Healthcare Coverage Expanded to DACA Recipients

By Tiffany Ferguson, LMSW, CMAC, ACM

In a significant move aimed at enhancing healthcare access for Deferred Action for Childhood Arrivals (DACA) recipients, the Biden-Harris Administration has finalized a rule that expands eligibility for health coverage under the Patient Protection and Affordable Care Act (PPACA) and Basic Health Program (BHP).

DACA is a program enacted in 2012 that provides relief from deportation and work authorization for immigrants brought to the United States as children. This policy shift, announced by the U.S. Department of Health and Human Services (HHS) through the Centers for Medicare & Medicaid Services (CMS), represents a step in the right direction toward ensuring equitable healthcare for residents in the United States.

Specifically, the ruling makes a minor but important change to the definition of “lawfully present,” which is a requirement for eligibility enrollment in a qualified health plan. The current definition of “lawfully present” does include certain immigration classifications, such as Green Card holders, Cuban and Haitian entrants, and so many other classifications; however, it specifically excludes DACA. With this modification, DACA recipients will no longer be excluded from that definition, making it possible to participate in the next enrollment period starting Nov. 1, 2024.  

It is important to note that the change of definition for eligibility under “lawfully present” does not apply to Medicaid or the Children’s Health Insurance Program (CHIP) at this time. The current eligibility for Medicaid and CHIP allows states to include coverage for children and pregnant individuals who are lawfully residing in the United States, including those within their first five years of having certain legal status.  

To fill the gap, the PPACA will allow noncitizens who are ineligible for Medicaid because of their immigration status to access financial assistance, such as the Premium Tax Credits and Cost Sharing Reductions through a Marketplace plan, even if their income is below 100 percent of the federal poverty level.

This measure is expected to extend health coverage to approximately 100,000 previously uninsured DACA recipients, addressing a pressing need within the community. The news briefing on this change from CMS stresses the belief that healthcare coverage is a right, not a privilege.

CMS expressed a commitment to providing comprehensive education and technical assistance to support the implementation of this rule, ensuring that immigrants and other communities receive the necessary guidance to navigate the healthcare enrollment process effectively.

CMMI Independence at Home Program Falling Short After 8 Years

By Tiffany Ferguson, LMSW, CMAC, ACM

In late April the Center for Medicare & Medicaid Innovation Center (CMMI) released the evaluation of their Year 8 Independence at Home (IAH) demonstration. IAH is a Congressionally mandated initiative that seeks to evaluate the efficacy of incentivizing home-based primary care, reducing healthcare spending, and enhancing the quality of care for high-cost, high-need Medicare beneficiaries. This evaluation has provided valuable insights into the impact of such interventions, particularly in the context of the COVID-19 pandemic.

The IAH initiative commenced in 2012 with 18 participating practices, aimed at testing whether payment incentives could drive improvements in healthcare outcomes. Over subsequent years, the number of participating practices decreased, with only seven practices remaining by Year 8, amid the challenges posed by the pandemic for in-home services.

Some of the decline in participating primary care clinics is attributed to the program’s strict requirements, such as being available for primary care home visits at all hours, pending patient need, and the requirement to achieve success in cost reduction at least once in three consecutive years. The beneficiary requirements include that Medicare Fee-for-Service (FFS) patients have at least two chronic conditions, require assistance with at least two activities of daily living, and have been hospitalized and received acute or subacute rehabilitation services in the 12 months prior to program enrollment.  Beneficiaries must also not be in any long-term care or hospice program at the time of enrollment in the demonstration.

The evaluation focused on assessing the effects of IAH on total Medicare spending per beneficiary per month (PBPM) and other relevant outcomes, such as the number of ambulatory visits compared to acute-care services the members received during the demonstration period. In Year 8, although there was a potential reduction in total Medicare spending, it was not statistically significant. Notably, the incentive payments made to IAH practices exceeded the estimated spending reduction, raising questions about the cost-effectiveness of the program.

The report noted that while IAH beneficiaries experienced 16 percent more ambulatory visits compared to their counterparts, primary care remained the central service to their healthcare delivery needs. The breakdown of results was mixed: although inpatient spending was down, hospital admissions increased in Year 8, as did readmissions. 

The findings suggest that while the IAH initiative may seem theoretically appropriate to enhance the patient-PCP relationship, the sole mechanism of home-based services did not yield significant results (and likely was near-impossible during the pandemic). In addition, this is likely difficult to scale, given the already known shortage of primary care physicians and the efficiencies that telemedicine can provide, which are outside model expectations.

Additionally, the role of extenders to support home-based services such as chronic care management and community health workers may be better-suited to address in-home care for patients with chronic conditions and in need of home assistance than pulling primary care providers out of the clinic for home-based services.    

In conclusion, this model makes splitting the value-based and FFS payment structures difficult, as program design was incentivizing services on top of a FFS reimbursement structure, rather than a replacement via other capitation or value-based payment methodologies.

Coding Questions Arising From NPAC, Answered

By Erica Remer, MD, FACEP, CCDS, ACPA-C

I attended the 2024 National Physician Advisor Conference (NPAC) hosted by the American College of Physician Advisors (ACPA) in the middle of April. Its theme was “Safeguarding Patients Amidst Shifting Currents of Healthcare.” I love this conference because it is so rich with information and expands my knowledge base beyond clinical documentation integrity (CDI).

I gave an intro to CDI talk at the Essentials and Fundamental course on the first day, where we trained new physician advisors (PAs) and prepared veterans to sit for the ACPA-C. This is a new certification developed by the premier physician advisor organization to signify that an individual has the working knowledge to serve as a PA.

I also had the honor of kicking off the second day with a plenary session called Physician Advisors: Lifeguards Innovating Solutions to Diverse CDI Problems, in which I shared some details about projects I implemented while I was a physician advisor. I received some questions after the fact, and thought this might be a good venue in which to answer them.

How can you get organizations to move beyond only using MS-DRGs as the tool of risk-adjusting metrics?

Originally, CDI was meant to seek out and capture comorbid conditions and complications (CCs) and major CCs (MCCs), thus optimizing each MS-DRG and tier and improving reimbursement and length of stay. When the All-Patient Refined (APR)-DRG methodology was introduced, optimizing the severity of illness (SOI) and risk of mortality (ROM) metrics was a companion goal.

Then came value-based purchasing and other related quality metrics, again establishing other risk-adjustment-type models. And we can’t forget the Hierarchical Condition Categories (HCC) model for Medicare Advantage (MA) and other Accountable Care Organizations (ACOs).

If an organization is only looking at MS-DRGs, they are missing opportunities in multiple other risk-adjusted models. It’s a good place to start for burgeoning CDI programs, but it is only a jumping-off point.

My philosophy always has been to encourage providers to deliver excellent medical care, foster excellent documentation, have CDI specialists (CDISs) pick up the slack when needed, and ensure that coders accurately and compliantly code – and your reimbursement and quality metrics will fall where they belong in every model.

This segues into another question asking if I have any comment on documentation for getting out of PSIs (patient safety indicators). I attended two great talks on the topic of PSIs and quality metrics, by my Vice Chairs (Waldo Herrera-Novey and Adriane Martin) and two other members of my committee (Neelima Divakaran and Joey Cristiano). We all agree: We want folks not to get dinged when the problem is not really a post-procedural condition, and to address medical quality issues if it is. I never condone doing excessive contortions to avoid legitimate post-operative complications. Providers need to be taught that post-op is not a temporal reference, and to ensure that proper linkage is present. If the acute hypoxic respiratory failure is due to an exacerbation of underlying chronic obstructive pulmonary disease (COPD), say that, not “post-operative respiratory failure.”

Another PA asked if I could suggest resources through which you can access how CC/MCCs have financial impact on reimbursement. MS-DRGs are tiered by whether there are CCs or MCCs. Having a single CC is equal to having five of them. The relative weight is a measure of the average resource consumption, severity, and complexity of the patient. When you multiply the relative weight by the hospital’s blended base rate, you determine the reimbursement. If you refer to Table 5 of the current fiscal year’s Inpatient Prospective Payment System (IPPS) Final Rule (https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/fy-2024-ipps-final-rule-home-page), you can find the specific DRGs’ relative weights. You can see the difference between a base DRG without a CC or MCC versus with one. You have to ask your administration for your hospital’s base rate.

Our health system has chosen to use Sepsis-2 as our criteria. Are we wrong? and Why not use severe sepsis if it’s on the list of CMS-approved codes and there’s a recognized definition?

First, let me get the terminology straight. SEP-1 is the terminology that indicates The Severe Sepsis and Septic Shock Management Bundle, which is the National Quality Forum sepsis quality measure that the Centers for Medicare & Medicaid Services (CMS) use. Its aim is to standardize sepsis treatment to reduce morbidity and mortality from the condition.

(To find the most up-to-date version, search for Specifications Manual for National Hospital Inpatient Quality Measures and the year of interest. It is listed by quarter. For Q3 and Q4 2024: https://qualitynet.cms.gov/files/65972a96d4b704001df0ae89?filename=HIQR_SpecsMan_v5.16.zip)

In the 1990s, esteemed medical groups came together to try to define the condition of sepsis and operationalize its treatment. Multiple iterations of the literature came out every few years, but Sepsis-2 (not SEP-2) was essentially defined as a presumed or confirmed infection with some systemic inflammatory response syndrome (SIRS) criteria. Although there were always other clinical indicators that could be seen in sepsis, the medical community gravitated towards using the general SIRS criteria, which were ubiquitously collected in all patients in whom the diagnosis was being considered. These were:

• Fever or hypothermia;

• Tachycardia;

• Tachypnea; and

• Elevated or low white blood cell count.

In Sepsis-2, there were three buckets of sepsis: sepsis as defined above, severe sepsis, which was sepsis with organ dysfunction, and septic shock, which was severe sepsis with hypotension not reversed with fluid resuscitation. ICD-10-CM has codes to indicate all three gradations.

Eventually, it was recognized that this was too broad a definition – there were many patients with infections who exhibited SIRS criteria but did not have sepsis, and some patients who had sepsis but didn’t demonstrate these particular signs.

