documentation in the record, but denied both codes stating, “No record was found in the chart of a plan for weight loss or specific treatment related to morbid obesity. No obstacles to treatment were documented that related to body habitus. Diagnoses that have no impact on patient care during the hospital stay are not reported even when they are present." (Coding Handbook, 2016, page 34).” This case also went to external review after exhausting the internal appeal process. Once again, the IRO overturned the denial citing the Coding Clinic for ICD-10-CM/PCS, Fourth Quarter 2018 where obesity and morbid obesity are always clinically significant and reportable.
Now, could you describe in your appeal how the obesity was clinically evaluated, received treatment, increased the length of the hospital stay, or increased nursing care or monitoring? Sure, you could, but you shouldn’t have to. In fact, doing so would be like acknowledging that those criteria must be present for obesity to be coded. If doing so results in an overturn, then it might be worthwhile to continue that appeal strategy. But, that strategy won’t help support an argument back to the payer that the denials are inappropriate.
This pattern suggests a waste of resources all the way around. The third-party auditor denies with incorrect rationale. The provider moves through two levels of internal appeal and then external appeal to gain an overturn. The auditor continues to audit and deny with flawed rationale. Where is the payer in all of this? Why isn’t the payer auditing the auditor that they are paying? Why employ an auditor that repeatedly issues incorrect denials which results in payer resources being consumed to uphold the denial only to have the denial overturned consistently at external review? But let’s not forget that the provider also has an opportunity to stop the cycle by bringing data that exposes this pattern to the payer and demanding an end to the wasteful auditing.
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Analysis of March 2021 Observation Cases |
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Provided by the Members of the ACPA Observation Committee
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Case 1
75 year-old male covered by traditional Medicare with multiple medical comorbidities including diabetic mellitus on metformin, hypothyroidism on Synthroid, CAD on aspirin, and prostate cancer s/p radiation in remission presented to the ED with complaints of fever, cough, nausea, shortness of breath at rest and exertion. Patient also notes loss of taste for past few days with other members of the family with similar symptoms. Upon presentation patient is afebrile, respiratory rate of 30, BP 124/84 and 100% on room air. Patient is placed in Observation due to tachypnea with isolation requirements for suspected COVID.
After one midnight patient continues to have some nausea with shortness of breath upon exertion but notes improvement in shortness of breath at rest. COVID test is positive. Associated inflammatory markers show slight elevation of CRP from 45 at admission to 50 after 1 midnight. Vitals remain stable on room air with no documented hypoxia or tachypnea. Hospitalist is awaiting Infectious disease consultation regarding adding IV steroids vs watchful waiting. Hospitalist would like to monitor patient overnight regardless of initiation of IV steroids due to up trending CRP although symptoms have improved. Hospitalist reaches out to you to see if patient can be considered for inpatient status due to plan to monitor a second midnight with or without IV steroids. What would you recommend?
Committee Analysis of Responses
Thank you for your responses. The responses were almost split evenly with 50% in favor of Observation status and 45% in favor of changing to Inpatient status. The other 5% added comments regarding recommendation for discharge given patient is no longer receiving active medical intervention. There were not many comments regarding rationale for favoring Observation status likely secondary to lack of active intervention with steroids and other medical treatment. However, those favoring inpatient status did comment that it would be imperative to document the associated risk of mortality and morbidity in symptomatic patients with COVID. Inpatient status can also be supported given patient was experiencing continued symptoms of dyspnea after the first midnight and the hospitalist wanted to monitor clinical progression regardless of acute treatment.
Additional CMS Reference that maybe helpful for Case 1 and other cases we encounter daily as Physician Advisors.
“The 2-midnight benchmark is based upon the physician's expectation of the required duration of medically necessary hospital services at the time the inpatient orders written in the formal admission begins. CMS will direct Medicare review contractors that in conducting patient status reviews, Medicare review contractors should consider complex medical factors that support a reasonable expectation of the needed duration of the stay relative to the 2–midnight benchmark. Both the decision to keep the beneficiary at the hospital and expectation of needed duration of the stay are based on such complex medical factors as beneficiary medical history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk (probability) of an adverse event occurring during the time period for which hospitalization is considered. In other words, if reviewer determines that it was reasonable for the physician to expect the beneficiary to require medically necessary hospital care less than 2 midnights, and that expectation is documented in the medical record, inpatient admission is generally appropriate, and payment may be made under Medicare Part A; this is regardless of whether the anticipated length of stay did not transpire due to unforeseen circumstances. “
(Bolded by Author, not bolder in original CMS reference)
Case 2
As per Triage RN: asthma/SOB x 3 days.
