ACPA Update – April 2022

ACPA Update

April 2022

Editor's Note

Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI

Member, ACPA Advisory Board

Editor, ACPA Update

Unlike journals like JAMA, the ACPA Newsletter does not, as of yet, publish single issue editions. As physician advisors, we are rarely challenged by a single issue during a day. But this month, we do have a two articles on the status that is not a status, observation. Dr. Maria Johar discusses observation in relation to transfers and the Observation Committee has presented more observation cases. Feel free to jump right into the observation cases right now- you can find them right here.

How many of us are frustrated with insurance companies and how they do everything in their power to avoid paying for rehabilitation for their policy holders. Reminds me of that saying from hospital IT personnel that their job would be so much easier if there were no doctors, nurses, or patients. I know, I should have more compassion for the investors who count on their insurance company stock holdings to provide them a decent return on their investment. Well, one system has developed a patient-centered approach to the problem. Take time to read the article by Sue Erwin on their very innovative program to help reduce length of stay and speed patient recovery that would work at any hospital.

The CDI Committee remains one of the hardest working bunch of physician advisors I have seen. And they must be as the changes to coding and clinical documentation requirements never seem to stop. Be sure to check out their new CDI documents on pressure injuries on the ACPA website and read this month’s article by Dr. Erica Remer on the critical importance of specificity in documentation of surgical approaches. Who would have ever thought it wasn’t enough to simply say “I cut it out and the patient is better”?

Finally, Dr. Deb Banerjee provides a nice review of the “return on investment” that a physician advisor brings to a hospital. I will use my editorial discretion to note here to be very careful with ROI measurements. What happens when you implement a plan to ensure joint replacements are in the right status and revenue declines because most patients are now outpatient? How do you measure the ROI on improved compliance? If you come into a system where the philosophy was “inpatient admission for all since there is an audit moratorium” and you implement short stay reviews and a self-denial and rebill process, your measured ROI will be negative. Your value is much more than monetary although knowing what dollars you do generate cannot hurt.

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

Condition Code 44 and its Compliant Execution

Dr. Maria Johar MBA CHCQM-PHYADV

Member, ACPA Government Affairs Committee

92 year old independent lady who lives alone in a rural area is brought in by her granddaughter, who is a nurse, for persistent tachycardia and disorientation with difficulty following commands. She has persistent alteration in mental status, a heart rate of 160- 190 which has remained elevated in the ED. ECG in the ED is interpreted as possible WPW syndrome. Cardiology is consulted; they determine IV meds and aggressive care is required for the new symptoms.

Pt arrived at the first hospital on 1/31/2022 at 9:30 pm.

Pt has an inpatient order placed at 2/1/ 2022 at 1:30 am. IMM signed by granddaughter.

Pt was being treated but due to persistent atrial fib in the setting of WPW and documented change in mental status the cardiologist suggests a transfer for the patient to another hospital with ICU and interventional cardiology capabilities. The patient is picked up by the ambulance on 2/2 at 10 am.

Insurance: Traditional Medicare

Pt arrives at the tertiary hospital on 2/2/2022 at noon with persistent atrial fib, iv meds and intermittent confusion and lethargy. Hospitalist admits as inpatient, IMM is signed again, and a very concerned granddaughter is aware her grandmother is an inpatient and will probably need ongoing care. Cardiology recommends an intervention. Patient is awaiting transfer to the cath lab.

On 2/3, a new hospitalist (who has recently undergone UM training and is a new student of the 2 midnight rule) reviews the record and reads that patient is feeling better and has converted back to sinus rhythm and become more lucid and after speaking with the cardiologist again has decided she is not interested in an intervention and decides she wants to go home. The hospital is full and the RN granddaughter agrees to honor her grandmother’s wishes and will be able to stay with her at her home. The doctor decides to discharge the patient per her wishes later that evening once he has communicated with cardiology. Then he realizes she was in his hospital for only one midnight and changes the order to Observation. He wants to put his new knowledge into practice and be compliant with Medicare rules.

This change in status causes the overworked Utilization Nurse to stress out and call on the friendly physician advisor immediately. The physician advisor reviews the case and disagrees regarding the change to observation status. The physician advisor wants to call the attending regarding status change, but the physician is unavailable, he is working the covid unit and missed the call. The attending places a discharge order at 4:30 pm on 2/3/2022. The anxious granddaughter wants to drive the patient home by car as soon as the discharge papers are done due to the long drive home and needs to pick up supplies.

