Alabama Quality Assurance Foundation

1

• Alabama Quality Assurance Foundation
• Medical Necessity
• Hugh M. Hood, MD
• Lesia Knight, RN

2
PEPP

• In 2000, 39.5 million beneficiaries
• 173.6 billion in processed FFS claims
• 11.9 billion, or 6.8 improper payments in 2000

3
Total Alabama Discharges

• 382,126 discharges in 1999 for 719,159
  beneficiaries
• 372,884 discharges in 2000 for 725,819
  beneficiaries

4
Types of Error (OIG Audit-2000)

• Unsupported Services
• 
  
• Medically Unnecessary Services
• Coding Errors
• Non- covered Services

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Non-covered Services

• Dental
• Elective sterilizations
• Cosmetic procedures
• Custodial care
• Terminal care in acute care setting
• Comfort and convenience items

6
Obligations of Medicare Providers (Title XVIII
SSA)

• Provide care economically and only when medically
  necessary
• Of a quality that meets professionally-recognized
  standards of health care
• Documented in a form that a reviewing agency may
  require to assure these obligations are being met

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Medical Necessity for Hospital Admission

• MD must document Severity of Illness (SI) and
  Intensity of Service (IS) in the medical record
  to justify necessity of the admission.

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Severity of Illness/Intensity of Service (SI/IS)

• Intended to be a first-line screening tool for
  non-physician reviewers
• Not intended to replace medical judgment
• Allows hospitals to identify questionable
  inpatient admissions on a timely basis
• Same criteria used by QIO

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Severity of IllnessIntensity of Service

• Defined Responsibility
• Case Manager/UR Coordinator
• ER Physician/Attending Physician
• Physician Advisor (PA)
• If admission criteria are not met, the hospital
  can issue a HINN (hospital issued notice of
  non-coverage) - patient liable for charges

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HINNs

• Hospitals may issue HINNs
• Pre- Admission
• Admission
• Continued Stay
• Swing Bed
• Exempt Units

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HINNs (contd)

• How HINNs may assist physicians
• Abandoned patients
• Patient/family forced admissions
• Patient/family refusing to elect alternative care
  setting when medically feasible

12
Consequences of Unnecessary Admissions

• Hospital is obligated to self-report
• Hospital must refund paid claims or submit no
  pay claim
• Hospital may be subjected to audits by the OIG or
  QIO review

13
Physician Obligations

• The physician must order the specified level of
  care at the time of admission
• Specific admission order required
• Admit to Hospital Outpatient Dept.
• Admit to Outpatient Observation
• Admit to Inpatient

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Alternative Settings

• Outpatient
• Observation
• Skilled Nursing Facility
• Rehab Facility, Psych Facility

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Outpatient Procedures

• The physicians order should state that the
  procedure to be performed will be done in the
  outpatient setting
• All procedures defined by OPPS as Inpatient
  Only may result in loss of payment if performed
  in the outpatient setting

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Observation

• Used solely as alternative to inpatient status to
  determine need for inpatient admission
• Usually for 24 hrs, limited to max of 48
• Procedure prep/recovery included in reimbursement
  for procedure and not appropriate use of
  Observation.

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Observation (contd)

• If patient meets inpatient criteria, admit
• Can upgrade to inpatient from observation but
  cannot revert to observation. Must have physician
  order,dated and timed, to convert to inpatient
  care.
• Physician intent at time of admission the
  controlling factor, cannot be retroactively
  changed

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Observation (contd)

• Three new observation APCs may be added pending
  final ruling
• Chest Pain
• Asthma
• CHF

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Non-covered Services for Observation Setting

• Routine prep for recovery from procedures
• Services for convenience of patient, family,
  facility or physician
• Services exceeding 48 hrs unless exceptional
  circumstances noted
• Services provided in an intensive care setting

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Skilled Nursing Facility

• Requirements for admission to SNF to receive
  Medicare benefits
• Medically necessary inpatient stay of at least 3
  consecutive calendar days within 30 days of SNF
  admission
• SNF treatment must be for a condition treated
  during the qualifying hospital stay

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Skilled Nursing Facility (contd)

• The qualifying hospital stay must be medically
  necessary on its own merit
• Avoid admit for SNF placement
• Patients can be admitted to SNF from home - care
  will not be covered by Medicare