Hence Sepsis-3. In 2016, The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) were rolled out. The definition was established as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” It was recognized that SIRS was sometimes an appropriate response to infection, and therefore, might not indicate sepsis. Furthermore, the presence of organ dysfunction is the critical ingredient for the diagnosis of sepsis.

This contracted the buckets to two: sepsis (the condition formerly known as severe sepsis, which includes organ dysfunction) and septic shock. ICD-10-CM did not change the coding schema. As a result, all sepsis now should have a code for the sepsis, another code indicating the presence of organ dysfunction, with or without shock, and additional codes for the causative infection and the resultant organ dysfunction.

In early 2017, Surviving Sepsis Campaign adopted the Sepsis-3 definition. They concurred with the International Consensus folks that “The current use of two or more SIRS criteria to identify sepsis was unanimously considered by the task force to be unhelpful” because “SIRS criteria do not necessarily indicate a dysregulated, life-threatening response.”

During the reign of Sepsis-2, many organizations put in place an alert system, and they utilized those basic SIRS components as the trigger. It is still useful as a warning signal, but SIRS does not establish sepsis. Many providers are resistant to change and cling to SIRS. I am supportive of using SIRS to identify patients who might have sepsis, but I strongly caution against using it as the diagnostic criteria.

The question I would ask the first organization is: do they want to catch in their net patients who do not end up having sepsis? Identify potential sepsis patients preliminarily and then have the clinicians rule it out over the course of the encounter. Then, the diagnosis should be removed before being coded and final-billed.

If you don’t, you frontload the system with patients who are erroneously assigned into a sepsis DRG, and you will be inundated with clinical validation denials on the back end. Not only that, but the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has added Medicare inpatient hospital billing for sepsis to their workplan.

Is it wrong to use Sepsis-2 as your criteria? I would not recommend it. The current definition has been around for seven years. It’s time to transition.

Why shouldn’t providers use “severe sepsis” if it is on the list of CMS-approved codes and there’s a recognized definition? I don’t believe clinicians should alter their practice of medicine to satisfy coding. They may need to include some antiquated terminology, however, for the coders to capture legitimate conditions, due to the peculiarities of coding rules. Fortunately, there is coding guidance instructing coders that if providers diagnose sepsis with related organ dysfunction, the coder may compliantly pick up R65.20, Severe sepsis without septic shock, without the doctor using the obsolete qualifier “severe.” The condition formerly known as “severe sepsis” is now just “sepsis.”

Consider inserting my macro into your electronic health record (EHR):

Sepsis due to (infection) with acute sepsis-related organ dysfunction, as evidenced by (organ dysfunction/s).

This allows the clinician to avoid having to use old terminology, with the bonus of helping them ensure that the condition is indeed present and clinically valid.

The last question was, “How do you message the importance of thorough and complete documentation when physicians/providers are thinking the E&M 2023 changes have now relieved them of ‘note bloat?’”

I don’t endorse conveying the message that documentation is for billing. I believe thorough and complete documentation is important to tell the story of each patient encounter.

The professional fee Evaluation and Management (E&M) changes made in 2023, when Inpatient and Observation Hospital Care merged, are only based on medical decision-making (MDM) or time, which now should reduce note bloat. The history and physical examination should be performed and documented “as medically appropriate.” No more gratuitous review of systems just to check a billing box. There is no reason to embed a radiology report in the progress note at all, let alone every day of the admission. The provider only gets credit for it once. Rather than copying and pasting the assessment and plan daily, maybe spend a few moments thinking about what needs to be in the note today and how it informed your decisions.

Reducing note bloat means streamlining the documentation to make it really count. Does “no acute events overnight, no acute distress this morning, reportedly at baseline” explain why the patient in Room 204 is still here today? Does a list of signs and symptoms relay what your impression is? Does a hodgepodge of copied and pasted paragraphs really constitute a discharge summary? Remember that your “copying and pasting saves me time” is someone else’s “I hate slogging through other people’s copying and pasting to find the essential points.”

It is crucial to not buy into the “documentation is an unwanted burden on the provider” nonsense. Documentation is part of the process of delivering quality medical care to the patient and enabling others to recognize it. If providers put “mentation” into their documentation, the medical record and the patient will be better off for it.

Who Can Perform Clinical Validation?

By Erica Remer, MD, FACEP, CCDS, ACPA-C

There has been a kerfuffle on LinkedIn I would like to expound upon today. A colleague of mine, Siraj Khatib, was recently expressing his exasperation at clinical validation audits.

He referred to the Recovery Audit Program Statement of Work (SOW). In 2011, there was a paragraph in the section titled DRG Validation vs. Clinical Validation, which read, “clinical validation is a separate process, which involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented. Clinical validation is beyond the scope of DRG (coding) validation, and the skills of a certified coder. This type of review can only be performed by a clinician or may be performed by a clinician with approved coding credentials.”

Dr. Khatib went on to posit that “only a bedside clinician is able to understand, interpret, (and) judge a patient’s clinical condition,” and pondered how “a medical director can have clinical acumen … (having) relinquished bedside medical practice for the comfort of an office, awaiting a bonus to churn out denials.”

There is a lot to unpack here.

First, I would like to validate the frustration of incurring unfounded denials. It requires a great deal of time, effort, and money to combat denials. Sometimes, there is legitimacy – the medicine is questionable, or the documentation is weak. Often, it is infuriating – the medicine is solid, the documentation impeccable, and the insurer is just throwing spaghetti against the wall to see what sticks.

Who is qualified to perform clinical validation, determining if a patient possesses a condition that is documented? The only one who truly can perform clinical validation is a clinician who is taking care of the patient. Did the patient have an exacerbation of their chronic systolic heart failure or not?

However, that is not how the system works. People who are not responsible for the patient’s medical care review the documentation and must make determinations based on the way the encounter is portrayed in the medical record. That is referred to as “clinical validation.”

Who is sufficiently competent to perform this role? The 2011 SOW expressed the decision of the Centers for Medicare & Medicaid Services (CMS) that they were going to only permit clinicians to make clinical validation determinations. I have always asserted that their decision to only utilize clinicians, such as nurses or physicians, is not a universal mandate. It was the stated practice of CMS.

Two of the best clinical documentation integrity specialists (CDISs) I have ever known were non-clinicians, and came from the health information management (HIM) world (you know who you are, Colleen and Kathy!) I do not think it is out of the question that someone from HIM would be capable of doing clinical validation, but I do contend that not all HIM individuals would be able to do so. They need to have experience in the clinical setting and long-term exposure to the medical record. Although clinicians (e.g., nurses, advanced practice practitioners, foreign medical graduates, etc.) are more commonly employed as CDISs, knowledgeable HIM folks are allowed to be CDISs. If they can serve as a CDIS, they can perform the task of clinical validation.

Institutions and systems can make the determination as to whom they deem competent to perform clinical validation. They do not need to insist on clinician credentials. By the same token, commercial payors have the latitude to make this same decision for their organization.

I completely missed the memo about this: in 2017, CMS revised its SOW to read, “clinical validation is prohibited in all RAC (Recovery Audit Contractor) reviews.” CMS no longer specifies that a clinician must perform clinical validation; they say that they are no longer doing it at all. I’m not sure that all the RACs got that memo, either!

But I want to address Siraj’s last contention. When I became a physician advisor for a large multi-hospital system, the system chief medical officer (CMO) advised me to continue practicing clinically. As an obstetrician, he missed operating. I, on the other hand, believed that for the safety of my patients, there was a minimum threshold of hours to remain clinically competent, especially in terms of procedures. If a patient needed an emergency thoracotomy or tracheostomy, I was not the right person for that job. However, I was really good at my non-clinical physician advisor job, despite no longer practicing at the bedside. I am really good at deciphering documentation, and I have 25 years of clinical experience to back it up. I am more than capable of determining medical necessity and quality of care from the medical record, without seeing patients on a daily basis. I suspect that medical directors in insurance companies also have years of experience behind them.

That is not really the fundamental issue.

How people wield their knowledge and generate denials is the problem. Having artificial intelligence (AI) generate a zillion denials in a matter of seconds is a problem. Working on contingency, whereby throwing spaghetti on the wall is profitable, is highly questionable. Rejecting an appeal without weighing its merits is an issue. Having a bonus based on productivity and not on merit is a problem.

One of my superpowers is being able to see things from all sides. I believe the system as it is designed is important, with checks and balances. Providers shouldn’t be able to engage in fraud and abuse, and payors should have to pay for services legitimately rendered without throwing up roadblocks. The government is the biggest payor, and they get their money from me and you. We don’t want them to be squandering our taxpayer dollars, but we don’t want our hospitals to go bankrupt fighting ridiculous denials, either.

If providers deliver excellent medical care and document their thought process well, then payors should pay for medically necessary care of their beneficiaries. If any of these elements is not present, there should be consequences. Clinical validation is one cog in that process, and you don’t have to be an actively practicing practitioner to make that judgment.

Pediatric Sepsis Defined: Experts Endorse Organ Dysfunction

By Erica E. Remer, MD, FACEP, CCDS, ACPA-C

Those of you who live in the adult world may not even be aware that the sepsis conundrum (i.e., Sepsis-2 vs. Sepsis-3) didn’t really pertain to pediatrics. That matter was tabled whilst the so-called grown-ups squabbled. Their previous criteria hailed from 2005, specifically from the International Pediatric Sepsis Consensus Conference. But it was already clear then that sepsis needed to be updated and better defined for the pediatric population as well, so an international consensus panel was convened in 2019, and the results were published online on Jan. 21, 2024.

The International Consensus Criteria for Pediatric Sepsis and Septic Shock (hereafter referred to as the International Consensus) were derived by 35 clinical experts from diverse pediatric practice in 12 different countries. The first thing that struck me was that they refer to a sentinel article titled Guidance for Modifying the Definition of Diseases: A Checklist, published in the Journal of the American Medical Association (JAMA) Internal Medicine in July 2017. It didn’t occur to me that there is a process to make adjustments in disease definitions. I wonder if it was crafted in response to the mess that arose after Sepsis-3 was introduced. The article explains that there is a fine line to walk between over-diagnosing conditions and capturing them early and often, versus harming patients by not entertaining a diagnosis quickly enough.