The Utilization Nurse and case manager are now firmly planted in the physician advisor’s office, do they give the MOON or not? Do they inform the granddaughter and patient that now the patient has no appeal rights etc.?

Physician advisor Dr. Calmly Confident explains to the Utilization Nurse that the patient is still inpatient appropriate due to Medicare rules. Condition Code 44 is not applicable. The case manager is concerned she needs to get the right paperwork done or it will be counted against her by her manager as a “failed cc44.”

The attending physician has gone for the day, the new on call hospitalist says “I do not know the patient, my colleague has already done a discharge summary and signed off, I am no longer involved in the care of this discharged pt.” While all this is going on the patient leaves the building with her family.

Questions:

UR = Is this an observation case?

Biller = how are we billing this claim?

Billing auditor = the last order is observation so are we billing observation?

CDI = is this an inpatient or observation and who is going to follow up on the query placed for malnutrition, BMI 16.5 but not clarified?

Coder = is this to be sent to the inpatient or outpatient coder?

Answers:

Dr Calmly Confident explains to the staff, while the order is valid both for the intervention planned and the observation, both are immaterial. Patient will remain an inpatient.

Just like we cannot bill for the valid interventional procedure that was never performed, we will not bill for the observation services. We provided valid inpatient care due to

Pt did receive inpatient well documented active care for more than 2 midnights.
Pt was sick enough, persistent symptoms requiring only inpatient care, intent well documented at both hospitals
Pt declined the procedure and insisted on going home, or she would have spent more nights at the hospital.
Compliant billing will be an Inpatient claim.

Physician advisor makes an appointment to go over the case at the next departmental meeting as well as having a conversation with the attending next day. UM committee would also be notified for further discussion as they do go over monthly condition code 44 and failed condition code 44 (part b billing) on a regular basis.

Please audit your cc44 cases, ensure the process is compliant, they should be rare and unusual as well as part of your UM committee agenda.

Dr Johar is Lead Physician Advisor for Ensemble Health Partners

Length of Stay Management

Sue Erwin DNP, RN, MHA, ACM-RN, CMAC

Member, ACPA Advisory Board

Post-acute placements in a skilled nursing facility (SNF) often delay discharges from the inpatient setting. While we have been fortunate to have the “3 day qualifying inpatient stay” removed under the 1135 Public Health Emergency (PHE) waiver since 2020, most anticipate that will be ending sometime in 2022.

Many insurance companies have had intermittent waivers for Prior Authorization (PA) over the past two years, which was very beneficial to improving patient progression. On average hospital case managers wait one to three days for approval from insurers to place a patient in a SNF which can delay discharge and tie up beds when medical necessity is waning.

We promote to our team that discharge planning begins of the day of admission and advocate for early communication to secure SNF beds. With Omicron we experienced several SNF staffing shortages due to illness which made locating beds even more of a challenge than normal.

As a high reliability organization, our safety tenants recognize that remaining in the hospital increases the risk for Hospital Acquired Infections (HAI) and falls. Additionally from a financial perspective we have acknowledged that some expenditures can positively impact patient progression.

Our organization developed Letters of Guarantee (LOGs) for placements in SNF to expedite discharges where the delays are purely administrative and the patient is medically ready for discharge. There is a five day LOG that guarantees payment by the organization to the SNF while awaiting prior authorization, rather than having the patient sit awaiting PA only. If the prior authorization is obtained on day three, the SNF bills us for days 1-2 at the Medicaid rate and on day three the insurer begins payment. This has been a win-win for both parties as desperately needed beds are opened in the hospital and the vacant SNF beds are filled.

We also have thirty day LOGS which permit a patient with no insurance coverage to receive up to thirty days of SNF care and receive reimbursement from the organization. This is indicated when a patient is uninsured or using motor vehicle liability insurance patient which may take months to sort out and assign payment in these instances.

The final method we use as a tool for “difficult to place” patients is leasing twenty-five nursing home beds where we can send patients that have no other options for post-acute care. These beds are tightly managed by the AVP and Medical Director for Care Coordination on a monthly basis to ensure proper utilization and that patients are moved from the difficult to place bed on to the next most appropriate level of care timely.

Key Performance Indicators (KPI) for Care Coordination include Length of Stay (LOS), Observation Hours. Case Mix Index (CMI) and CMI adjusted LOS. Innovative approaches like LOGs have a positive impact on LOS metrics and facilitate the best possible level of care for patients. A Cost-Benefit analysis supports this concept.

