New from CMS: “Age-Friendly Hospital Rating”

By Tiffany Ferguson, LMSW, CMAC, ACM

The Age-Friendly Hospital Rating is a new structural measure included in the Centers for Medicare & Medicaid Services (CMS) 2025 Inpatient Prospective Payment System (IPPS) Final Rule.

This measure is designed to assess hospitals’ commitment to delivering high-quality care to patients 65 and older. The rating focuses on five key domains: patient goals, medication management, frailty screening, social vulnerability, and leadership commitment.

Hospitals must affirmatively attest to these domains to demonstrate their compliance with best practices for older adults. The implementation of this measure includes specific data collection and submission requirements, as outlined by CMS.

Under the 2025 IPPS Final Rule, hospitals and health systems are required to submit data for the Age-Friendly Hospital Rating measure on an annual basis. The data submission is structured around the five domains, and hospitals must evaluate whether they meet the criteria for each domain fully to receive credit.

Partial compliance with a domain does not earn points, meaning hospitals must engage with all the elements within a domain to receive one point for that area. For example, in the domain focused on frailty screening and intervention, a hospital must meet all corresponding attestation statements to earn a point. This includes a requirement to screen for risks of malnutrition, mobility, and mentation, upon admission or before major surgery. Qualifying plans must submit management plans, and data collection is required.

This measure also requires processes to lower the risk of delirium in the emergency room.

The data collection process is streamlined through the CMS Hospital Quality Reporting (HQR) system. Hospitals will use this tool to submit their data once per year. The CMS tool will collect the hospitals’ attestation statements for each of the five domains, verifying whether they can affirmatively attest to engaging in the best practices defined by CMS for the care of older adults.

Additionally, the IPPS Final Rule mandates that hospitals report their measure results, regardless of their responses to the attestation questions. This reporting is part of the pay-for-reporting structure of the Hospital Inpatient Quality Reporting (IQR) Program, which ensures that hospitals provide transparent data about their care practices for older adults.

Hospitals are not penalized financially for their attestation responses, but are required to submit accurate and timely data through the HQR system.

Hospitals must submit this information annually, with mandatory reporting beginning in the 2025 reporting period. The Age-Friendly Hospital measure aims to ensure transparency and consistency in hospital reporting, allowing CMS to monitor and improve the quality of care delivered to older adults across the healthcare system.

Although many of the measures in this initiative overlap with other quality reporting requirements, it may be beneficial to review and ensure there is a crosswalk with the initial nursing documentation, therapy evaluations (PT, OT, and ST), and case management/social work documentation to ensure that information is easy to extract for data collection, reporting, and future interventions.

CMS OPPS Proposed Rule: Considerations for Outpatient Social Drivers

By Tiffany Ferguson, LMSW, CMAC, ACM

If you’ll recall, I recently reported on the Centers for Medicare & Medicaid Services (CMS) Proposed Rule for the social determinants of health (SDoH) in the outpatient settings, specifically Hospital Outpatient Departments (HOPDs), Rural Emergency Hospitals (REHs), and Ambulatory Surgical Centers (ASCs).

To recap, CMS has proposed in the 2025 Outpatient Prospective Payment System (OPPS) Rule an expansion of the SDoH initiatives for quality reporting, with a similar staged rollout to what we experienced during the Inpatient Prospective Payment System (IPPS) rule for the 2024 mandate. The same measures and processes used in hospitals for inpatients 18 and older are proposed to be incorporated into the Hospital Outpatient Quality Reporting (OQR), Rural Emergency Hospital Quality Reporting (REHQR), and Ambulatory Surgical Center Quality Reporting (ASCQR) programs.

Voluntary reporting will begin with the 2025 reporting period, followed by mandatory reporting in the 2026 reporting period/2028 payment or program determination.

Logistical Considerations for Implementation

Similar to the inpatient setting, the SDoH measure in outpatient settings will be calculated based on each outpatient encounter for patients 18 and older. Patients must be offered five specific Health-Related Social Needs (HRSN) domain questions related to personal safety, utilities, housing, transportation, and food insecurity during their care in a HOPD, REH, or ASC (https://www.federalregister.gov/documents/2024/07/22/2024-15087/medicare-and-medicaid-programs-hospital-outpatient-prospective-payment-and-ambulatory-surgical). The first measure will evaluate the proportion of patients who are offered the screening tool versus those who actually complete the questions. There are exclusions for those unable to complete or refusing to undergo the screening, which must be appropriately documented. CMS highly recommends that the tool be electronic.