Something specific in that article struck a chord with me: “Diseases do not generally have discrete boundaries, and (my inserted word: clinical) judgment is required to determine the thresholds for diagnoses.” It seems as though it is more prudent to have many multidisciplinary representatives with expertise in the condition being addressed, making thoughtful decisions about diagnostic criteria than it being the Wild West, where everyone uses whatever criteria suit them that day – and for their own purposes.

The approach they took for the pediatric sepsis criteria was first to administer a global survey of 2,835 clinicians, published in The Current and Future State of Pediatric Sepsis Definitions: An International Survey, asking what the condition sepsis constituted and what the word should mean. I found this curious until I realized before there was even a Sepsis-1, we used to diagnose sepsis by gestalt. You walked in a room and said, “Uh-oh, this patient is really sick!”

The ultimate conclusion, supported by the majority of respondents, was that sepsis is an “infection with associated organ dysfunction.” The International Consensus authors noted that this was preferable to “infection-associated SIRS (Systemic Inflammatory Response Syndrome),” and that this evolved definition indicates “widespread adoption of the Sepsis-3 conceptual framework.”

Next, they undertook a systematic review of more than 3 million pediatric encounters, letting that inform the design of a derivation and validation study. The original concept was an eight-organ system model, but they ultimately dropped the renal, hepatic, endocrine, and immunological dysfunction criteria, seemingly to reduce “requirements for laboratory investigation and data collection.” I watched a presentation by the Children’s Hospital Association, and their commentary was that isolated hepatic, renal, endocrine, or immunological dysfunction was unusual, and it was far more common to be seen in conjunction with dysfunction of one of the other included systems, thus rendering those systems redundant.

The International Consensus settled on a composite four-organ system model, which was coined the Phoenix Sepsis Score (PSS). It seems as though the PSS was originally intended to be a prognosticating tool for mortality, similar to the Sequential Organ Failure Assessment (SOFA) score, but ultimately, attaining a score of 2 or more on the PSS was defined as identifying sepsis in an “unwell child with suspected infection.” Accruing ≥ 1 point from cardiovascular dysfunction establishes septic shock.

The PSS includes respiratory, cardiovascular (CV) (with age-based mean arterial pressure values), coagulation, and neurological systems. They are variably weighted, with CV potentially offering up to 6 points, respiratory up to 3 points, and the other two only up to 2 points. The score was designed to be able to be utilized even in low-resource areas.

There are a few more points regarding the International Consensus:

• If a child manifests organ dysfunction remote from the site of localized infection, they are recognized as being at higher risk of mortality than if they only have a localized, single-organ system impairment (e.g., respiratory failure in pneumonia).

• The PSS is assessed in the first 24 hours of presentation to the hospital. The article notes that the PSS “is not intended for early screening or recognition of possible sepsis and management before organ dysfunction is overt.”

• Due to the difficulty of defining organ dysfunction in neonates born < 37 weeks’ gestation and the contribution of perinatally acquired infection, term newborns remaining in the hospital after delivery and neonates whose postconceptional age is younger than 37 weeks are excluded.

Here are some of my concerns regarding the International Consensus:

• They use mortality as their only endpoint (morbidity is also a major concern post-sepsis);

• They limited the development of the PSS to data from the first 24 hours of hospitalization (again, with the primary endpoint of predicting risk of mortality). Clearly, children with infections and organ dysfunction discovered later on, or who acquire infections during the encounter, can suffer from sepsis. I asked the corresponding author, and he asserted that they expect the PSS to perform similarly whenever during the hospitalization the condition crops up; and

• If the Phoenix-8 score had comparable performance to the Phoenix-4 score (PSS), shouldn’t we diagnose sepsis if a patient has an infection and organ dysfunction not included in the PSS (e.g., hepatic or renal failure)? I’m going to hope that this is a rare occurrence, but what is the role for clinician judgment? Are payors going to deny claims of sepsis even if the clinician believes there is life-threatening organ dysfunction of a non-Phoenix-4 organ system?

This International Consensus statement certainly demonstrated rigor in development. The most important sentence to me in the paper is “SIRS should no longer be used to diagnose sepsis in children, and because any life-threatening condition is severe, the term severe sepsis is redundant.”

Fortunately, we have guidance permitting the capture of the code for severe sepsis if organ dysfunction is linked to the sepsis, even if the provider doesn’t document the word “severe.” Until the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) eliminate the ICD-10/-CM code for severe sepsis without shock (R65.20), all patients with sepsis and sepsis-related organ dysfunction should receive at least four codes:

• A code indicating sepsis (e.g., unspecified or organism-specific sepsis; perinatal, obstetrical, or postprocedural sepsis);

• An R65.2- code indicating severe sepsis without or with septic shock;

• A code specifying the underlying localized infection that is the source of the sepsis; and

• At least one code detailing the organ dysfunction.

Pediatric experts have expressed their agreement: there is no such thing as sepsis without organ dysfunction.

Now, if we can only get the adult practitioners to buy in, too.

OIG Sets Sepsis in its Sights

By Erica Remer, DM, FACEP, CCDS, ACPA-C

I am going to begin a two-part look at sepsis, starting with the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) focus on Medicare Inpatient Hospital Billing for Sepsis, brought to our attention by Dr. Ronald Hirsch; next time, I am going to write about updates to pediatric sepsis.

The introduction to the OIG’s plan to analyze Medicare claims for sepsis says some very impactful things. It asserts that “sepsis is the body’s extreme response to an infection,” and that “it is a life-threatening, emergency medical issue that often progresses quickly and responds best to early intervention.” It acknowledges that “the definition of and guidance for sepsis have changed over the years,” in an attempt to capture sepsis better. It identifies the issue that the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) “currently recognize an older, broader definition,” and the OIG expresses a concern that hospitals may take advantage of the broader definition because they are financially incentivized to land patients in the relatively higher-weighted sepsis Medicare-Severity Diagnosis Related Groups (MS-DRG).

Their study will analyze patterns in inpatient hospital billing for 2023 and assess the variability of sepsis billing among hospitals. They plan to compare costs using the broader definition (i.e., Sepsis-2, according to SIRS, or systemic inflammatory response syndrome, criteria) versus the narrower definitions of sepsis, that is, Sepsis-3.

On Feb. 23, 2016, The Third International Consensus Definition for Sepsis and Septic Shock (Sepsis-3) was published in the Journal of the American Medical Association (JAMA), written by Mervyn Singer, Clifford Deutschman, et al. Surviving Sepsis Campaign followed up in March 2017, with their acceptance of the definition as “life-threatening organ dysfunction caused by a dysregulated host response to infection.” Whereas Sepsis-3 defined the condition, Surviving Sepsis Campaign operationalized how to treat sepsis, issuing best-practice statements and utilizing the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system. Prior to 2016, Surviving Sepsis Campaign (SSC) was where we had derived Sepsis-2.

This was over seven years ago. Why are we still adjudicating this? If the sentinel organizations use the same definition, why don’t all hospitals everywhere use it? Why hasn’t SIRS been put to bed?

There are multiple reasons, and the reason the OIG is leveraging is the money. The relative weight (RW) for sepsis without mechanical ventilation > 96 hours with a major comorbid condition (MS-DRG 871) in 2024 is 1.9826, and its “without MCC” counterpart (MS-DRG 872) has a RW of 1.0299. For comparison, Respiratory Infections and Inflammations with MCC (MS-DRG 177) has a RW of 1.6964, with CC (MS-DRG 178) is 0.9867, and MS-DRG 179 without CC or MCC has a RW of 0.7633. The MS-DRG for urinary tract infections w/wo MCC (MS-DRGs 689 and 690) have RWs, respectively, of 1.1744 and 0.8069. Hence, the most profitable DRG for a patient who is admitted with an infection is in the sepsis set.

What other reasons enter into this persistent utilization of SIRS? Clinician ignorance or clinicians clinging to “the way it has always been done” are obvious factors. The fact that the core measures bundle and New York has its own criteria that don’t align with either Sepsis-2 or Sepsis-3 are others. There are also practitioners who, out of an abundance of caution, would rather err on the side of picking up “early sepsis” than missing the boat and having a patient die, so they would rather liberalize the criteria to catch cases that turn out not to be sepsis. I am supportive of making a tentative diagnosis early, but the key to compliance is to remove the diagnosis once it has been ruled out.

We all designed our sepsis alerts to use the general variable SIRS criteria because it was easy, convenient, and ubiquitous, but the diagnosis of sepsis always included other clinical indicators. For instance, altered mental status, hyperbilirubinemia, thrombocytopenia, and coagulopathy were included in the Surviving Sepsis Campaign 2012 table of diagnostic criteria for sepsis. But everyone gets vital signs taken and a white blood cell (WBC) count drawn if they have a potential infection, so those were attractive as a screening diagnostic tool.

SIRS is a great marker for clinically significant disease; however, it is very non-specific. Conditions not infectious in etiology may demonstrate tachycardia, tachypnea, fever, or elevated WBCs. Patients with infections may demonstrate those symptoms without having progressed to sepsis. It may represent an appropriate response to the infection.

I once was rounding with a provider who documented sepsis as her clinical impression on a patient who was on the fourth day of their admission and was sitting in bed smiling and eating a sandwich. I asked the provider if the patient met the criteria of sepsis – were they “sick” with a capital S? The provider replied that this wasn’t part of the definition. I disagreed, saying it was so integral to the definition of sepsis that the experts didn’t think they needed to explicitly say it. It is my opinion that the indication of being “sick” with a capital S is organ dysfunction.

I had a reader ask me once why I don’t want providers to diagnose “sepsis without organ dysfunction. Don’t you think that it is better to catch it early than to miss it?” My response was that patients who have infections should be treated aggressively and appropriately, whether or not they have sepsis. If you nip the infection in the bud and avert the development of sepsis, good for you!

Dr. Hirsch used a great analogy that I would like to reuse. He said lots of patients have chest pain without enzyme markers for heart attack. They will be monitored and might be catheterized and stented. We don’t make the diagnosis of impending myocardial infarction (MI) and get paid in an MI DRG.

When I review records in the context of clinical validation denials, invariably, most of the cases I find righteously denied are billed as sepsis. Sepsis without organ dysfunction is…pneumonia or urinary tract infection or cellulitis. It doesn’t belong in the sepsis DRG, and I am going to predict that the OIG is going to agree with me.

