Medical Necessity Glenn Krauss BBA RHIA CCSP CPUR

Medical Necessity Glenn Krauss, BBA, RHIA, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI Manager Accretive Health 1

Medical Necessity • Medical Necessity – Fundamental to Medicine – Integral to Revenue Cycle – Basis for healthcare delivery transformation • Right care • Right time • Right reason • Right place • Right documentation 2

NEW PEPPER Target Areas TARGET AREA Full and Abbreviated Title TARGET AREA DEFINITION Two-day Stays for Medical DRGs (2 DS Med) *new as of the Q 1 FY 14 release N: count of discharges for medical DRGs with a length of stay equal to two days (“through” date minus “admission” date = 2 days), excluding patient discharge status codes 02, 20, 07, 82 Two-day Stays for Surgical DRGs (2 DS Surg) *new as of the Q 1 FY 14 release D: count of discharges for medical DRGs N: count of discharges for surgical DRGs with a length of stay equal to two days (“through” date minus “admission” date = 2 days), excluding patient discharge status codes 02, 20, 07, 82 One-day Stays for Medical DRGs (1 DS Med) *new as of the Q 1 FY 14 release D: count of discharges for surgical DRGs N: count of discharges for medical DRGs with a length of stay equal to one day (“through” date minus “admission” date = 1 day), excluding patient discharge status codes 02, 20, 07, 82 One-day Stays for Surgical DRGs (1 DS Surg) *new as of the Q 1 FY 14 release D: count of discharges for medical DRGs N: count of discharges for surgical DRGs with a length of stay equal to one day (“through” date minus “admission” date = 1 day), excluding patient discharge status codes 02, 20, 07, 82 D: count of discharges for surgical DRGs Same-day Stays for Medical DRGs N: count of discharges for medical DRGs with “admission” date equal to (Same DS Med) “through” date, excluding patient discharge status codes 02, 20, 07, 82 *new as of the Q 1 FY 14 release Same-day Stays for Surgical DRGs (Same DS Surg) *new as of the Q 1 FY 14 release N: count of discharges for surgical DRGs with “admission” date equal to “through” date, excluding patient discharge status codes 02, 20, 07, 82 D: count of discharges for medical DRGs D: count of discharges for surgical DRGs 3

Two-Midnight Rule • “When a patient enters a hospital for a surgical procedure not on the inpatient only list, a diagnostic test, or any other treatment and the physician expects the beneficiary will require medically necessary [emphasis added] hospital services for 2 or more midnights (including inpatient and pre-admission outpatient time), the services are generally appropriate. . . ” 4

Two-Midnight Rule • “Documentation in the medical record must support a reasonable expectation of the need for the beneficiary to require a medically necessary stay lasting at least two midnights. ” • The entire medical record may be reviewed to support or refute the reasonableness of the decision, but entries after the point of the admission order are only used in the context of interpreting what the physician knew and expected at the time of admission 5

Clinical Documentation Improvement Today • Principal Diagnosis • Secondary Diagnosis • Present on Admission • Query Process Today • Holistic Documentation – – What Why Where am I? Where am I going • Complete and Accurate Medical Record Documentation – Hospital – Physician – Patient 6

Medical Necessity • What is Medically Necessary Care? – Care that needs to be provided during a stay at the hospital – Medically necessary for diagnosis & treatment (Social Security Act § 1862(a)(1)(A)) • Documentation to establish medical necessity – Clinical status of the patient 7

Medical Necessity • Not just a “hospital thing” • Information used by Medicare is contained within the medical record documentation of history, examination and medical decision-making. 8

Medical Necessity • Medical necessity of E/M services is based on the following attributes of the service that affected the physician’s documented work: – Number, acuity and severity/duration of problems addressed through history, physical and medical decision-making. – The context of the encounter among all other services previously rendered for the same problem. – Complexity of documented comorbidities that clearly influenced physician work. – Physical scope encompassed by the problems (number of physical systems affected by the problems). 9

Physician Engagement Getting physicians’ Attention Getting physicians’ Involved Getting physicians’ Committed 10

Physician Engagement • An engaged physician is directly proportional to the degree of satisfaction with his/her profession and specific situation • Engaging physicians – Improving their outlook and viewpoint on documentation – Query process • “Burden” vs. “Benefit” 11

Clinical Documentation Improvement • Expanded CDI Chart Review – Real documentation improvement opportunities – Severity of illness congruent with intensity of service • H & P-context of admission • Progress notes • Discharge summary – Documentation mutually beneficial – Services that are reasonable and necessary 12

CERT Resource • Documentation Improvement Opportunities abound • Read the report of findings WPS Medicare CERT Error Summary-1 st QT 2014 – http: //www. wpsmedicare. com/j 5 macparta/departments/cert/ j 5 mac-1 st-qtr-error-summary. shtml – http: //www. wpsmedicare. com/j 5 macparta/departments/cert/ j 5 nat-1 st-qtr-error-summary. shtml • Identify your facility opportunities 13

Thank you. Questions? 14