Additionally, the Screen Positive Rate for SDoH measure will report on the percentage of patients who screen positive for one or more HRSNs. This data will be reported separately for each of the five HRSNs, allowing healthcare providers and policymakers to understand the prevalence of specific social risks in different care settings. The data will be reported annually. This will also provide continued data support for Z code capture.

Challenges in Operationalizing SDoH Screening

While this screening tool marks a critical step toward addressing the SDoH on a broader scale, there are legitimate concerns regarding how to operationalize this process when a patient screens positive – and determining who will follow up on those needs. Currently, HOPD encounters include lab, imaging, radiology, bedded outpatients, same-day surgery, physician offices, and infusion departments, to name a few. It will be a massive undertaking to determine how these questions will be provided to patients and how appropriate follow-up will be conducted when a patient responds positively to one of these questions.

To prepare for this rollout, HOPDs, REHs, and ASCs should start discussing the following:

• Mechanisms for incorporating SDoH Screening into the Registration Process: Consider integrating these questions into your patient portal, to be completed before or at the time of check-in. This will streamline data collection and quality reporting. HOPDs, REHs, and ASCs will need to assess all portals of entry to ensure that these questions are being provided for applicable patient encounters. It will be valuable to consider prior patient responses from previous encounters with an update-and-validate approach, rather than starting from scratch each time.

• Plan for Escalation and Triage: Develop a process for how organizations will respond to positive SDoH screenings. Something hospitals, and particularly case management departments, have learned from responding to the numerous positive screens on the inpatient side is that not all questions require immediate follow-up, nor is the patient always interested in assistance.

Consider including a question that asks if the patient is already receiving assistance for each need. The questionnaire should also include a question as to whether the patient would like to speak to someone further about their response. If the answer is no, follow-up may not be required, and should be documented as such. If the answer is yes, determine if the issue can be addressed via a phone call at a later date or if someone should be available to address the need during the visit.

Immediate action should be taken for concerns related to personal safety, while issues related to housing, utilities, food, and transportation could be routed to appropriate teams for timely but non-immediate follow-up. This approach could involve partnerships with community organizations, ambulatory care management departments, post-acute resource centers, or telehealth/phone-call outreach services, likely some type of case management outreach support.

Although we do have time to prepare, as we have seen from the inpatient SDoH initiative, using the voluntary reporting period if this ruling is finalized will be a key method for trialing various strategies to ensure appropriate outreach and follow-up occurs. As you can expect, I will continue to follow this ruling and see where CMS lands in their finalized determination. 

Important Information Concerning Aetna

By Tiffany Ferguson, LMSW, CMAC, ACM

Aetna’s recent policy update, which became effective July 1, marks a significant change in how the insurer will manage hospital readmissions.

Previously, Aetna’s Diagnosis-Related Group (DRG) Readmission Policy focused on individual facilities by using the Provider Identification Number (PIN). The new policy now applies at the Tax Identification Number (TIN) level, meaning entire health systems are being evaluated as a single entity.

Although this does appear to have been a previously held practice by Aetna in some of their Medicaid products, such as Aetna Better Health, this new update will globally apply to all of Aetna’s products, unless there are state or provider contracting provisions to limit such practices.

This change was briefly mentioned in Aetna’s April 2024 update: “We want to improve the quality of care and general health of our members. Readmissions can put our members at risk for unnecessary complications. We currently apply the Diagnosis-Related Group (DRG) Readmission Policy on hospitals at the Provider Identification Number (PIN). Effective July 1, 2024, we will apply the policy at the Tax Identification Number (TIN).” 

This broader scope means that if a patient is readmitted to any facility within the same health system, the readmission could be flagged and potentially denied, even if the initial and subsequent admissions occur at different locations. This policy is designed to reduce unnecessary readmissions, which Aetna views as a risk to patient safety and a burden on healthcare resources.

This statement is interesting, as reports were recently released regarding the fact that Aetna’s operating income is down 39 percent, or $938 million, from the prior year. Conveniently, Aetna’s stricter criteria will result in higher denial rates, impacting reimbursement and patient care.

Health systems must now closely examine their discharge processes, post-discharge follow-ups, and care coordination across all facilities under the same TIN to avoid preventable readmissions. However, in reviewing Aetna’s policy, it becomes clear that health systems are able to request reconsideration to contest any denials that are potentially unrelated or were the result of a scheduled procedure. 

Aetna’s expansion of its DRG Readmission Policy to the TIN level is a strategic move to improve patient outcomes by reducing avoidable readmissions – and to likely yield financial benefit to Aetna. Health systems should proactively adapt their procedures to minimize the financial and operational impacts of this policy change.

Recommendations should be considered to check internal contracting language and state protections and to continue to adopt care transition protocols that will help with readmission prevention.

