Editor's Note

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

Member, ACPA Advisory Board

Member, ACPA Government Affairs Committee 

Editor, ACPA Update

Summer is nearly upon us and I am sure many of you will be taking vacations with family and friends. My wife and I have trips to Alaska and Oregon planned to visit our children. (The third one is in Minnesota; talk about geographic dispersion!) Speaking of vacation in the most depressing way, I was reading LinkedIn and noted a post about a hospital director of nursing who was vacationing in Costa Rica with her husband and a large tree branch fell on her and she suffered a significant spinal cord injury. Her colleagues have started a GoFundMe to raise the funds to transport her back to the US. 

Reading this reminded me that in 2019 I was a speaker at a case management conference that took place on a cruise ship. One of the speakers, Eric Bergman, RN, CCM, spoke about health-related issues that occur during travel. And one of his most important take home points was to never, ever leave the country without purchasing comprehensive travel insurance that includes care coordination and evacuation coverage back to the United States. Imagine being on vacation in a developing country and needing a blood transfusion or surgery. The cost of air evacuation can easily get into six figures and the hospital in the foreign country is unlikely to be of much assistance in making arrangements. Many years ago, my uncle was on a European cruise and had a kidney stone. He was taken to a local hospital for treatment and the hospital would not let him leave until they were paid in full, in cash, in American dollars. My aunt actually paid a few of the cruise ship staff to sneak into the hospital in the middle of the night and “kidnap” her husband, freeing him from this situation.

As those of you who heard Dr Charles Locke speak at NPAC, he made the wise choice in 2019 to spend a few extra dollars for insurance coverage for an infectious disease outbreak to protect NPAC 2020. Of course in 2019 not one of us had any inkling that COVID-19 would occur and he was certain he was throwing away money, but that tiny investment paid off big time for ACPA. Keep that in mind as you travel this year and in the future. No matter how healthy you are, get comprehensive travel insurance. 

June is Pride month and ACPA is proud to stand with all our members, supporters, and every single one of the patients cared for in our hospitals. There is just no place in health care for hatred, bigotry, stereotyping, or lack of compassion. The role of the physician advisor requires always doing what is right, and that includes ensuring that every patient gets the necessary medical care provided in the right setting without regard to their identity. I am personally happy to see many national medical associations reevaluating their conference location choices to ensure that every single one of the attendees can get comprehensive medical care if it is needed emergently. 

Finally, take some time to read this month’s articles. It’s certainly a month of articles about abbreviations - SNF, Z codes, R codes, and BMI. I will take this opportunity to point out that while many will refer to SNF and BMI as acronyms, that is not correct. SNF is an acronym since the letters are pronounced as a word as we do with HINN and RAC, but BMI is different as each letter is pronounced separately, as we do with ABN. The term for that is “initialism.” Now how would you properly describe “CD-ROM”? I have no idea. 

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. 

ACPA Comment on CMS-2439-P

The Centers for Medicare and Medicaid Services (CMS) issued proposed rule (CMS-2439-P) regarding access to and quality of care provided by Managed Medicaid and Children’s Health Insurance Program (CHIP) plans. It can be found at this link: https://www.federalregister.gov/documents/2023/05/03/2023-08961/medicaid-program-medicaid-and-childrens-health-insurance-program-chip-managed-care-access-finance

Given the impact on hospital care, the American College of Physician Advisors (ACPA) Government Affairs Committee and Pediatric Committee seek to offer CMS comments on this proposed rule to encourage adoption of appropriate and consistent inpatient care definition for application to Managed Medicaid and CHIP.

Why should you care? 

1. More than 70% of the Medicaid and CHIP population are enrolled in managed care plans. 
2. Managed Medicaid plans do not offer consistent application of inpatient and outpatient rules.
3. Underpayment occurs frequently for the hospital level of care provided.
4. Administrative burden to fight inappropriate denials is at an all-time high. 

A few highlights of the proposed rule: 

1. Better address health equity issues for Medicaid and CHIP managed care enrollees.
2. Enhance quality, fiscal, and program integrity standards for Medicaid state-directed payments (SDPs).