History of Present Illness Patient is 75-year-old African-American female with traditional Medicare who has significant past medical history of COPD, 50-pack-year smoke history, stage III lung cancer with metastases to adrenal glands, status post lobectomy, hypertension, diabetes presents here today with worsening symptoms of coughing, dyspnea, wheezing. Patient states she feels very weak and tired. Patient is complaining of feeling short of breath and chest discomfort with coughing. Patient denies any fever or chills. She denies any abdominal pain, nausea, vomiting, or diarrhea. No leg pain or leg swelling.
Patient was seen here for same 6 days earlier. At that time, she tested COVID-19 negative. She was given steroids and bronchodilator protocol; she improved and was discharged to follow-up with primary care doctor.
ED Re-visit : Patient is a 75 year old AAF from home with hx of COPD, 50-pack-year smoke history, not on oxygen, stage III lung cancer with metastases to adrenal glands, status post lobectomy, hypertension, diabetes type II presenting to the ED with increased SOB/DOE X 1 week. Initially COVID negative and treated with prednisone taper, but as symptoms worsened, she returned to ED and was ultimately found to be COVID positive. Admitted to observation for further mgmt.
Committee Analysis of Responses
We note a more variable shift in responses for this case compared to the first case. 55% of the respondents recommended Inpatient admission while only 12% recommended observation status. The other 15% wanted more information prior to making a determination. The additional information requested in the comments included number of midnights crossed and imaging findings. Several comments highlighted they would need more clarification regarding intensity of treatment with an example that if patient did meet criteria for IV Remdesivir, that alone would qualify for Inpatient status recommendation.
The key in this case is also regarding the fact that patient was recently discharged from the ED and now returns with worsening dyspnea on exertion despite outpatient treatment and now testing positive for COVID-19 with multiple co-morbidities. Therefore, one could expect the patient to require greater than 2 midnights in setting of failed outpatient treatment with prednisone. Having the new diagnosis of COVID-19 and knowing that potentially high flow oxygen, IV steroids and Remdesivir could be utilized in the treatment of this patient’s disease.
One of the comments also wanted more details about the insurance plan but please note the body of the question does provide that information. In general, the cases submitted by the Observation committee will continue to use patients with traditional Medicare to highlight any teaching points. Other payers and status determinations are dependent on additional factors besides medical necessity including contract stipulations.
Additional References for COVID-19
While many health care systems have developed their own clinical guidelines on Inpatient vs Outpatient monitoring, home monitoring criteria as well as discharge criteria for COVID patients but please see some standard guidelines below.
Bhimraj A, Morgan RL, Shumaker AH, Lavergne V, Baden L, Cheng VC, Edwards KM, Gandhi R, Gallagher J, Muller WJ, O'Horo JC, Shoham S, Murad MH, Mustafa RA, Sultan S, Falck-Ytter Y. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19. Infectious Diseases Society of America 2021; Version 4.1.2. Available at https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/. Accessed April 9, 2021.
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This Month’s Observation Cases |
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Provided by the Members of the ACPA Observation Committee |
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Note: Traditional Medicare fee for Service for both cases.
Case 1
80-year-old female with PMHx of CAD, CABG, Atrial fibrillation s/p ablation on Xarelto, DM, HTN, and Hyperlipidemia presents with progressive exertional dyspnea with recent outpatient positive stress test. Patient was supposed to have elective cardiac catheterization later this week but due to worsening dyspnea presents to the ED. Patient is placed in Observation status to cardiology service with plan for cardiac catheterization given recent positive stress test and symptoms concerning for angina. Cardiac catheterization that day reveals LAD stenosis and a DES stent is placed. Patient is observed overnight post stent placement. Next morning patient is noted to have decline in Hemoglobin from 9.0 to 8.1 and upon further questioning patient now reports recent dark stools. Cardiology service consults GI team given that patient is now on triple therapy with aspirin, Plavix, and Xarelto and high risk for worsening anemia. GI team evaluates the patient and recommends EGD in house due to recent dark stools and reflux symptoms. Patient is hemodynamically stable but noted to be guaiac positive on exam.
Utilization Management RN sends you the case for a second level review since patient has traditional Medicare fee for service and anticipated to cross a second midnight for EGD procedure and hemoglobin monitoring.
Case 2
67-year-old male with obesity, OSA, and hypertension presented with abdominal pain at 6 am. He is diagnosed with appendicitis by CT scan. Surgery is consulted in the ED at 9 am and after discussion with the patient, conservative treatment with antimicrobial therapy is chosen. You are asked to help the surgeon determine the proper status at this point. The surgeon plans to start iv antibiotics and monitor the patient.