A New Code: Z51.A, Encounter for Sepsis Aftercare

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

Today I am going to focus on a new ICD-10-CM code, as of Oct. 1: Z51.A, Encounter for sepsis aftercare.

We think about sepsis mortality a lot. Since there isn’t a universally applied definition of sepsis, exact rates are elusive. According to the Centers for Disease Control and Prevention (CDC), 75 percent of sepsis deaths in the United States are in the Medicare population, and the death rate for this group exceeds 300 deaths per 100,000 people.

The death rate is higher for men, as opposed to women, Blacks compared to others, and rural versus urban dwellers, and mortality also is noted to increase with age.

Dying is not the only consequence of sepsis. Besides the fact that sepsis survivors are at higher risk for another bout of sepsis from a subsequent infection (and for readmission), there are potential sequelae of sepsis, especially if a patient was in an intensive care unit. The condition “post-sepsis syndrome” (PSS), which includes long-term physical, cognitive, and psychological effects after surviving sepsis, affects up to half of all sepsis survivors.

A nice graphic detailing the manifestations of PSS can be found in this article:  Understanding Post-Sepsis Syndrome: How Can Clinicians Help? Physical manifestations of PSS can include dyspnea, heart failure, chronic kidney disease, immunosuppression, fatigue, and muscle and joint pain. Mental effects include post-traumatic stress disorder, depression, deranged sleep, and memory deficits.

There are striking similarities and overlaps between PSS, post-intensive care syndrome (PICS) and post-acute sequelae of SARS-CoV-2 (PASC). Most patients who develop PSS and PICS had been gravely ill; long COVID can persist even after a seemingly minor bout of COVID-19. That condition is the only disorder that has a dedicated ICD-10-CM code, U09.9, Post-COVID-19 condition, unspecified, and the specific condition (e.g., loss of smell or pulmonary embolism) is meant to be coded first.

There is no way to code PSS in ICD-10-CM at the present time.

Once resolved, there is no way to capture that a patient had suffered and survived sepsis. After resolution, a code indicating sepsis (e.g., A41.9, Sepsis, unspecified organism) is no longer appropriate, because that is for an acute and current episode of sepsis. Z09, Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm, is non-specific, requires an additional code to identify any applicable history of disease code, and would not be considered appropriate if there were persistent issues related to the condition, because treatment would not be “completed.” Z86.19, Personal history of other infectious and parasitic disease, is again non-specific and is not appropriate if there are ongoing medical issues.

As a result, University of Colorado/UCHealth submitted a request to the CDC for a code to indicate sepsis survivorship (Topic Packet March 2023), and it was discussed in the Coordination and Maintenance Committee Meeting in March 2023. In particular, UCHealth felt that post-acute care and home health care could benefit from having a means to signify continued recovery from sepsis. They felt that increased awareness among healthcare providers and policymakers would be beneficial, and that it would be easier to perform epidemiological monitoring post-sepsis.

Z51 is Encounters for other aftercare and medical care, and we are instructed to also code the condition requiring care. Since the condition is still ongoing, there is an Excludes1 for using the follow-up exam after treatment code, Z09. I would envision that a primary care provider following up after a hospitalization for sepsis, home health continuing care, physical or occupational therapy, and post-acute facilities will welcome the ability to assign Z51.A, Encounter for sepsis aftercare, to explain why they are treating ongoing sequela. It is not entirely clear to me for how long this code would be utilized. If there are ongoing manifestations, obviously. But the increased of risk of recurrent sepsis is for at least a year, even if there are no long-lasting obvious sequelae.

I wish they had developed a specific code for personal history of sepsis, too. I think there will be times when there is no longer sepsis aftercare being provided, but it would be useful to know that a patient had the condition in the past and might be vulnerable to another episode now. Z86.19 is too vague for me.

There’s a big difference between having had the chicken pox or strep throat and sepsis.

Until this is all sorted out, I am still grateful for this new code. I think it will contribute to our overall understanding of sepsis.

Proposed Ruling Focuses on Social Drivers in Outpatient Settings

By Tiffany Ferguson, LMSW, CMAC, ACM

Today I would like to elaborate on recent remarks from Colleen Ejak regarding the 2025 Outpatient Prospective Payment System (OPPS) Proposed Rule regarding quality metrics and the inclusion of the social determinants of health (SDoH).