Check in your email inbox – a comment template you can use to provide commentary to CMS in support of the proposed rule. The main point of this comment is to encourage adoption of appropriate inpatient care definitions to Managed Medicaid and CHIP. Please note, the comment period ends July 3, 2023.

Reference:

https://www.cms.gov/newsroom/fact-sheets/notice-proposed-rulemaking-medicaid-and-childrens-health-insurance-program-chip-managed-care-access

Z Codes Another Tool to Demonstrate the Value Hospital Case Managers Provide to Their Patients and Their Hospitals

Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM.

Chair, ACPA Advisory Board

The health care team is acutely aware that the hospital is the first and sometimes the last safety net patients’ use when community, family, and health plans fail them. Hospitals are unique in that they cannot deny access to care, nor should they, despite health plans and governmental decisions to deny payment. It is nonsensical for hospitals to carry this burden alone, but health care providers need to document the common reasons patients fail at home and find possible solutions.

Many patients continue to use the Emergency Department for their primary care. The social needs of patients can overwhelm busy physicians and frustrate hospital leaders as well as physician advisors as patients stay long beyond the DRG length of stay or extend their observation hours because they cannot leave the hospital safely for a myriad of reasons. Eligible patients may appeal their discharge under their Medicare rights because they do not want to leave the security of the institution. Many patients readmit to the ED or to acute care in less than 30 days because the social problems they face are not resolved and they return to hospital. Fifty percent of readmissions are due to social issues. These include home and transportation instability (ASC Communications, 2020). It is necessary for the health care team to identify those social barriers and the possible causes. 

Physician Advisors spend significant time educating colleagues on the value of excellent clinical documentation to reflect the clinical picture of the patient from admission to discharge. Physicians’ documentation details risk of mortality, affects the level of reimbursement, and justifies the need for specific post-acute care. Case managers can also contribute significantly in painting the patient’s story through documenting their Social Determinants of Health (SDOH).

CMS introduced Z codes in fiscal year 2016, as a method for hospitals to capture issues related to a patient’s socioeconomic condition. SDOH contribute to patients’ individual health, population health, and health care costs (Weeks, Cao, Lester, Weinstein, Morden, 2019). Studies demonstrate patients with a documented SDOH related Z code suffer a higher proportion of chronic disease (Lee, MacLeod, Kuklina, Tong, Jackson, 2023). Understanding how the SDOH affect chronic disease prevalence in the ACO, or Health Plan allow the allocation of dollars to mitigate the actual factors contributing to chronic illness. 

However, hospitals are slow to capture the valuable information that will translate to meaningful data. CMS reports health care providers used Z codes for 1.6% of Medicare fee for service beneficiaries in 2019 (AHA, Jan. 2022). Accurate documentation of social and economic patient factors allow the team to track and address risks for specific patient populations. Although the Z codes are not currently reimbursable, their use contributes to the picture of a hospital system’s value based program and the inherent risk associated with the patient populations they serve. The aggregate data collected across populations can shape public health policy, influence reimbursement models, and target cities, counties, and states that can benefit from increased government or private funding.

The good news about the use of Z codes is that in 2018, CMS allowed non-physician team members, such as case managers and social workers to identify the SDOH, and through their written assessments support coding for the hospital (ASC Communications, 2020). Case manager can provide the necessary documentation to support the implementation of the codes, so it is not solely incumbent on the physician to provide the documentation or duplicate what the case manager documents. Hospital case managers expedite discharges, mitigate readmissions, and solve hefty social dilemmas for patients on a daily basis. They screen for social issues, health literacy, and medication adherence. The systematic collection of information case managers’ document in the assessment, plan, and discharge note paints the picture of the population in aggregate the hospital serves.  

Case manager, like physicians can learn clinical documentation integrity. They can accurately document a patient’s socioeconomic profile through targeted questions and motivational interviewing. Coders will also require the support of the hospital leadership to retrieve the necessary documentation from case managers and social workers and assign the appropriate Z codes.