If your hospital still uses SIRS criteria, it’s time for them to transition to Sepsis-3. It’s time for the state of New York to transition to Sepsis-3. If your institution uses Sepsis-3, but your providers document poorly or inconsistently, they should be educated and monitored.

Clinical documentation integrity specialists (CDISs) should put a program in place to perform clinical validation of the diagnosis of sepsis. Clinical validation denials are predictable, and a pain, but nothing compared to an unfavorable OIG determination.

CMS IPPS Proposed Rule: Expansion of SDoH Designations as CCs

By Tiffany Ferguson, LMSW, CMAC, ACM

In its Inpatient Prospective Payment System (IPPS) Proposed Rule for the 2025 fiscal year (FY), the Centers for Medicare & Medicaid Services (CMS) is considering a change in the severity level designation for the social determinants of health (SDoH) diagnosis codes denoting inadequate housing and housing instability from non-complication or comorbidity (Non-CC) to complication or comorbidity (CC).

Consistent with the annual updates to account for changes in resource consumption, treatment patterns, and the clinical characteristics of patients, CMS is recognizing inadequate housing and housing instability as indicators of increased resource utilization in the acute inpatient hospital setting.

“Inadequate housing” is defined as an occupied housing unit that has moderate or severe physical problems, such as plumbing, heating, electricity, or upkeep issues. CMS describes concerns with patients living in inadequate housing by noting they may be exposed to health and safety risks that impact healthcare services, such as vermin, mold, water leaks, and inadequate heating or cooling systems.

Housing instability encompasses difficulties related to paying rent, overcrowding, frequent relocations, and/or other financial challenges associated with maintaining housing. While not directly citing from external sources, CMS asserts that studies have demonstrated moderate evidence linking housing instability to a higher prevalence of conditions such as overweightness/obesity, hypertension, diabetes, and cardiovascular disease, as well as poorer management of hypertension and diabetes, with increased acute healthcare utilization among individuals with these conditions (CMS-1808-P). Expanding on this impact, CMS suggests that these circumstances could lead to limited or no access to prescription or over-the-counter medications, inadequate storage facilities for medications, and challenges in adhering to medication regimens.

Based on an analysis of resource use data extracted from claims in the September 2023 update of the 2023 FY MedPAR file for seven ICD-10-CM diagnosis codes describing inadequate housing and housing instability, CMS is proposing to elevate the severity level designation of these codes from Non-CC to CC for the 2025 FY:

• Z59.10 (Inadequate housing, unspecified);

• Z59.11 (Inadequate housing, environmental temperature);

• Z59.12 (Inadequate housing, utilities);

• Z59.19 (Other inadequate housing);

• Z59.811 (Housing instability, housed, with risk of homelessness);

• Z59.812 (Housing instability, housed, homelessness in past 12 months); and

• Z59.819 (Housing instability, housed unspecified).

Evaluating the data in this category and selection for this change is a deviation from typical CMS practices for CC designation, as the quantity of these Z codes are minimal; however, CMS believes that this is likely related to the new releases of many of the subcategories in the Z59.00 category, as well as the lack of financial alignment.

CMS expects an increase in Z code utilization as a result of the IQR Social Drivers of Health initiatives. This change continues to demonstrate the commitment by CMS to health equity as well as whole-person care.

Proposed 2025 IPPS Rule: CMS Targets Readmission Metrics

By Tiffany Ferguson, LMSW, CMAC, ACM

When it comes to healthcare policy, even seemingly minor adjustments can have significant ripple effects across the industry. The Centers for Medicare & Medicaid Services (CMS) recently unveiled its proposed changes for the Inpatient Prospective Payment System (IPPS) for the 2025 fiscal year (FY). Among the notable alterations is a heightened focus on readmission metrics, reflecting CMS’s ongoing commitment to enhancing patient care quality and healthcare efficiency.

Redefining Metrics

One of the most significant shifts proposed by CMS involves the removal of five measures in the Hospital Inpatient Quality Reporting (IQR) program pertaining to payment associated with a 30-day episode of care for various conditions, which include acute myocardial infarction (AMI), heart failure (HF), pneumonia (PN), and elective primary total hip or knee arthroplasty (THA/TKA). These condition-specific assessments, collectively known as the Hospital-level, Risk-Standardized Payment Measures, are set to be phased out beginning with the FY 2026 payment determination.

The rationale behind this decision stems from the availability of a more comprehensive measure: the Medicare Spending Per Beneficiary-Hospital Measure (MSPB Hospital) in the Hospital Value-Based Purchasing (VBP) Program. Unlike the condition-specific metrics, MSPB Hospital evaluates hospitals’ efficiency and resource utilization relative to the national median, providing a broader perspective on healthcare delivery. Additionally, CMS has highlighted the stability or decline in performance on these measures since FY 2019, signaling the need for a reevaluation of the program’s measure set to accommodate emerging clinical priorities.

Hospital Readmissions Reduction Program (HRRP)

Meanwhile, CMS is reaffirming its commitment to the Hospital Readmissions Reduction Program (HRRP), a cornerstone of value-based purchasing initiatives aimed at reducing payments to hospitals with excess readmissions. With no proposed changes in the FY 2025 IPPS/LTCH (Long-Term Care Hospital) PPS ruling, previously finalized policies under this program will persist, ensuring continuity in efforts to improve healthcare quality.

However, CMS has invited commentary on a specific aspect of the readmissions landscape: patients returning to the hospital for emergency-level and observation services within a 30-day period following an inpatient hospitalization. While not categorized as readmissions, these instances warrant scrutiny due to their potential implications for care coordination. CMS is highlighting concerns surrounding medication management support, social determinants of health (SDoH), and health literacy as contributing factors for 30-day emergent utilization of services. This focus on transitions of care is signaling a nuanced approach to understanding and addressing the intricacies of patient care beyond traditional readmission metrics we have previously reported under the HRRP.

Additionally, CMS provided specific details about their value-based initiatives and their focus on readmissions. The proposed changes to the IPPS demonstrate the agency’s stance toward optimizing healthcare delivery and outcomes, with several mentions of the SDoH. By refining measurement strategies and soliciting input on emerging challenges, CMS is continuing to prioritize quality, efficiency, and patient-centered care.

Understanding the “Safe Discharge” plan

By Tiffany Ferguson, LMSW, CMAC, ACM

A concept commonly discussed but not well-defined in healthcare is the necessity for a patient to have a “safe discharge plan.” Defining what constitutes “safe” in this context isn’t always straightforward. How much safety is required for the patient? Ultimately, the determination rests with the treating physician, who must rely on their clinical expertise (and possibly, ethical considerations) to gauge the acceptable level of risk. It’s the physician’s responsibility to assess whether the patient’s plan for leaving the hospital is sufficiently safe, regardless of the patient’s level of care status.

In research endeavors, the Conditions of Participation (CoP) serves as a foundational reference point. However, the CoP does not explicitly delineate what constitutes a safe plan. Indeed, expecting such a definition from the CoP would be unrealistic since the primary focus spelled out in 42 CFR 482.43 is to define the discharge planning process requirements, not the expectation of a safe plan, which is intentionally absent in the language. Instead, the regulation calls out an effective transition to post-discharge care, and reduction in factors that may lead to preventable hospital readmission. 

Alternatively, the American Medical Association’s (AMA’s) Code of Medical Ethics defines the ethical responsibility associated with formulating a safe discharge plan, in 1.1.8 Physician Responsibilities for Safe Patient Discharge From Health Care Facilities. Physicians are expected to balance their need to advocate on behalf of the individual patient while also recognizing the broader needs of other patients. This continues to hold true when a discharge is appealed to the Quality Improvement Organization (QIO), specifically when the reviewer evaluates the assurance of a “safe discharge” plan. This review is defined by the physician’s “professional judgement regarding the safety of a discharge,” based on the medical stability of the patient and a safe discharge plan; ironically, “safe” is not defined.

In 2006, S. Goodacre published an article in the Emergency Medicine Journal titled “Safe Discharge: an irrational, unhelpful and unachievable concept.” The article focuses on the dilemma emergency-room physicians face in determining the need for hospital admission and weighing this decision against the ability to discharge the patient home. In this fast-paced environment, compounded with pressures for emergency department (ED) throughput, physicians are faced with making quick decisions on assessing whether a patient can safely return home from the ED. When a patient’s evaluation indicates that returning home is not a straightforward option, then bedding the patient occurs.

In cases in which there’s clear medical necessity or when patients demonstrate stability within secure home environments, the decision-making process regarding admission or discharge is relatively straightforward. However, as the social complexity of a patient’s situation increases, so does the perceived risk for the physician tasked with determining the appropriate plan of care. This heightened complexity introduces ambiguity, making the concept of a “safe discharge” plan unclear. Physicians are confronted with the challenge of balancing medical needs with social factors while bearing ultimate liability for the chosen course of action. Consequently, the delineation between a safe discharge and the necessity for further care becomes increasingly nuanced in scenarios where social complexities come into play.

Indeed, despite the comprehensive efforts of a multidisciplinary care team, including the involvement of case management personnel to orchestrate a “safe” discharge plan, the threat of potential litigation or adverse patient outcomes looms heavily within hospital settings. This dynamic introduces additional pressures on attending physicians, sometimes leading to reluctance to discharge patients even when a genuinely safe discharge plan seems attainable. Instead, the focus should shift toward mitigating risks to the best of the care team’s abilities and ensuring that patients receive the support they need to navigate the post-discharge period.

The optimal strategy for hospitals to support their physicians, care teams, and the organization is to establish a clear definition of a safe discharge plan for their patients. This definition can be included in existing policies that provide procedures for patient appeal rights and discharge planning practices. Hospital compliance and ethics must be part of the discussion to provide support from a policy standpoint and at an individual case level, ensuring that decisions for socially complex patients do not rest exclusively on the physician and case management department. The hospital must consider the needs of the one against the needs of the many when patients are being deferred or holding in the ED; utilizing ethics consultations can be instrumental in navigating these complex scenarios effectively.  

Although the definition of a safe discharge can be ambiguous, here are some questions that can help clarify expectations:

• Is the patient’s medical condition stable and manageable enough for them to continue their recovery at home, or in another care setting?