The Centers for Medicare & Medicaid Services (CMS) is expanding its SDoH initiatives for quality reporting from the inpatient setting, where they are currently in the mandatory reporting phase, to the outpatient setting, with a similarly staged rollout. The same measures and processes used in hospitals for inpatients 18 and older are proposed to be incorporated into the Hospital Outpatient Quality Reporting (OQR), Rural Emergency Hospital Quality Reporting (REHQR), and Ambulatory Surgical Center Quality Reporting (ASCQR) programs. Voluntary reporting will begin with the 2025 reporting period, followed by mandatory reporting in the 2026 reporting period/2028 payment or program determination.

Addressing Gaps in Care

CMS acknowledges that patients’ interactions with the healthcare system are often fragmented, and limited by the care setting. For instance, patients receiving care in Hospital Outpatient Departments (HOPDs), Rural Emergency Hospitals (REHs), or Ambulatory Surgical Centers (ASCs) may not have recently accessed care in acute-care hospitals or other facilities where SDoH screenings are already mandated. CMS’s proposed rule highlights that this gap can lead to missed opportunities to identify and address key social risk factors that significantly impact health outcomes. Notably, while the identification of social risk factors is included in this process and reporting, the systematic addressing of these factors is not yet standardized across many HOPDs, REHs, or ASCs.

The expansion of SDoH screening to the outpatient setting aims to align and enhance the delivery of holistic care, ensuring that patients receive the necessary referrals and support to address critical needs in the five Health Related Social Needs domains, which include food insecurity, housing instability, transportation, utility challenges, and interpersonal safety.

Logistical Considerations for Implementation

Similar to the inpatient setting, the SDoH measure in outpatient settings will be calculated based on each outpatient encounter for patients 18 and older. Patients must be offered five specific Health-Related Social Needs (HRSN) domain questions related to personal safety, utilities, housing, transportation, and food insecurity during their care in a HOPD, REH, or ASC. The first measure will evaluate the proportion of patients who are offered the screening tool versus those who actually complete the questions. There are exclusions for those unable to complete or refusing to engage with the screening, which must be appropriately documented. CMS highly recommends that the tool be electronic.

Additionally, the Screen Positive Rate for SDoH measures will report on the percentage of patients who screen positive for one or more HRSNs. This data will be reported separately for each of the five HRSNs, allowing healthcare providers and policymakers to understand the prevalence of specific social risks in different care settings. The data will be reported annually. This will also provide continued data support for Z code capture.

Challenges in Operationalizing SDoH Screening

While this screening tool is a critical step toward addressing the SDoH on a broader scale, there are legitimate concerns regarding how to operationalize this process when a patient screens positive – and determining who will follow up on those needs. Currently, HOPD encounters include lab, imaging, radiology, bedded outpatients, same-day surgery, physician offices, and infusion departments, to name a few. It will be a massive undertaking to determine how these questions will be provided to patients and how appropriate follow-up will be conducted when a patient responds positively to one of them.

To prepare for this rollout, HOPDs, REHs, and ASCs should start discussing the following:

Mechanisms for incorporating SDoH Screening into the registration process: consider integrating these questions into your patient portal to be completed before or at the time of check-in. This will streamline data collection and quality reporting. HOPDs, REHs, and ASCs will need to assess all portals of entry to ensure that these questions are being provided for applicable patient encounters.

Plan for escalation and triage: develop a process for responding to positive SDoH screenings. Something we have learned from responding on the inpatient side to numerous positive screens is to include a question that asks if the patient is already receiving assistance for each need. The questionnaire should also include a question as to whether the patient would like to speak to someone further about their response. If the answer is no, follow-up may not be required, and this should be documented as such. If the answer is yes, determine if the issue can be addressed via a phone call at a later date, or if someone should be available to address the need during the visit. Immediate action should be taken for concerns related to personal safety, while issues related to housing, utilities, food, and transportation could be routed to appropriate teams for timely but non-immediate follow-up. This approach could involve partnerships with community organizations, ambulatory care management departments, post-acute resource centers, or telehealth/phone-call outreach services, likely some type of case management outreach support.

This measure represents both a challenge and an opportunity. It challenges clinicians to integrate SDoH screening into routine care processes, ensuring that all patients are assessed for social risks that may impact their health. At the same time, it offers an opportunity to enhance patient care by addressing the root causes of health disparities and expanding Z code capture, which can improve patient care outcomes.

For a listing of definitions associated with the five core HRSN domains, reference:

https://www.federalregister.gov/documents/2024/07/22/2024-15087/medicare-and-medicaid-programs-hospital-outpatient-prospective-payment-and-ambulatory-surgical

Expansion of SDoH Codes as CCs

By Tiffany Ferguson, LMSW, CMAC, ACM

As previously reported for the proposed ruling, it was confirmed in the 2025 Inpatient Prospective Payment System (IPPS) Final Rule that the Centers for Medicare & Medicaid Services (CMS) is changing the severity level designation for the social determinants of health (SDoH) diagnosis codes denoting inadequate housing and housing instability, from non-complications or comorbidities (non-CCs) to CCs for the 2025 fiscal year (FY).