The following are a list of ICD-10-CM codes retrievable from the case manager’s initial assessment and ongoing documentation. 

Z59.0, Homelessness

Z59.1, Inadequate housing

Z59.5, Extreme poverty

Z75.1, Person awaiting admission to adequate facility elsewhere

Z75.3, Unavailability and inaccessibility of health-care facilities

Z75.4, Unavailability and inaccessibility of other helping agencies

Z76.2, Encounter for health supervision and care of other healthy infant and child

Z99.12, Encounter for respirator [ventilator] dependence during power failure

The codes reflect the reasons patients cannot be safely discharged, and reflect the discharge check off lists used by many case managers while planning a discharge. Case managers should organize the discharge plan and the accompanying documentation to reflect what steps are in place to offset the barriers patients face. 

Physician Advisors and hospital leadership can struggle with the questions, why do patients spend time at the hospital, when their medical issue is resolved and why do patients readmit so quickly. Hospital case managers know they contribute to the successful resolution of social and economic barriers for patients but may not have a method to quantify the value of their assessments and interventions.

Accurate and through documentation of a patient’s social and economic status and subsequently coded in the medical record, may provide an answer for both groups.

Citations:

American Hospital Association. ICD-10- coding for Social Determinants of Health, Jan. (2022). https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-health.pdf

Beckers ACS Review. June 14, 2018: https://www.beckersasc.com/asc-coding-billing-and-collections/icd-10-permits-non-physician-providers-to-document-social-determinants-6-insights.html 

Use of Z-Codes to Record Social Determinants of Health Among Fee-for-service Medicare Beneficiaries in Weeks, William B., et al. "Use of Z-codes to record social determinants of health among fee-for-service Medicare beneficiaries in 2017." Journal of general internal medicine 35 (2020): 952-955.2017 

Jun Soo Lee PhD , Kara E. MacLeod DrPH , Elena V. Kuklina MD, PhD , Xin Tong MPH , Sandra L. Jackson PhD , Social Determinants of Health-Related Z Codes and Health Care Among Patients With Hypertension, AJPM Focus (2023). https://doi.org/10.1016/j.focus.2023.100089

Mary McLaughlin Davis is the Director of Care Management Cleveland Clinic Main Campus and Akron General and past president of CMSA.

Using ICD-10-CM R Codes When Indicated

Erica Remer, MD, CCDS

Member, ACPA Board of Directors,

Chair ACPA CDI Committee

Even if you attended NPAC 2023 in person, you couldn’t attend all the concurrent sessions. Did you know that they are available on demand? Simply open the Whova app and start watching. I have started reviewing the ones I missed, and one of them triggered this article.

I’d like to discuss R codes with you. ICD-10-CM has a category called “Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified,” and the code set is R00-R99 (https://www.icd10data.com/ICD10CM/Codes/R00-R99). The ICD-10-CM Official Guidelines for Coding and Reporting state that “Signs/symptoms and ‘unspecified’ codes have acceptable, even necessary uses.” (Section I.B.18) These codes are to be used when there is no more definitive diagnosis which would explain the patient presentation.

For instance, a patient presents to the emergency department complaining of abdominal pain. There are a host of R10- codes depicting abdominal pain, although they can be quite specific like denoting location (e.g., right upper quadrant or periumbilical pain) or specifying it as abdominal tenderness or rebound tenderness (again, with the ability to specify location of tenderness). If the patient gets admitted and it is determined that the abdominal pain was from a specific etiology, like acute cholecystitis, then the diagnosis should evolve. 

The principal diagnosis (PDx) is “the condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” (Section II). In the example above, the admitting diagnosis could be R10.11, Right upper quadrant pain, but the final PDx would be K81.0, Acute cholecystitis. The R code might be found on the coding abstract as the admitting diagnosis, but it would not be found in the set of final diagnoses.

The reason for this absence is that abdominal pain is considered “integral” or “inherent” to acute cholecystitis. Per the Official Guidelines, “signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.” (Section I.B.5) Once a definitive diagnosis is determined, many of the signs and symptoms become superfluous. You don’t code right wrist pain if a Colles fracture is discovered; you don’t code fever if the patient is diagnosed with pneumonia.