• Does the patient and/or their caregivers have a clear understanding of the diagnosis, treatment plan, medications, follow-up appointments, and any necessary lifestyle modifications that have been arranged, or need to be made post-hospitalization?  

• Have proactive measures been taken to ensure a seamless transition in communicating the handoff between the hospital and any other healthcare providers, facilities, or agencies involved in the patient’s treatment?

• Has the patient been adequately educated about warning signs or potential complications post-discharge, along with guidance on who to contact if they have concerns, and provided with resources detailing where and when they should seek further medical attention if needed?

In conclusion, the concept of a “safe discharge plan” in healthcare is inherently complex. While it may lack a universally agreed-upon definition, the importance of ensuring patients’ transition from hospital to home or another care setting with adequate support and resources remains fundamental. From regulatory frameworks to ethical responsibilities and practical considerations in emergency care, this discourse has illuminated the intricate dynamics at play in the discharge planning process. However, by establishing clear definitions, incorporating ethical considerations, and fostering multidisciplinary collaboration, healthcare institutions can better support physicians and care teams in navigating these challenges.

Kepro rebranding As Acentra Health

Sometime this fall, Kepro will be known as Acentra Health.

During this rebrand, case reviews and all other services will continue without interruption. Providers will be encouraged to update their beneficiary notices – the Important Message from Medicare (IM) and the Notice of Medicare Non-Coverage (NOMNC) – by replacing "Kepro" with "Acentra Health." However, notices with the QIO name of “Kepro” listed will still be accepted and validated.

For ongoing updates about Kepro’s name change and the impact it has on Medicare providers, stakeholders, and beneficiaries, visit www.keproqio.com/acentrahealth. It is anticipated that the transition to Acentra Health will be complete by Fall 2024.

Major Healthcare Initiatives Get Presidential Push

By Tiffany Ferguson, LMSW, CMAC, ACM

In March the Biden-Harris Administration submitted their budget proposal for the Health Resources and Services Administration (HRSA) for the 2025 fiscal year, which outlines several key investments to tackle their top healthcare initiatives. These include the following:

• Youth Mental Health Crisis: There have been several disturbing trends emerge in the area of youth mental health, with nearly one-third of youths reporting experiences with poor mental health and 1 in 5 students reporting seriously considering suicide. The budget focuses on expanding access to mental health and substance use disorder treatment. Investments include training 12,000 new behavioral health providers, creating a peer-to-peer mental health support program for youths, supporting mental health training for pediatricians, and integrating mental health services into community health centers.

• Maternity Care Deserts: To address the lack of maternity care services in certain areas, the budget invests in building obstetric capacity in underserved areas, training more labor and delivery nurses and certified nurse midwives, establishing a community-based doula workforce, and expanding access to maternal mental health support through the National Maternal Mental Health Hotline at 1-833-TLC-MAMA.

• Closing Gaps in Access to Primary Care: The Administration has indicated that it recognizes the barriers to accessing primary care, such as lack of providers, lack of access to transportation, and limited availability in appointment times and provider hours; this is only exacerbated in rural and underserved communities. The budget aims to double the federal investment in community health centers, expand health center street medicine services for the homeless, and extend health center operating hours.

• Meeting Opioid Treatment and Recovery Needs: Given the challenges in rural communities regarding opioid use disorder treatment, the budget focuses on creating more access to treatment, supporting mobile units for medication-assisted treatment, integrating support services, and expanding the rural substance use disorder workforce.

• Growing the Healthcare Workforce: Addressing projected shortages in healthcare occupations, the budget provides scholarships and loan repayment programs to over 24,000 clinicians, nurses, and healthcare professionals to provide services in underserved areas. The budget will also be supporting more than 1,800 medical and dental residents to work and train in rural communities, and funds new approaches to recruit and diversify the healthcare workforce.

• Transforming the Organ Matching System: To enhance the organ procurement and transplantation system, the budget doubles funding for the system, aims to increase competition, and supports updates to improve performance and innovation.

Overall, these investments align with the Administration’s goals of improving healthcare access, addressing mental health challenges, and ensuring equitable care for all Americans.

Understanding the Connection Between Observation Rate & CMI

By Tiffany Ferguson, LMSW, CMAC, ACM

EDITOR’S NOTE: The context for this article was conceptualized from a recent ACPA Town Hall meeting on observation metrics and a presentation by the author and Dr. Mohla at NPAC 2024 on observation metrics. Also used as a reference was the ACDIS white paper “Demystifying and Communicating Case-Mix Index,” published in 2022.

Those in healthcare roles frequently experience the stress associated with meeting key performance indicators (KPIs) compared to benchmark standards. While achieving these goals can be gratifying, there are instances when they can seem unattainable, often due to the arbitrary nature of how the metrics are set, relying on external benchmarks or ambitious targets without a comprehensive review of processes and data. Metrics like observation rate, denials rate, and case mix index (CMI), although interconnected, are frequently established with independent goals, further complicating the pursuit of comprehensive success.

Utilization management (UM) has long grappled with a historical bias, perceiving observation as unfavorable while favoring inpatient care for financial security – an orientation reflected in the overarching objective of hospitals and departments to “lower the observation rate.” While there may be valid opportunities to reduce the observation rate, it is crucial to carefully consider internal processes and target needs before establishing an ideal or benchmarked lower limits.  

Simultaneously, clinical documentation improvement (CDI) aims to accurately capture patient acuity, with benchmark objectives to achieve higher-weighted DRG classifications, resulting in a higher CMI for the hospital. Both objectives are financially significant and encouraged by hospital leaders, particularly in a fee-for-service environment.

However, they can be at odds; aggressively reducing the observation rate might prompt a shift towards designating more cases as inpatient care, leading to a higher proportion of lower-weighted DRG patients for CDI review and lowering the hospital’s CMI. Although the observation rate may decrease, so would the CMI.

This practice could also lead to an increase in post-discharge W2s and payer denials, potentially increasing accounts receivable (A/R) days and denial recovery, thus negatively impacting the financial goals for your revenue cycle and business office. It is plausible that cases initially pushed towards inpatient care, when observation might have been more appropriate, could eventually result in payment at the outpatient rate, often less than if observation was ordered properly at the outset, during the appeals process.

This lower-than-expected reimbursement would then hide in the patient accounting world, while the reported observation rate would remain low.

On the flip side, adopting an excessively conservative approach in determining level of care to preempt payer denials could lead to a situation in which more patients are retained in outpatient status with observation services, driven by apprehension of payer resistance. In this context, although the observation rate might be higher, the CMI could also rise, given that only patients unequivocally confirmed for inpatient care contribute to this metric. While denials may decrease, this cautious strategy carries the inherent risk of establishing a reimbursement structure that limits potential level-of-care opportunities for inpatient designation, despite the medical treatment delivered or clinical guidelines. Striking the right balance is not easy, but it is crucial to avoid the unintended consequence of limiting revenue for the sake of an overly conservative stance on care-level designations.

Determining level of care should by prioritized by doing what is right for the patient, considering factors such as medical necessity, patient acuity, and medical decision-making, rather than the pressures of meeting arbitrary benchmarks, which are often based on data from hospitals whose demographics and offerings are in distinct contrast to a hospital’s own.

Finding hospitals with similar patient populations, services, and physician behavior can allow developing appropriate benchmarks, which then could serve as a barometer to ensure that a health system aligns reasonably with their peers, rather than the sole driving force being operational efficiency.

Instead, consider a focus on understanding how data is collected and analyzed, with a collective goal that assesses hospital processes and performance opportunities across utilization management, CDI, and the denials/appeals team.

White House Makes Additional $1.7 Billion Investment In Health

By Tiffany Ferguson, LMSW, CMAC, ACM

The Biden-Harris Administration has unveiled 141 new commitments from diverse stakeholders nationwide as part of the White House Challenge to End Hunger and Build Healthy Communities.

Such stakeholders include health systems, insurers, companies, nonprofits, philanthropic groups, academic institutions, and local elected officials. Second Gentleman Douglas Emhoff announced these commitments alongside key figures like White House Domestic Policy Advisor Neera Tanden, Agriculture Secretary Tom Vilsack, and the Chairs of the President’s Council on Sports, Fitness, and Nutrition: chef José Andrés and basketball player Elena Delle Donne.

This Challenge is aligned with President Biden’s goal to end hunger and reduce diet-related diseases by 2030, while also addressing health disparities. The $1.7 billion in new commitments announced build upon the $8 billion commitments made at the White House Conference on Hunger, Nutrition, and Health in September 2022. These efforts complement the National Strategy on Hunger, Nutrition, and Health, with commitments cultivated in collaboration with the Centers for Disease Control and Prevention (CDC) Foundation.

One significant aspect of the commitments is the partnership between major sports leagues, players’ associations, and the President’s Council on Sports, Fitness, and Nutrition, which aims to boost physical activity and increase nutrition programming across the country. Fourteen sports leagues and players’ associations have committed to expanding access to physical activity and promoting healthy lifestyles.

Various commitments were announced, ranging from the Harlem Globetrotters’ public awareness campaign on nutrition and physical activity in cities like Cleveland, Baton Rouge, and Seattle, which also includes the launches of task forces to end hunger and reduce diet-related diseases. Companies such as Ahold Delhaize USA have committed almost $1 million for nutrition education for children, while health systems like Ascension are focusing on addressing the social determinants of health (SDoH) through a closed-loop referral process and providing hospital-based produce markets in 100 percent of their sites of care (that is, 139 hospitals across 19 states).

Other commitments include Blue Cross Blue Shield of North Carolina expanding nutrition coaching and healthy food delivery, Food Forward providing access to 290 million pounds of fresh produce to distribute to those facing food insecurity, and the Gaples Institute offering nutrition education resources to 100 additional U.S. medical schools.

Highmark Health and Allegheny Health Network will mobilize over $30 million through 2030 to conduct assessments, expand Healthy Food Centers, and address non-medical barriers to health. Homeplate Solutions, through an artificial intelligence (AI)-enabled technology platform, aims to provide greater affordability and accessibility to food for community-based nutrition providers.

The National Association of Chronic Disease Directors has committed $2 million to improve physical activity and nutrition, and to reduce chronic and diet-related diseases, through various programs across states and school districts.