Sue Erwin is Associate Vice President, Care Coordination at Atrium Health Wake Forest Baptist in Winston Salem, NC.

Physician Advisors - Know thy Worth!!

Deb Banerjee MD, FACP, MBA/HC, CHCQM-PHYADV

“I feel helpless!! All my fellow peers are in the throes of a pandemic and all I am doing is trying to justify a status for the patient,” lamented my partner in crime.

I have always felt that physicians should be at the helm of health care delivery. Unfortunately, while the intricacy of giving insulin and fluids and managing electrolytes are drilled into our very core, we have in the past been left to our own resources to imbibe the business of health care delivery, a trial by fire approach. It was to rectify the status quo in a small way that I decided to become a physician advisor. Let me be a liaison between the physicians and the administration, and put our issues on a common platform, speaking the same language to achieve a common goal of exceptional delivery of health care.

As the old adage goes, “No Money, No Mission”, I embarked on a journey to find the value of a physician advisor. We are the grease that improves the efficiency of health care delivery, and while a lot of the administrators recognized this early, remembering they all attended business classes in some form, the impetus to a physician advisor becomes greater when we as advisors know our self-worth.

A few of the examples below give a concrete value in terms of cost savings and revenues generated, but there is a whole segment of health care delivery which when made efficient delivers the goal, despite the Paradox, “Highest Quality for the Lowest Cost.”

Let us look at what happens when you appropriately status an inpatient from outpatient.

Revenue from an outpatient is approximately $2,500.

Revenue from an inpatient approximately $6,500 (at the lower end).

Difference $4,000 with a range of 4k-8k. If there are 3,000 such conversions made in a year then revenue generated is $12,000,000.

Denial overturn is a significant revenue generator. Every denial which is overturned generates an average revenue of about $4,000-$5,000 additional revenue. So if there are 10 denials overturned per month, it results in a revenue generation of $40,000-$50,000 per month, giving an additional revenue to the healthcare facility of close to $600,000 per year! And this is only a small part of what a physician advisor does on a daily basis.

What about cost savings? Every time you help with improving throughput efficiency whether by improving length of stay or decreasing observations hours, it is a cost saving to the health system and helps with decreasing the cost to patients. If the average cost per bed day is between $800-$1800/day, and you are able to decrease the LOS by 0.152 days, 10,000 discharges year gives the health system a potential cost savings of between $1.2-$2.7 million.

The above are just a few of the examples how a team of physician advisors can help add tremendous value to a health care system.

And why is it important to show the value? Understanding the value helps with getting our voices heard amongst the policy makers, and delivery systems, and gets us a seat at that table that makes a great health care delivery system.

Whether it is improving the case mix index through improved clinical documentation, or educating patients and their caregivers, or guiding peers into following best practice processes, or challenging existing regulations, it creates a system of healthcare delivery that is optimal for the people, by the people, made up of the people that we serve as physicians.

So, hold your heads up high my fellow physician advisors, you are priceless.

Dr Banerjee is a Physician Advisor at Dignity Health.

Surgery Documentation Specificity Key to Proper Coding

Erica E. Remer, MD, FACEP, CCDS

Member, ACPA Board of Directors

Co-Chair, ACPA Clinical Documentation Integrity Committee

People often ask me questions about fascinating CDI topics which spawn ICD10monitor articles, Talk Ten Tuesday TalkBacks, and newsletter articles. These topics that they broach usually come from some condition which has been difficult to understand, to reconcile the coding-clinical disconnect, or which the CDIS or PA has been tasked with formulating materials to teach their colleagues or medical staff.

One of our ACPA CDI Committee members just sent me this: CDI team just emailed me that they are always confused about “procedure specificity not only with debridement type and depth, but also laceration repair depth, abscess drainage depth, etc.” This intrigued me because it illustrates how you must understand WHY the question is being asked to be able to give a cogent answer or effective assistance.

A provider has to repair a laceration, or an abscess needs to be drained. What’s the difference how deep the injury or abscess extends?! You debride until you are done removing icky tissue, so why do I need to be so specific?

First, as the PA, you need to understand that there are two different coding systems which are utilized to code procedures. For outpatient procedures facility fee billing and coding for the professional fee, the Current Procedural Terminology system (CPT) is used. Inpatient procedures are codified with ICD-10-PCS (PCS = Procedure Coding System). CPT has codes with precise definitions, and clinicians are more accustomed to providing those terms. ICD-10-PCS requires the coder to understand what was accomplished by the procedure and to pick the correct root operation/s and the correct body part/s. This is why the operative note is so important – if the coder can’t tell what was done to what part, they can’t derive an accurate code.