What if the source of the abdominal pain is never ascertained? All the imaging and laboratory studies were negative. The endoscopy was unrevealing. There has to be a final impression. The diagnosis would have to be abdominal pain, and an R code would be assigned.

Another option could be an uncertain diagnosis. Uncertain diagnoses are conditions which are not definitively established but are strongly suspected or have yet to be ruled out. For inpatient coding, an uncertain condition is coded as being present if it has not been ruled out by the time of discharge or demise, as long as it appears in the documentation at the end of the admission (Section III.C.). 

I always recommend combining an uncertain diagnosis with the signs/symptoms which prompted it (e.g., Chest pain, probable acute coronary syndrome; Abdominal pain, rule out mesenteric ischemia). This helps convey the provider’s thought process to other caregivers. However, on the outpatient side and for professional billing, uncertain diagnoses are not capturable. You can only code to the highest degree of certainty. For the pro fee, you would code the sign or symptom even if the facility were allowed to pick up the uncertain diagnosis on the technical (DRG) side. You aren’t permitted to drop the uncertain qualifier and select the definitive diagnosis just to have a code to apply to the patient’s record.

When Dr. Robert Leviton suggested in his “Transitioning Observation to Admission Care, Managing Length of Stay Hours, Discharge Decisions” session that “symptom diagnoses” are never acceptable for an inpatient admission, I believe he was pointing out that encounters which land in a signs/symptoms Diagnosis Related Group (DRG) are often targets for status determination denial. I think he really meant to say that an R code should never be used as a PDx if a more definitive diagnosis can be identified. It is not accurate that “use of an R code mandates outpatient status for observation services as opposed to inpatient status.” At the time of status determination, the final PDx may not yet be apparent. It is not true that “R codes must never be used as PDx.” A sign or symptom may ultimately be the only truthful diagnosis the clinician can use. It just may land the encounter in a less favorable DRG.

The slide that shows his preferred more specified diagnoses to avoid using an R code for a PDx demonstrates a peculiarity of electronic health record systems. When clinicians type in verbiage, the computer offers potential matches. For instance, if we type in “metastatic prostate cancer,” we think there should be a single code describing that. However, in ICD-10-CM, it requires two codes: one for the prostate cancer (C61) and one code detailing the site afflicted with the secondary malignant neoplasm (e.g., C77.5, Secondary and unspecified malignant neoplasm of intrapelvic lymph nodes). However, many EHRs erroneously present a single code (either for the primary or the secondary malignancy) as the correct option. Since the provider doesn’t know any better, they think they have completely captured the condition. This can result in the loss of a risk-adjusting comorbid condition.

Thus, providers who are not familiar with ICD-10-CM may think they are specifying a distinct combination condition, but they are not. For example, the “preferred” verbiage from Dr. Leviton’s slide of “Chest pain due to gastrointestinal reflux disease” is getting translated into two distinct codes: K21.9, GERD without esophagitis and R07.9, Chest pain, unspecified. This has not eliminated the R code; it has merely inserted a more specific code because the practitioner made a diagnosis of gastrointestinal reflux disease. The R code might not even be codable if one considers chest discomfort integral to GERD.

Dr. Leviton and I totally agree on this: the provider should practice excellent medicine, place patients in the appropriate status, and document the encounter accurately. The codes must represent what happened during the admission. Tell the story, tell the truth, and use R codes as PDx only if absolutely, absolutely necessary.

Reference

ICD-10-CM Official Guidelines for Coding and Reporting, FY 2023-Updated April 1, 2023, accessed online May 26, 2023. https://www.cms.gov/files/document/fy-2023-icd-10-cm-coding-guidelines-updated-01/11/2023.pdf 

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

Diabetes, Hyperlipidemia and Hypertension…Metabolic Syndrome check! : Diagnosing Metabolic Syndrome

Rima R. Mercado, MD, CHCQM PHYADV

Member, ACPA CDI Committee

Metabolic syndrome, a.k.a. Syndrome X, a.k.a. insulin resistance is becoming more and more prevalent in our country as the Western lifestyle continues to evolve. Once identified, it rather recognizes a constellation of risk factors that increase the risk of developing type 2 diabetes and cardiovascular disease and more ominous things to come. 