The National Strategy underscores the Administration’s whole-of-government approach, with actions including U.S. Department of Agriculture (USDA) investments in school meal programs, the Food and Drug Administration’s (FDA’s) study on a front-of-package system for food packages, and U.S. Department of Health and Human Services (HHS) initiatives to address the SDoH under Medicaid and the Children’s Health Insurance Program (CHIP). This initiative directly compliments the SDoH food insecurity domain for questions in the outpatient and inpatient settings. These commitments collectively contribute to demonstrate comprehensive efforts and offer tangible solutions to tackle hunger, improve nutrition, and reduce health disparities.

How to Prevent Pneumonia DRG Denials

By Erica E. Remer, MD, CCDS

When I ask facilities what their most common denials are, invariably, pneumonia makes the list. That was my personal experience when I handled clinical validation denials as a physician advisor. Most of them I deemed appropriate denials and declined to appeal. Recently, I’ve been working on a project where I’ve been assessing encounters resulting in DRG (Diagnosis-Related Group) downgrades, and I would like to specifically address pneumonia today.

The typical scenario is a patient with underlying comorbidities of heart failure or chronic obstructive pulmonary disease (COPD) and presents to the emergency department complaining of shortness of breath and cough. The patient may have no or low-grade fever. The chest X-ray is not compelling – no distinct infiltrate is seen. The radiologist may be hedgy, noting markings that “could be pneumonitis or pulmonary edema or atelectasis; clinical correlation necessary.”

The emergency physician or hospitalist empirically treats for pneumonia and makes an uncertain diagnosis (e.g., possible, probable, likely). The issue arises when the condition is neither definitively ruled in, during the course of the encounter nor conclusively ruled out. The uncertain diagnosis is propagated through copying and pasting. There are also concomitant issues, with hypoxia being labeled acute hypoxic respiratory failure, or sepsis being diagnosed without evidence of organ dysfunction.

As a reviewer, I am able to take in the entire admission through the lens of the retro-spectoscope. At the end of the stay, it may be that much easier to ascertain that the entire clinical presentation was due to acute-on-chronic heart failure (HF) due to fluid overload (e.g., missed dialysis) or exacerbation of COPD from viral bronchitis. The definition of principal diagnosis, which establishes the DRG, is “that condition which, after study, was chiefly responsible for occasioning the admission of the patient to the hospital for care.” If I can tell that the derangement causing the hospitalization was the HF or COPD, and I doubt the validity of the pneumonia, so can the payor, and they will want to revise the DRG accordingly.

The initial providers are not going to know how the encounter is going to play out. It is reasonable to empirically treat for pneumonia. The error occurs when the subsequent providers fail to evolve, resolve, remove, and recap. The diagnosis should evolve as more information becomes available, like culture results. Resolving is documenting that the condition has been successfully managed and is no longer an active problem. “Remove” is what should be done when a condition has been ruled out. All clinically significant diagnoses should be recapped in the discharge summary to encapsulate the hospital course and tell the story of the encounter.

Elements that imperil the diagnosis of pneumonia are:

• Lack of fever or elevated white blood cell count, normal vital signs; no evidence of the patient being in any respiratory distress, or appearing ill or toxic;

• No infiltrate ever materializes on either chest X-ray or CT scan;

• The provider hesitantly diagnoses pneumonia in the setting of organ dysfunction (e.g., metabolic encephalopathy, acute hypoxic respiratory failure, acute kidney injury, Type 2 myocardial infarction), but does not diagnose sepsis;

• Consultants such as pulmonologist or infectious disease don’t make a diagnosis of pneumonia in the same patient with the same information;

• The assessment and plan (A&P) is unchanging, and the diagnosis remains uncertain; and

• Pneumonia is absent from the discharge summary.

Here is what the provider can do to prevent pneumonia denial jeopardy:

• Paint the picture of a patient with pneumonia – providers should call out fever, tachypnea, increased shortness of breath, chest pain, and/or hypoxemia, and link the signs/symptoms with the pneumonia, especially if there are other pulmonary confounding diagnoses;

• Rethink the diagnosis if there are no radiological findings suggestive of pneumonia. It is hard to sell pneumonia to a payor without an infiltrate;

• As the encounter progresses in a patient with an uncertain diagnosis of pneumonia, either definitively rule in, rule out, or intentionally maintain uncertainty. Each day, you should have more information and data on which to base your diagnosis;

• Link pneumonia with acute hypoxic respiratory failure or with sepsis if those diagnoses are concurrent. If pneumonia gets ruled out but the provider is retaining sepsis as a diagnosis, ensure there is an alternate infection as a source;

• Consider the consultants’ opinions. Either agree and incorporate their diagnoses and specificity into your documentation, or disagree and document your rationale. Discuss it with them so everyone can be on the same page while taking care of the patient. Avert internal inconsistency;

• If pneumonia is ruled out, document the reasoning, and declare it ruled out. The next day, pneumonia should no longer be on the impression list. Don’t just drop it without explanation. It will not be clear whether it was ruled out or just accidentally forgotten; and

• The discharge summary should tell the story of the patient encounter. If they really had pneumonia, it should appear in the list of discharge diagnoses. If the course of antibiotics is not complete, prescribe it in the discharge instructions.

One of the most important things to do is to perform clinical validation prior to final coding and billing. Make sure clinical documentation integrity specialists are vigilant when reviewing records of patients with pneumonia, and query when indicated. It may not be feasible to do a mandatory review of all patients with pneumonia, but it may be possible to review all pneumonia from a specific provider who has a history of being lax at diagnosing it.

It is understandable, even desirable, to make the diagnosis of pneumonia preliminarily and have it ruled out over the course of the next few days. However, the provider needs to make sure their documentation tells the story of the patient encounter accurately. An ounce of prevention is worth hours of fighting clinical validation denials!

CDI Queries Work Best if the Recipient is Kept in Mind

By Erica E. Remer, MD, CCDS

I had an epiphany the other day while discussing compliant query composition with a very knowledgeable clinical documentation integrity specialist (CDIS). It will be easiest to explain if I share the original query first.

The following clinical indicators were noted in this patient’s medical record:

A 70-year-old female was admitted with sepsis, pyelonephritis, urinary tract infection, and documented “worsening altered mental status.” There was an infectious disease consult. The urine culture grew Klebsiella. The patient was treated with IV antibiotics. 

Please clarify the patient’s altered mental status.

Based on these clinical indicators and your professional judgment, please document in the medical record whether you believe any of the following conditions are present:

• Acute metabolic encephalopathy

• Septic encephalopathy

• Confusion only

• AMS with no further specificity

• Delirium

• Other (specify)

• Unable to determine

When a CDIS composes a query, they should be providing the provider with the clinical indicators they need to make a thoughtful, informed decision. The CDIS can pick and choose which clinical indicators to offer, but they should give both clinical indicators that support the condition they might be hoping to get in response AND clinical indicators that might not be consistent. The intent is to get the right answer, meaning the condition that is clinically valid and significant. The fact that a blood culture grew out streptococcus might be very pertinent in a clinical validation query regarding “probable gram-negative pneumonia.”

This was a made-up scenario, but other clinical indicators that might have been relevant could have been the results of blood cultures, information from a neurology consult, and whether the final mental status returned to baseline. And what did the discharge summary say?

Next, ensure that the question being asked is the question you want answered. In this case, the CDIS wants to know if the “altered mental status” could be categorized as some comorbid condition (not used in this context here as a CC or MCC), as opposed to a sign/symptom.

(As an aside, a symptom is a manifestation of a condition subjectively reported by the patient, whereas a sign is a manifestation which the provider objectively perceives, e.g., “felt feverish” versus T 39° Celsius)

The questions asked were: “Please clarify patient’s altered mental status” and do you “believe any of the following conditions were present?” The provider may think to himself/herself: saying “altered mental status” is pretty clear. The reader may disagree. Altered mental status could mean lots of things, including lethargy, confusion, or difficulty understanding or expressing oneself.

An alternate way to pose the query could have been, “Based on your clinical judgment, is there a more specific diagnosis that clarifies the patient’s altered mental status?”

We then honed in on the offered choices. My colleague felt we could eliminate “septic encephalopathy,” since it gets coded as metabolic encephalopathy anyway. This was emblematic of one of the key points of this article. Doctors don’t really do their documentation for coding. They do it for clinical communication. In fact, they probably don’t even know (or would particularly care) that “septic encephalopathy” is compliantly coded as “metabolic encephalopathy.”

But I wouldn’t remove that choice, because there may be providers who do use that terminology, and would feel it clarified the altered mental status. It also might serve as support for acute sepsis-related organ dysfunction (establishing sepsis). So, I would leave two choices that get coded the same way. I want the verbiage to feel authentic, in their voice.

I would also remove the “acute” from “acute metabolic encephalopathy.” I don’t want to leave words in choices that might make a clinician hesitate or scratch their head. What if they felt it had developed over two or three days and they really thought it was “subacute.” Would offering a choice with “acute” in it stymie them?

If the provider had described the altered mental status as “confusion” somewhere, then “confusion only” would be acceptable (even if it is undesirable!). If they had not, I would not potentially put those words in the provider’s mouth.

I also wouldn’t use “AMS” in a choice because I can’t compliantly index that to R41.82, Altered mental status, unspecified. I wouldn’t use an initialism here; I would type out “altered mental status.”

Another aside (from the CDC):

• Abbreviation: truncated word; e.g., “min” for minutes

• Acronym: made up of parts of phrases it stands for and pronounced as a word; e.g., SIRS for Systemic Inflammatory Response Syndrome

• Initialism: Similar to acronym, but pronounced by enunciating each letter; e.g., SOB for shortness of breath

What about delirium? Should we introduce a new condition that wasn’t mentioned in the record? It depends. Is it consistent with the clinical indicators? If the nurses or different providers mentioned waxing and waning attention or a fluctuating course, I would present that in my clinical indicators and then offer that a selection of “delirium” would not be inappropriate.

Lastly, I HATE “unable to determine” as a choice in multiple-choice queries. If you give an “other” or free-text option, you don’t need to use “unable to determine.” It is appropriate and “required” in POA and yes/no queries, per the Compliant Query Practice Brief. I don’t like setting myself up for the provider choosing an option that is uncodable, sets up more questions, or is not clarifying.