22
Rehabilitation Facility

• Admission requirements
• Diagnosis
• Potential for improvement
• Skilled Rehabilitation Therapy
• Ability to tolerate rehabilitation activity
  minimum of 5 hrs per day

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Hospice Requirements
Hospice Requirements

• Must be ordered by physician
• Patient must have life expectancy of 6 months or
  less
• Patient must have primary care giver

24
AQAF Medical NecessityProjects

• Same Day Readmission Project
• Admission Necessity for Inpatient Admissions with
  a Symptom Code Billed as the Principal Diagnosis

25
Same Day Readmit Project

• Admission Necessity 1st Admission Readmit
• Jan - Dec 1999 (Baseline Sample)
• 1139 cases abstracted
• Unnecessary 117 (10)
• July - Dec 2000 (Study Sample)
• 468 cases abstracted
• Unnecessary 69 (15)

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Same Day Readmit Project

• Medically Stable at Discharge 1st Admission
• Jan - Dec 1999 (Baseline Sample)
• 575 cases abstracted
• Not stable 93 (16)
• July - Dec 2000 (Study Sample)
• 229 cases abstracted
• Not stable 103 (45)

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AQAF Medical NecessitySymptom Code Project

• 461 cases abstracted
• Admission not medically necessary in 176 cases
  (38)
• Hospitals monitoring August 2001 November 2001
• AQAF re-measurement
• January-March 2002

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Symptom Codes

• 786.50 - 786.59 Chest Pain
• 780.2, 780.4 Syncope and Collapse
• 786.00 - 786.09 Respiratory
• 780.6 Fever
• 789.0X, 789.6 Abdominal Pain
• 787.01 - 787.03 Nausea/Vomiting
• 780.9 General Symptoms

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Symptom Codes

• 790.7 Bacteremia
• 780.09 Other Altered Consciousness
• 780.71, 780.79 Other Malaise Fatigue

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Medical Back Pain - DRG 243 Third Year Projects

• All records assigned DRG 243 with a principal
  diagnosis of back pain, excluding fractures,
  will be reviewed for admission necessity and
  coding accuracy

31
Medical Back Pain (contd)

• 724.02 Spinal Stenosis/Lumb
• 722.52 Lumb/Lumbosac Disc Degen
• 724.2 Lumbago
• 722.10 Lumbar Disc Displ. 724.5 Backache NOS
• 721.3 Lumbosacral Spondylosis
• 724.4 Lumbosac Neuritis NOS
• 721.90 Spondylos NOS w/o Myelop
• 723.0 Cervical Spinal Stenosis
• 722.0 Cervical Disc Displacmnt

• 721.0 Cervical Spondylosis
• 723.1 - Cervicalgia
• 721.1 Cerv Spondyl w/Myelopathy
• 724.00 Spinal Stenosis NOS
• 722.93 Disc Dis NEC/NOS - Lumbar
• 724.3 - Sciatica
• 722.4 Cervical Disc Degen
• 847.2 Sprain Lumbar Region
• 722.73 Lumb Disc Dis w/Myelopathy

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Medical Back Pain (contd)

• Cases selected from Medicare discharges during
  Jan - Jun, 2001
• 824 cases identified across Alabama
• Full case review currently in progress

33
Medical Back Pain (contd)

• Preliminary results revealed 57 of the cases
  reviewed failed to meet Severity of
  Illness/Intensity of Service criteria for
  admission
• After physician review, 85 of the cases referred
  to PA failed admission necessity

34

Scope of Work 7

• Hospital admission pattern monitoring
• Continue with CDAC surveillance sample
• Projects based on analysis of CDAC sample

35
Quote from Mark Twain

• Always do right. This will gratify some people,
  and astonish the rest.
• ---Card sent to Young Peoples Society,
  Greenpoint Presbyterian Church, Brooklyn 1901

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Alabama Quality Assurance Foundation

• The data in this and subsequent presentations
  related to Alabamas Payment Error Prevention
  Program (PEPP) are preliminary subject to
  adjustments for quality control. They are not
  final or official. In accordance with CMS
  restrictions on non-disclosure, collaborators
  must not publicly disseminate the data.

This material was prepared by Alabama Quality
Assurance Foundation under a contract with the
Centers for Medicare Medicaid Services (CMS).
Contents do not necessarily represent CMS
policy. 6SOW-AL-PEPP-02-02.