The codes for laceration repairs and abscess drainage vary for both CPT and ICD-10-PCS depending on certain factors, which might include depth. Let’s explore which specific factors affect the codes for these procedures.

For CPT, the determinants of the Incision and Drainage code set (10040-10180) are:

What type of fluid collection it is, e.g., acne, abscess, pilonidal cyst, subcutaneous foreign body, hematoma/seroma/other fluid collection, postoperative wound infection.
Whether it is an incision and drainage or a puncture aspiration. If excision, debridement, wound exploration, imaging guidance, or secondary closure of a surgical wound is necessary, an additional or alternative code set is used.
Whether it is simple, complicated or multiple. Complicated indicates there was a placement of a drain or packing, probing, or deloculation (isn’t that a great word?!).

I&Ds can also be found elsewhere in CPT, for instance, intraoral, perianal, and vulvovaginal abscess I&Ds.

In ICD-10-PCS, the first decision point is which body system is involved. The deepest layer involved establishes the body system. Skin has a second character of H, subcutaneous tissue and fascia are designated with J; muscles, tendons, and ligaments have their own characters. Once the body system is selected, the fourth character is for the body part, e.g., scalp, face, right or left neck, chest, back, right upper arm, left lower leg, right or left foot. Additionally, the coder needs to be able to ascertain if the procedure was done open or percutaneously and whether a drain was placed.

Similarly, laceration repairs require specificity for both CPT and ICD-10-PCS.

CPT:

Is the repair simple, intermediate, or complex?
Simple: simple single-layer closure, no contamination
Intermediate: layered closure of more than just epidermis and superficial subcutaneous tissues, may require limited undermining, can have significant contamination
Complex: involving or requiring extensive exposure of deep tissues like bone, nerves, or tendons, necessity for debridement or extensive undermining, need for precise alignment like helical rim or vermilion border, or need for retention sutures.
Site of laceration
Size – lacerations at same site with same complexity have their linear length summed

ICD-10-PCS

This one flummoxed me for a bit. If the laceration depth is only skin and superficial subcutaneous tissue and a single-layer repair is done, the approach (for the body system of Skin) is external. However, if the body system is subcutaneous tissue and fascia or deeper, the choices for approach were open and percutaneous. It took me a while to comprehend the concept of percutaneous laceration repair, because intuitively, a laceration seemed like it was by definition “open.”

The essence is the same for any distinction between open and percutaneous – is the part being operated on directly visualized or not? Percutaneous either means through the skin or through a small skin incision where the deeper part is accessed but is not directly visualized. If the fascia or muscle is exposed (often requiring undermining), approximated, and repaired, that is open. If big, deep bites of suture material involve deeper tissues which are not directly visualized, that is percutaneous, even if there is a skin incision. Examples would be fascial plication sutures or galeal repair in scalp laceration when it is done as a single layer (skin, subcutaneous, and galea). I can definitely see where a query might be needed to sort this out.

Finally, debridement.

For CPT:

Is there eczematous or infected skin, necrotizing soft tissue, burns, foreign or prosthetic material or mesh, or injured tissue?
What is the deepest level involved – skin, subcutaneous tissue, fascia, muscle, or bone?
What is the site?
What is the size? If there are multiple sites, the area of like depth is added.
If pressure ulcers are being addressed, excision of tissue may convert the procedure into the 159—series.

For ICD-10-PCS, the CDI Committee has devoted a whole set of materials for the PA on the ACPA website CDI Resource Page. The essential question is whether the procedure involves excision which is the removal of a portion of a body part (e.g., a hunk of skin and subcutaneous fat). An excisional debridement takes the Diagnosis Related Group (DRG) from a medical to a surgical grouping which reimburses higher due to increased resource consumption.

In comparing all of these different procedures, we can see that the elements required to assign an accurate CPT code may not be exactly the same as those needed for the ICD-10-PCS code. The provider may be more focused on the CPT selection because that determines their professional fee, and the CDIS or coder may be more interested in the ICD-10-PCS constituents. The practitioner may be documenting everything they need to support their CPT and may need education as to what is needed for a correct ICD-10-PCS code. Depth and size are critical components.