The diagnosis of metabolic syndrome is met if any three of the following 5 traits are present: 

1. Increased waist circumference, with ethnic-specific waist circumference cut-points (table 2)
2. Triglycerides ≥150 mg/dL (1.7 mmol/L) or treatment for elevated triglycerides
3. HDL cholesterol <40 mg/dL (1.03 mmol/L) in men or <50 mg/dL (1.29 mmol/L) in females, or treatment for low HDL
4. Systolic blood pressure ≥130, diastolic blood pressure ≥85, or treatment for hypertension
5. FPG ≥100 mg/dL (5.6 mmol/L) or previously diagnosed type 2 diabetes; an oral glucose tolerance test is recommended for patients with an elevated FPG, but it is not required

Prior to 2006, central obesity was a pre-requisite to meet the criteria. Different organizations including the International Diabetes Federation (IDF), American Heart Association (AHA), National Heart Lung and Blood Institute (NHLBI) and The National Cholesterol Education Program Adult Treatment Panel III (ATP III), with slightly different disease focused targets had mild variations in defining the disease. In 2009, there was a consensus to standardize the criteria to what it is today. 

The challenges sometimes is that clinicians often fail to document the diagnosis of metabolic syndrome even when all the elements are present. Some often still think that BMI and abdominal circumference are absolute criteria necessary to meet the diagnosis. 

This is when a checklist comes in handy. By creating a document template with a standardized format, It can help ensure criteria is met and can facilitate improved documentation despite the busy clinical setting when time is limited and not remembering can be costly. 

As there is no specific MS-DRG for metabolic syndrome, the individual components of the metabolic syndrome such as HTN, Diabetes and dyslipidemia may be assigned relative weights based on the severity of the condution and resources required for treatment. 

Obesity as stated is a risk factor for metabolic syndrome. Therefore, if a patient with metabolic syndrome is also obese, the obesity can be docuemnted as a CC, which can bump to a higher DRG that may add an increase in GMLOS and reimbursement as below. 

It is important for health care providers to accurately capture the comorbidities to ensure appropriate MS-DRG is assigned. In our institution, the template above was created with the stakeholders to help ensure awareness and education was provided. In two months time, there was an exponential increase in the documentation of the diagnosis. 

References

1. Metabolic Syndrome. UpToDate. https://www.uptodate.com/contents/metabolic-syndrome-insulin-resistance-syndrome-or-syndrome-x?search=metabolic%20syndrome&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
2. The Global Epidemic of Metabolic syndrome. Saklaye, Mohammad. Current Hypertension Reports (2018) 20:12 https://doi.org/10.1007/s11906-018-0812-z

Dr Mercado is physician advisor at Dartmouth-Hitchcock Medical Center in Lebanon, NH.

Fighting Back Against Medicare Advantage SNF Denials

Ben Kartchner, MD

The Learning Center Champion

Member, ACPA CDI Committee

Medicare Advantage (MA) companies continue to be a hot topic in the news, as their market penetration continues to increase despite ongoing concerns regarding denials and beneficiary access to care.

A U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) report released in April 2022 stated that “a central concern in the capitated payment model used in Medicare Advantage is the potential incentive for Medicare Advantage Organizations (MAO) to deny beneficiary access to services and deny payments to providers in an attempt to increase profits.”

This report likely led to a rapid response from the Centers for Medicare & Medicaid Services (CMS) in issuing rule 4201, which was proposed and then finalized in only four months. The central tenet of the rule was codifying existing manual language regarding not only the two-midnight rule, but expanding on existing regulations found at 42 CFR 422.101, which states that Medicare Advantage must provide equal or better benefits than a beneficiary would receive with traditional Medicare. While much of the conversation has centered around status determinations, it also applies to beneficiary access to post-acute care.