My advice is to make sure that every query is for a purpose (to clarify the record and make it as accurate and specific as possible) and ensure that it is understandable by the clinician. It doesn’t help the CDIS’s metrics and productivity to generate a query if it just confounds the provider and doesn’t result in a useful response.

New Outpatient SDoH Codes: How they Apply and What Can be Done

By Tiffany Ferguson, LMSW, CMAC, ACM

I thought I would provide some clarity regarding the new social determinants of health (SDoH) and supportive service codes that have been released in the 2024 Outpatient Prospective Payment System (OPPS) – specifically, the SDoH assessment, community health integration, and principal illness integration. This article was prompted after some questions from clients and the case management professional community about who can provide these services. 

SDoH Assessment: G0136

Unlike the social drivers of health screening in the inpatient setting, this SDoH assessment is a 5-15 minute add-on assessment to an existing evaluation and management (E&M) visit or annual wellness visit with a provider to assess social factors that may be impacting a patient’s health status. The assessment must include the domains of housing, food, utility, and transportation needs or insecurity. Consideration should be given to utilizing the Centers for Medicare & Medicaid Services’ (CMS’s) cited SDoH screening tools for convenience to help facilitate conversation, but it is not required. These approved tools can be completed as a self-exam by the patient in the visit; however, the responses and applicable needs must be pulled into the provider’s documentation. CMS has made it clear that in order to bill for G0136, the provider cannot simply screen for SDoH, but must demonstrate an assessment of need and its impact in the medical visit. 

For instance, the patient may complete their Health-Related Social Needs (HRSN) Screening Tool in the lobby prior to the visit, through which they identify that they are struggling with keeping food on the table in their house. During their annual wellness visit (AWV) with their provider, they then discuss how food insecurity has impacted their ability to manage their diabetes. This finding is then incorporated into their care plan, and the patient is referred to the clinic’s case management program to assess further needs to support diabetes management and layout community food options. Ideally, there would also be Z codes that are captured as a result of the documented SDoH factors assessed.

Say the HRSN tool was provided to the patient, yet no SDoH needs were identified – then the provider would have no need to incorporate or bill for G0136 during their visit. The patient would screen negative and be listed as having no further needs. This code can billed every six months, which would allow the provider to follow up with their patients regularly should social factors change, requiring adjustments to the medical plan of care because of new considerations related to social domains.

Community Health Integration: G0019 and G0022

The Community Health Integration (CHI) codes are billed as a monthly charge, initiated after a provider visit in which community health integration needs are identified related to specific SDoH concerns that are impacting the patient’s medical treatment. G0019 is for 60 minutes in the month in which services are performed “incident to” by a community health worker or trained auxiliary personnel representative who is able to assist the patient in addressing their SDoH needs, such as obtaining food assistance, completing a housing voucher, or obtaining a monthly bus pass. 

Community health workers (CHW) are typically frontline public health workers who are trusted members of the local communities they serve. They serve a unique role in receiving training and/or certification to link the healthcare system to local social services and the cultural community. These individuals may provide translation services and typically reside within the community in which they are working. These individuals may work directly under a provider, or serve as auxiliary staff connected under the social work and/or case manager to provide “on-the-ground” and in-home support services for patients receiving services through nontraditional means.

For G0019 to be utilized, there would need to be an initial assessment that would determine the appropriate services and goals that are going to be accomplished between the CHW and the patient. There would then need to be continued documentation demonstrating progress and contact between the patient and CHW throughout the month that demonstrates the time expectation. G0022 would be added for each additional 30 minutes beyond G0019 that is completed within the month.  

Ideally, there would also be Z codes that are captured based on the findings from the provider’s initial visit and the CHW assessment and treatment goals.

Principal Illness Navigation: G0023, G0024, G0140, and G0146

Principal illness navigation (PIN) can best be understood as providing reimbursement to navigators who work with patients with significant chronic conditions. To qualify for PIN, these conditions, such as cancer, chronic obstructive pulmonary disease (COPD), congestive health failure, or HIV/AIDs, must exist for greater than a three-month duration and must present with enough significance that there is risk of hospitalization, nursing home placement, decompensation, or decline, should the condition not be addressed or treated. PIN is billed as incident to where the provider, through an initiating visit, identifies that the patient would receive PIN services appropriately to support and navigate the complexity of their condition(s) to guarantee access to services and avoid unnecessary decline.

G0023 serves as a monthly charge: 60 minutes of time initiated via verbal or written consent for a trained and/or certified professional to provide and assess a patient under the supervision of the provider. This individual would complete a biopsychosocial assessment and treatment plan that would connect the member’s condition to potential SDoH risk factors and identify need for education or supportive navigation services to coordinate care. G0024 would be billed for an additional 30 minutes of services in the month. All information and connections with the patient would be documented with capture of time and updates on treatment and goal progress. At this time, the specialist is listed generically for PIN services; however, in most clinical settings, a chronic disease navigator is often a nurse or social worker. These codes would allow for those individuals to count their time in working with patients to address their disease, medication needs, and psychosocial needs through the treatment planning and intervention process for reimbursement under the patient’s attending provider.

G0140 and G0146 are similar codes; however, they correspond to the principal diagnosis for navigation services in the behavioral health setting. These codes include circumstances in which the “incident-to” specialist is a certified peer support specialist, which is a specific call-out and varies from the PIN chronic medical disease codes.  The SDoH, CHI, and PIN codes are a step in the right direction towards acknowledging the social factors that impact patient complexity of care and navigation of the medical landscape. There are some unknowns in the specialization of certified professional skill sets in each of these codes, which are still broadly defined. Additionally, it appears that these codes are allowed to be billed in conjunction with chronic care management and remote patient monitoring as long as the time is not duplicative, and services are appropriately documented as medically necessary and socially relevant for the patient.

Livanta Offers Cerebral Edema Recommendations

By Erica E. Remer, MD, CCDS

Dr. Ronald Hirsch inspired this article – months ago, he asked me to look at a publication from Livanta and comment on it.

Livanta is a Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO), and one of its jobs is medical case review, to ensure that Medicare patients in their jurisdiction are receiving medically appropriate care and services. Their monthly publication, The Livanta Claims Review, from last August focused on the condition of cerebral edema (The Livanta Claims Review Advisor, Volume 1, Issue 19).

In it, they quote the Recovery Audit Contractor (RAC) Statement of Work in that “clinical validation involves a clinical review of the case to see whether or not the patient truly possesses the conditions that were documented in the medical record.” Livanta asserts that “clinical validity reviews are performed by currently practicing physician reviewers. The most common reason for denial of cerebral edema on claims is a failure of the provider to document the clinical information that supports the diagnosis – there is often no documentation of cerebral edema at all until the post-discharge query. It is vital for providers to document the clinical information that led to the diagnosis of cerebral edema rather than simply stating on a query that it is present.”

We must keep in mind that reviewers are making their judgments solely based on the available documentation.

It is completely legitimate to expect documentation to demonstrate that a condition being claimed and coded is clinically valid. The Livanta publication also has a section on Good Documentation Practices. Their expectation is that there will be documentation of the following:

• Clinical signs or symptoms such as headache, vomiting, altered mental status, or seizures;

• Findings on imaging. They only mention MRI, but CT scans may also reflect changes consistent with cerebral edema. They offer phraseology such as “brain compression,” “displacement,” or “midline shift.” I will add “mass effect” to their list. Later on in the document, they note that “vasogenic edema” isn’t found in the coding index, specifying that the words “cerebral” or “brain” must be linked with “edema;” and

• Clinical significance supported by documentation of treatment. Corticosteroids, mannitol, surgical decompression, a plan to monitor with repeat imaging, or a documented linkage between the condition (cerebral edema) and clinical deterioration could serve as evidence that the condition is not just an incidental and inconsequential radiological finding.

Post-discharge queries that result in a diagnosis of cerebral edema after the fact, without evidence of clinical significance, are to be dismissed, according to Livanta’s instructions.

This condition is illustrative of the concept that clinical validity is often predicated on clinical significance. A condition may be diagnosable, but not relevant if it does not impact the current encounter. A diagnosis is not codable if it is not documented in an appropriate format.

Some of you may have seen my macro for sepsis before: sepsis due to (infection) with acute sepsis-related organ dysfunction as evidenced by (specify organ dysfunction/s). This guides the provider to give the etiology and the evidence of clinical significance.

For all conditions, providers should be instructed to document their clinical support (signs and symptoms), any laboratory or imaging evidence bolstering the diagnosis, and what is being done about it (or when treatment is considered, but declined by the patient).

A single reference to a condition is only weak evidence; it is preferable for the discussion and diagnosis to appear multiple times in the record. It needn’t be redundant copying and pasting. Each day the provider should ponder and document how the situation is progressing. Are the symptoms improved? Are there new or worsening clinical indicators? Is the treatment succeeding, or does it need adjustment? A single mention in a post-discharge query very well may not be adequate support of a codable diagnosis, because if it was clinically significant, wouldn’t it have been noted and treated prior to discharge?

For this targeted condition, consider this model documentation:

Cerebral edema due to known glioblastoma, as evidenced by severe headache and projectile vomiting, new since Friday. MRI confirms increased brain compression and cerebral edema. Will administer dexamethasone and consult neurosurgery to assess for urgent decompression.

Determination of clinical significance shouldn’t be left to the imagination or whim of the reviewer. The provider should think in ink and explain why they are making their diagnoses (and what they are doing about them). Clinical documentation improvement specialists (CDISs) should do their traditional querying early to get the diagnosis input promptly. If there is inadequate support in the documentation, a clinical validation query may be indicated to ensure that the diagnosis is removed if not valid (or documentation is improved if it is valid).

Training the provider to supply linkage and evidence of clinical significance is a good proactive step. And it is a best practice for the diagnosis to appear when first noted, as it is treated, and as it resolves, and then brought back into the spotlight in the discharge summary.

Does Coding Clinic Allow Payers to Make Their Own Clinical Criteria?

By Erica E. Remer, MD, CCDS

I would like to focus on clinical criteria today. It has been brought to my attention that some payers are citing the American Hospital Association (AHA) Coding Clinic, pages 147-149 of the 2016 fourth-quarter edition, to justify using their own criteria as the basis for denials.