The next day, the patient was transitioned to oral antibiotics, pain medication, and antiemetics. Patient remains afebrile and hemodynamically stable. However, he developed increased nausea and did not feel able to safely go home independently, resulting in a second hospital night.
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American College of Physician Advisors
President's Corner
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I don’t know about you guys, but I’m feeling tired and conflicted. I can sense our own Dr. Clarissa Barnes, Vice President of Member Engagement’s ears pricking up as she reads this about a week into the future given her keen focus on provider burnout. Perhaps there’s a bit of that but also, I think we are all collectively experiencing an odd limbo.
COVID-19 came onto the scene almost 18 months ago, bringing with it so much suffering and far-reaching hardship it can make one uneasy to consider we might be headed toward less tenuous times given the promise of mass-vaccination. For physician advisors and other health system leaders who spent what seemed to be every waking moment trying to keep their hospitals from resorting to crisis standards of care (and away from terms like “rationing”), the decline in severe cases (in some areas of the country) feels like a reprieve. But, while normalcy in our work life seems to be within sight, so are all of the utilization, compliance, documentation, and revenue cycle challenges which remain to be addressed.
Most of us, if not all of us, long for the ability to focus on something other than the pandemic. But, am I the only one who feels other awfulness involving social injustice, mass shootings, and marginalization of at least a dozen groups are simply rushing in to take SARS-CoV-2’s place? As a pale-skinned, cisgender, heterosexual woman, the personal impact on me is low, at baseline. For too many others, many of these stressors ARE baseline and have never been far from thought – pandemic or no.
I live in an area where November through March is cold, grey, often inhospitable, and May honestly heralds in Spring with warmth, shades of green, and birdsong. Forgive me for waxing poetic, but it feels the natural landscape is egging on our infectious disease landscape. “OK, that’s enough of Winter…it’s time for Spring.” But, as the seasons go, we know what’s inevitably coming next in our battle with COVID. Between variants, vaccine hesitancy, vaccine availability, and the simple epidemiological factors involving viral spread in cold environments, we know – grudgingly – that we are not headed toward elimination of this blight despite the currently optimistic vibes. Which brings me back to the limbo.
I’m tired. You’re tired (it’s OK to admit you’re tired). WE’RE ALL TIRED and fed up for a multitude of egregious reasons. Luckily, at the present moment, we’re also in the presence of at least a handful of tiny mercies. Perhaps you can get back to hugging your grandkids and building a Lego castle after a year of absence. Perhaps you can enjoy dinner and a movie at home with your close friends without fear of making each other deathly (not an exaggeration, anymore) ill. Perhaps your teenaged daughter has a new-found interest in gardening and presented you with hand-written sketches of a modern victory garden. Or, perhaps the bird calls out the window are proving to be more of a siren song – beckoning you to lace up those hiking boots lying dormant in your hall closet.
There is still work to be done (SO much work to be done). There are still hardships to overcome and inequities to rectify. There remains the specter of fourth (or fifth or sixth…) waves of COVID-19 or frankly, a brand-new hell-scape of disease we can’t even conceive of. But, at THIS current moment, there’s a little bit of warmth. A little bit of sun, a little bit of hope. It’s OK to be tired. And, it’s OK to heal. The work will always be there, and the challenges won’t go away any time soon. I encourage you to put away your responsibilities and obligations from time-to-time and allow simple pleasures to become a part of your life, again. For now, please excuse me – I see the Ruby-Throated Hummingbirds have begun their migration back to Northern Illinois and I have feeders to fill.
Sincerely,
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Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV
(Pronouns: She/Her)
President, ACPA
Dr. Juliet B. Ugarte Hopkins is Physician Advisor for Case Management, Utilization, and Clinical Documentation for ProHealth Care, Inc. in Waukesha, WI.
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The American College of Physician Advisors (ACPA) publishes and distributes materials created by our members and speakers for the benefit of all ACPA members. ACPA does not certify the accuracy or authority of these materials. These materials are distributed and presented as research information to be used by ACPA members, in conjunction with other research deemed necessary, in the exercise of ACPA members’ independent professional judgment. Original and fully-current sources of authority should be researched by ACPA members. ACPA disclaims all liability in relation to reliance on the content of these materials. The views expressed in the materials are the views of the material's authors and do not represent the views of ACPA. Any references are provided for informational purposes only and do not constitute endorsement of any sources. |
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