The bottom line for the PA is that you need to impress upon your medical and surgical colleagues that the CDI team is not asking for gratuitous information, and that it is to everyone’s benefit for them to answer queries accurately and specifically. Understanding the provider’s WHY can help the PA figure out the HOW to close queries.

If you have a CDI situation that arises in your institution or system that you think would be excellent fodder for materials out of our CDI Committee, please send them to icd10md@outlook.com. We are always looking for topics that will help our membership.

Dr. Remer is the founder and president of Erica Remer, MD, Inc., icd10md.com.

Observation Cases April 2022

Provided by the Members of the ACPA Observation Committee

Case #1

80 year old with altered mental status presents to the ED on 2/1 at 8pm, and documentation supports patient is improving but confusion mild and still present. Inpatient order placed. CT negative, blood work negative, UA negative. On 2/2 in AM mental status is “back to normal.” Patient sent home as inpatient at 8 am on 2/2. No UR staff or physician advisor had a chance to review case.

Later that day on 2/2 family returns the patient to the ED with recurrence of slight confusion. The decision to admit to inpatient once again made at 2pm. US carotids negative. Consider MRI next day. IVF administered and neurochecks underway. It appears the patient is improved by 11pm with mental status again back to normal, ambulating, and eating adequately per nursing documentation. Physician rounds in the am and patient is discharged 2/3 11am after PT consult clears patient for safe discharge.

Case #2

85 year old elderly female with multiple medical comorbidities who was recently discharged from the hospital earlier in the day presents with inability to take care of self. Prior admission was a 3 day qualified inpatient stay for management of acute diverticulitis. Patient was recommended discharge to subacute rehabilitation facility however patient refused and wanted to be discharged home with husband.

Upon arrival at home with transportation services, patient with some difficulty ambulating with the walker. Husband became nervous about inability to take care of patient at home himself and patient now sent back to the ER for help with placement and inability to take care of self at home. Patient does report some abdominal discomfort, improved from last admission and equal to the discomfort she had upon discharge, able to tolerate oral intake and oral antibiotics prescribed upon discharge.

Go to https://www.surveymonkey.com/r/ZHZSHZH to read the cases and see the questions.

American College of Physician Advisors

President's Corner

March 2022

President’s Note: I am so happy to introduce ACPA’s Vice President of Member Engagement, Dr. Clarissa Barnes!

–Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, FABQAURP

Happy (belated) Doctor’s Day! The last several years have been challenging to say the least so I hope you were able to take a least a day to reflect on our shared profession. No matter how you split your time, everyone I know has been asked to expand our roles and responsibilities. Personally, as I reflected, it has been reassuring to me to know that even on my worst days, I’ve had the support of my colleagues. The physician advisor community has been one of the most welcoming groups I’ve ever had the privilege to be a part of. I don’t know if it’s because so many of us started this work as the sole physician advisor in their hospital/health system, learning as we went and therefore anxious to provide the support to others they didn’t have themselves or if physician advisors are an inherently welcoming sort. I suspect it’s some of both.

One of my favorite parts of my current role is getting to identify future physician advisors and help mentor them in this new career. Working as a physician advisor has allowed me to be able to help patients in new ways and I love being able to advocate on their behalf. I also think physician advisors have a key role in helping other physicians. We can take on administrative tasks that are burdensome to our patient-facing colleagues, tasks we know are associated with higher rates of burnout. So when I get to show all of these benefits to new physician advisors and watch as they grow in this profession, I cannot help but feel excited for the future of our profession.

As we come out of the survival mode we’ve been in due to COVID pressures, I hope you’ll reach out to your colleagues. There are so many ways to connect with each other and it’s more important than ever. Through the American College of Physician Advisors you can join a committee (Pediatrics, Observation, Government Affairs, Clinical Documentation). We’re always looking for people to submit articles to the Newsletter. Of course, one of the best ways to network is to attend a conference. The National Physician Advisor Conference (#NPAC2022) is happening April 11-13^th in Austin, Texas. NPAC Chair Dr. Elizabeth Quinn and NPAC Champion Dr. Emeric Palmer have been hard at work getting ready for our first in-person event since the pandemic started. If you’re attending, please say hello! I can’t wait to see everyone in person. If you’re not coming, you can always reach out to me via social media as well. The ACPA has a presence on LinkedIn, Facebook, and Twitter and I would love to talk to you!

Clarissa Barnes, MD, CHCQM-PHYADV, FACP

Vice President Member Engagement, ACPA

Dr. Barnes is a System Physician Advisor for Avera Health in Sioux Falls, SD.

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