The Coding Clinic advice attempts to explain Guideline I.A.19, “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

It is ironic that this guideline is specifically intended to explain that the coder is not permitted to assume diagnoses according to any published criteria, and then payers want to use this advice to justify their being able to discount diagnoses according to their own criteria.

The provider “may use a particular clinical definition or set of clinical criteria to establish a diagnosis,” but Coding Clinic cautions that the code is purely based on the documentation. The guidance states that “a facility or a payer may require that a physician use a particular clinical definition or set of criteria when establishing a diagnosis, but that is a clinical issue outside the coding system.”

I don’t think they mean the word “may” as in “we are granting them permission.” I think they mean the word “may” in the sense of “might.”

Let’s dispel this fallacy right here and now. I have yet to see a facility that strictly mandates a physician to use a particular clinical definition or set of criteria to make a diagnosis. The organization may convene an internal group to discuss a condition and what they would like to see in order to make a diagnosis, but there is always some disclaimer in the written policy that the provider must be permitted to use their clinical judgment. I recommend that they call their internally derived recommendations “internal clinical guidelines.” A guideline is a statement or declaration of policy that sets general standards for an agency or facility but does not have the force or effect of law.

If a provider is not following an internal clinical guideline for a considered reason, they should document the rationale for their deviation. If there is concern that the provider has acted way out of the boundaries of generally accepted medical care, then there should be a clinical quality review of the care. The provider’s medical colleagues are qualified to judge whether they believe care was appropriate after an investigation, in the context of a specific patient and that provider’s past actions.

If payers are using generally accepted consensus-based criteria to judge medical care, then it is reasonable to generate clinical validation denials if the provider has substantially deviated. For instance, a provider made a diagnosis of acute kidney injury (AKI) with a creatinine of 1.6, but the patient had a baseline of 1.4 with known chronic kidney disease (CKD), stage 3a. Generally accepted KDIGO (Kidney Disease Improving Global Outcomes) criteria for AKI are an increase of serum creatinine of greater than 0.3 mg/dL within 48 hours or more than 1.5 times the baseline within the prior seven days. Unless the practitioner has some compelling underlying reason for departing from the criteria that they hadn’t documented, it would be understandable to deny the assertion of AKI in this patient.

But a payer should not be able to demand that for the diagnosis of AKI; the creatinine elevation must be greater than 2.0 mg/dL within 24 hours, just on their whim, apparently. It is unreasonable for payers to create their own proprietary clinical criteria that have no discernible basis in science or medicine, and for insurers to be allowed to require facilities to adhere to those secret criteria.

The Coding Clinic segment recognizes that clinical guidelines may be crafted by institutions or payers, but affirms that coding experts do not have the authority to validate criteria; as they note, it is out of the scope of the coding system.

If you have contracted with a payer and there is a stipulation that they may use their own clinical criteria to determine clinical validity, you should either insist that you have access to their established criteria, or better yet, strike that from the contract.

Making diagnoses and documenting them is not for the sake of the payer. It is for the patient. The provider is trying to deliver optimal care and report it accurately. If a payer quotes this Coding Clinic advice, include in your appeal:

The Coding Clinic advice states, “Only the physician, or other qualified healthcare professional legally accountable for establishing the patient’s diagnosis, can ‘diagnose’ the patient.” Furthermore, although Coding Clinic is giving its recommendations, they are also acknowledging that it is not up to them to rule on whether a particular definition or set of criteria are valid to establish a diagnosis. They explicitly state that it is out of the realm of the coding professional.

My advice is for facilities to have ongoing discussions about changing and current clinical criteria to foster best clinical practice. Providers should be instructed to document their thought process well and in a codable format. Clinical validation queries should be composed to ward off clinical validation denials, as per the last sentence of I.A.19.: “If there is conflicting medical record documentation, query the provider.”

If a payer denies a claim due to legitimate clinical validation concerns, give the money back; it was a loan. If they are making up capricious criteria to unjustly deny proper diagnoses, don’t take that lying down.

If they quote this Coding Clinic advice as being support for their being allowed to make up their own criteria and hold you to them, fight it.

And make sure the folks who enter into contract negotiations don’t sanction it, either.

Listen to Dr. Remer today when she cohosts Talk Ten Tuesdays with Chuck Buck at 10 Eastern.

Take the Time to Get Time-Based Billing Right

By Erica E. Remer, MD, CCDS

I am currently performing a fraud assessment, and since I can’t go back and educate the provider in question, I am going to share my insights with you. Since Jan. 1, 2023, practically speaking, all evaluation and management (E&M) service coding is based on medical decision-making or time. And some providers are not documenting time appropriately.

• It’s no longer only face-to-face (F2F) time or time spent on the floor or unit that counts. It is the total time devoted to the patient, which includes some component of F2F time on the day of the encounter.

  Consider the following:

  • The face-to-face time may be delivered by another qualified healthcare professional, as opposed to the ultimately responsible billing individual, if the time is split/shared or incident-to.

  • Counseling and coordination of care not separately billed for may be counted, but there is no longer a threshold of greater than 50 percent of the time. That should be removed from any attestations.

• Time need not be continuous, but you can only count time solely devoted to the patient for that given time interval. Maybe it is your practice to review labs in the morning before you start your rounds or your office hours. Then, a few hours later, you see the patient and do a history and physical. You order some tests (the time clicking in the electronic medical record counts), which you discuss afterwards with the patient because it informs your shared decision-making. You prepare discharge instructions. At the end of the day, you spend quality time with the electronic health record (EHR) documenting the encounter. All of that time can be added up and claimed. Remember:

  • It may not be practical to use a time-tracking app, but you should be able to guesstimate accurately. Be truthful. Time spent on separately billed activities should be carved out. You can’t double-dip.

  • If two individuals see the same patient at the same time, providing the same service (e.g., rounding together), only one of them can claim any given moment in time. You can’t double-dip.

• Don’t give a range of time, e.g., 30-74 minutes. Some time-based services, like critical care, can be additive. What number would you use to add? How can you tell if prolonged services add-on is appropriate if a range is given?

• Don’t document “approximately 35 minutes.” Does that mean “34 minutes,” which is under the threshold, or “36 minutes,” which crosses it?

• Similarly, don’t document “greater than 35 minutes.”

• Detail some activities you are including in your time-based billing. If you have a standard macro, I strongly recommend editing it to reflect the services you provided today, with this patient.

• Personal chit-chat, although it can take time, cannot be counted in time-based billing. There are specific activities that are permissible (see https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf) to be counted.

Remember that an auditor is looking at documentation over time and over multiple patients. If you only use macros or templates or copying and pasting the reviewer will notice. The auditor will be trying to get a feel of what you are doing over the course of the day. Did you really perform that physical exam if it is identical from patient to patient, and never changes over time?

• If your documentation has a field to put the date and time seen, try to be accurate. Unless you are office-based and never run late or have issues that throw your schedule off, it looks suspicious to run exactly on the hour or half-hour for every patient, every day. In the hospital? You never used the restroom or grabbed a snack or answered a phone call or got waylaid in the hall by a nurse?

• If you have fields where you put start and stop times for your F2F time, label them as such. As noted, there are a lot of other activities that may be counted in time-based billing, and it is perfectly reasonable that you wouldn’t be documenting to account for those administrative and not-in-the-presence-of-the-patient times in the progress or office note. But it looks funny if it says at the top of the note, “Time: 4:00-4:30 p.m.” and at the bottom of the note, it just says “35 minutes were spent.” This is an internal inconsistency.

• It looks suspicious if you run back-to-back 30-minute intervals all day long, claiming 35 minutes for each, and completing the documentation before you see the next patient. It looks really bad if you document that you saw a patient when the nurse records they were sleeping. It is impossible to see patients in the drive time between facilities. You can’t prospectively document an encounter.

• In this day and age, assume that investigators will be able to ascertain where you physically were. Don’t lie and say you were at the hospital when you were in the grocery store or in another state.

• Remember that electronic records have an audit trail. You may (truthfully) assert that you saw a patient at 10 a.m. while documenting the encounter at 1 p.m., but you can’t fix it, so the computer says you typed it at 10 a.m.

In order for an encounter to be billable, it needs to meet medical necessity. If the medical decision-making is moderate, but the patient requires more time than is typical for a 99232 (subsequent hospital care) because they have a lot of questions, a 99233 can be justified on the basis of time. However, if a patient is completely stable and has no new problem, and there no studies to analyze or changes in medication or plan of care, and they are to be discharged the next day (i.e., = 99231), you are hard-pressed to claim the highest level of service. Why did it take you so much time?

Here are my recommendations:

• Only put your billing-by-time attestation on the encounters for which you are billing by time. It is confusing for your selected level of service to be one level, but the time attestation would support a different level. It calls into question the veracity of the time attestation on all patients.

• Be consistent. If you have start/stop times documented, but are claiming the encounter took more time, explain the discrepancy – e.g., “38 minutes spent, which includes 20 minutes face-to-face, as noted above, review of labs, ordering tests and neuro consult, and documenting in EHR.”

• Don’t let your times add up to more hours than it is humanly possible to work in a day.

• Tell the truth. Do good-faith guesstimates. Don’t always use the same number. Feel free to not use round numbers, like using 31 as opposed to 30.

• You won’t get in trouble for the occasional 35-minute encounter being claimed as 38 minutes. You will get in trouble if you claim one hour when you only spent 17 minutes.

Take the time to get time-based billing right. If you provided the service, you want to be appropriately compensated.

Compliant texting of patient orders approved by CMS

Christmas has come very early this year from CMS to our case management teams! On February 8, CMS released a memorandum outlining new guidelines and permission to text patient information and patient orders to health care team members. Of course, it will be required to take place through a HIPAA-compliant secure texting platform and in compliance with the Conditions of Participation (CoPs). We recommend you meet with your compliance and IT teams to discuss the next steps to texting status change orders. This new ruling is effective immediately and applies to both acute hospitals and critical access hospitals.

The link below will take you to the link to view the CMS memorandum related to this new change:

https://www.cms.gov/files/document/qso-24-05-hospital-cah.pdf