I recently gave a presentation at the National Physician Advisor Conference, and it was apparent that attendees were struggling with post-acute care (PAC), and specifically, skilled nursing facility (SNF) denials. During peer-to-peer conversations, it came to my attention that MA plans are denying based on criteria such as how far the patient ambulated or whether they required IV infusions such as antibiotics. It is critical that care management (CM) and physician advisors understand the actual medical necessity requirements for SNF transfer under traditional Medicare to effectively advocate for our patients and appeal these inappropriate denials.

Central to the understanding of medical necessity for SNFs is the understanding of skilled care. Conceptually, this can be difficult to see in a hospital setting, as there are no “non-skilled” personnel and the patients are acutely ill, but it becomes much more important as we move into the PAC space, where the patients have generally stabilized, and the focus is more on recovery. Skilled care is care rendered by medical professionals such as nurses and therapists, specifically ordered by a provider. Determination of skilled need is not via a specific diagnosis, nor is it based on the potential or likelihood of recovery. The care can be medically necessary to improve a patient’s condition or to prevent further decline in a patient’s condition. It is important to remember that some services that would ordinarily not be considered skilled can be considered skilled based on a patient’s condition or medical complications. If the care requires the supervision of nursing or rehabilitation personnel, it can be considered skilled care. Understanding the difference between skilled and non-skilled care is critical when discussing medical necessity for SNFs. Generally, the alternative to skilled care is custodial care, which is non-medical care that could be provided by non-licensed caregivers. The below table illustrates some of the important differences between skilled and custodial care.

The importance of understanding the difference between skilled care and non-skilled care is seen when we look at Medicare’s SNF requirements for medical necessity. Despite what Medicare Advantage has led us to believe, based on their inappropriate denials, the requirements are quite simple, and found at 42 CFR 409.31, which states that transfer to a skilled nursing facility is appropriate when the following four criteria have been met:

• The patient requires skilled nursing or rehabilitation services:
• For a condition for which the patient received inpatient hospital services; or
• For a condition that arose while receiving SNF care for a condition for which the patient received hospital services; and
• The patient requires skilled services on a daily basis;
• Daily skilled services can be provided only on an inpatient basis in a SNF:
• Need to consider practicality, economy, and efficiency in this decision; and
• Services are reasonable and necessary for the treatment of a patient’s illness or injury:
• Consistent with the nature and severity of the individual’s illness or injury.

There are a few important points we need to focus on for this discussion. First, does the patient require skilled care? If the answer is no, then the care is clearly custodial, and not appropriate for SNFs. If the answer is yes, then we must decide if the patient would be safe with skilled care 2-3 times per week, or if the patient requires this skilled care daily. If the patient would be safe with intermittent skilled services, home with home health care would be appropriate, but if daily skilled care is needed, then SNF care is appropriate and is covered by Medicare. That’s it! There are no requirements on how much assistance the patient requires or how far they ambulate with stand-by assist (SBA). If your patients are meeting these requirements and being denied by Medicare Advantage, stay tuned, because you should be fighting back.

Medicare Advantage organizations tend to focus on the third- and fourth-listed requirements above when issuing denials for SNF care, particularly when the skilled need is therapy-related. During peer-to-peer discussions, we should be reminding Medicare Advantage of these regulations, and focusing conversations only on these four requirements. MA plans often confuse skilled therapy needs associated with activities of daily living as custodial care. As mentioned above, some non-skilled needs can become skilled based on the patient condition and diagnosis, but this can be seen as a “gray area” by Medicare Advantage, and it can be difficult to convince them otherwise. In my experience, we tend to determine the need for SNF care based on therapy notes, and not based on the patient’s medical needs and comorbidities. Since MA plans often focus on therapy metrics in denials, I recommend focusing on the medical issues for which patients need skilled nursing. Remember, the requirement is that the patient requires daily skilled care that, for reasons of practicality and efficiency, can only be provided on an inpatient basis. Patients who require ongoing IV antibiotics, increased monitoring on diuretics, new blood pressure medications, wound care etc., all could benefit from daily skilled nursing, depending on risk. This alone technically meets the requirements for SNF acceptance and payment. In my experience, it is much more difficult for them to rationalize the medical care in addition to the therapy versus therapy alone. Remember, the above four criteria are not negotiable, as they are regulations. And, as noted, the regulations also state that MA plans must provide the same or better benefits as traditional Medicare.

We have discussed the medical necessity requirements for SNFs, but we also need to briefly review some of the other requirements, given the recent expiration of the COVID-19 emergency waivers. Recently, on Monitor Mondays, Dr. Juliet Ugarte Hopkins discussed the expiration of these waivers and the requirement for three inpatient days prior to discharge to an SNF. If you did not read her RACmonitor article, I suggest you do. The patient must also transfer to the SNF within 30 days of the qualifying stay, with a few exceptions. These exceptions involve predictable delays in the need of skilled care, or the “medical appropriateness exception.” For example, if a patient has a surgery to repair a broken hip, but is recommended to be non-weight bearing for six weeks, skilled therapy may not be appropriate until the patient is weight-bearing. In that case, Medicare does allow for the transfer to a SNF to be delayed beyond the usual 30 days. However, the delay must be predictable, and specifically documented at the time of discharge from the hospital. Care that is unpredictable does not qualify for this exception.

We have discussed Medicare regulatory requirements for SNFs and MA plans to provide the same benefits as traditional Medicare. I recommend that you focus on skilled medical needs in addition to therapy recommendations when sending authorizations and doing peer-to-peer conversations. I recommend you also use this information when discussing post-acute care with physicians. I’m sure that everyone reading this has sent a request for authorization because “the physician wants SNF,” only to have it denied. This results in an unnecessary delay and an avoidable increase in length of stay. Understanding these regulations works both ways. We need to advocate for our patients when MA plans are denying appropriate SNF referrals. These denials result in avoidable hospital delays, poor care, and risk of patient harm. We also need to understand when SNF care is inappropriate so we can educate the entire medical team and get the patient the right care in the right place at the right time.

Dr Kartchner is a Medical Director and Physician Advisor for Multicare in Spokane, WA.

**Reprinted from RACmonitor.com

NPAC 2023 – CME

Earn Up to 29.0 CME Credit Hours from NPAC 2023!

The NPAC 2023 agenda was packed with "must see" presentations. All sessions were recorded and are now available for streaming through the Whova Conference App. Earn 29.0 enduring CME credit hours through the post-conference streaming. Claim your CME in the Whova Conference App, under the Conference Info button on the home page before July 31, 2023, as NPAC 2023 Post-Conference Streaming will be temporarily unavailable due to scheduled maintenance. An invite link to the Whova Conference App will be sent once the registration has been processed.

June 2023

Happy Pride! This is the third year the ACPA has altered our logo in June to show support of our LGBTQ+ community (both within the profession and at-large). Given the state of politics in the United States right now, it’s clear there’s a long road ahead. Of course, changing our classic blues and oranges to the rainbow spectrum doesn’t do squat in the grand scheme of things. But, we embrace the opportunity to remind all of our commitment to inclusion, equity, and support of our patients and peers, alike.

The responsibilities of a physician advisor are incredibly broad but ultimately, we can boil it down to a simple concept: protection of our health systems’ patients by protection of our health systems. This is why celebrating Pride Month is “in our lane.” While our role does not involve patient care, it does involve ensuring the best and most complete care for all of our patients. Regardless of age, regardless of race, regardless of gender, regardless of orientation. I’d still love to hear from you via an article for this newsletter or guest blog post sharing your expertise and experience, including in relation to LGBTQ+ issues. Articles of any length can be directed to our ACPA Update editor, Dr. Ronald Hirsch, at signaturedoc@gmail.com . Thoughts which are more personal or reflective should go to the ACPA Community Blog by e-mailing ACPAdvisorsSocialMedia@gmail.com for consideration. We are so looking forward to hearing from you! 

#ProtectTransKids

Juliet B. Ugarte Hopkins, MD

(Pronouns: She/Her)

President, ACPA