Consistent with the annual updates to account for changes in resource consumption, treatment patterns, and the clinical characteristics of patients, CMS will now reimburse for 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 that 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 (see page 250).

The relevant codes include the following:

• 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).

Please see my prior article on the rationale for this decision. I will also mention that the final rule does express notable interest in food insecurity, Z59.41, as a potential conversion to a CC; however, there was not enough data provided on this Z code to justify the conversion.

Instead of repeating that information, I would like to focus on some of the comments that were released in the final rule.  

Generally, the public comments were widely supportive for the proposal to change the severity level designation for several ICD-10-CM diagnosis codes related to inadequate housing and housing instability from non-CCs to CCs for FY 2025. This change was seen as crucial for increasing healthcare access for underserved communities and recognizing the interconnectedness of health and social needs. CMS expects that the movement of these codes to CCs will improve data quality by encouraging providers to ask more detailed questions about patients’ housing status.

Despite the support, there were some continued issues raised regarding operational concerns, particularly the current limitation of only 25 diagnoses being captured on electronic claim forms and 19 on paper bills, which I believe was also mentioned in the FY 2024 Final Rule.

The known concern is that documenting SDoH Z codes could lead to overcrowding of other necessary diagnosis codes, potentially impacting payment and quality measures. Suggestions included expanding the number of diagnosis codes that can be reported or creating a separate reporting method for SDoH Z codes. CMS reminded us all again that these comments must be submitted to the National Uniform Billing Committee (NUBC), which maintains the Uniform Billing (UB) 04 data set and form.

Finally, some commenters expressed concern over CMS’s focus on SDoH Z codes, urging a comprehensive analysis of all diagnosis codes in the ICD-10-CM classification to ensure that MS-DRG payments align with the costs of patient care. They encouraged examining other SDoH Z codes related to food insecurity, extreme poverty, and other social factors to determine hospital resource utilization. Concerns were also raised about the challenges in documenting SDoH, including the lack of standard definitions, the need for training, and potential underreporting due to the sensitivity of the information.

CMS has confirmed that if SDoH Z codes are consistently reported on inpatient claims, the impact on resource use data may more adequately reflect what additional resources were expended to address these SDoH circumstances, in terms of requiring clinical evaluation, extended length of hospital stay, increased nursing care or monitoring (or both), and comprehensive discharge planning. CMS went on to say that they will re-examine these severity designations in future rulemaking. Moving forward, continuous dialogue and adjustments will be essential to address the operational challenges and further enhancements needed to impact the burden of resources related to social circumstances in the acute-care setting.

Community-Acquired Pneumonia is Being Over-Diagnosed

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

I continue to find multiple instances of misdiagnosis and miscoding of respiratory conditions.

A common scenario was the emergency physician interpreting outside or portable chest X-rays as demonstrating a possible right lower lobe infiltrate indicative of pneumonia, but no additional confirmatory or exclusionary test was performed. Or the emergency physician was the only one who mentioned pneumonia until the clinical documentation integrity specialist elicited subsequent documentation with a query.

Another situation was the patient originally being treated empirically as having pneumonia; it was ultimately not thought to be present, but was never eliminated from the problem list. In retrospect, the patient had some alternate respiratory diagnosis, such as acute exacerbation of chronic obstructive pulmonary disease (COPD) or heart failure, but the pneumonia was never declared ruled out in the record.

The typical chief complaint was shortness of breath, which can herald pneumonia…or an exacerbation of COPD or heart failure. What dissuaded me from thinking these patients had pneumonia?

If they didn’t have a fever, a cough (especially productive), or increased respiratory rate, pneumonia seemed less likely to me. If an outside facility’s chest X-ray was not repeated and there was no official radiology overread, if a CT was done and the lung fields were commented on as being clear, or if the pulmonologist did not draw a conclusion of pneumonia on their assessment, I felt the clinical validity was in question.

A recent article published in the Journal of the American Medical Association (JAMA) Internal Medicine validated my impression and sought to characterize the inappropriate diagnosis of pneumonia in hospitalized patients. Authors from a collaborative of hospitals in Michigan asserted that the diagnosis of community-acquired pneumonia (CAP) was inappropriate if the patients had fewer than two signs or symptoms of CAP or negative chest imaging. Signs or symptoms include new or increased cough, change in sputum production, new or increased dyspnea, hypoxemia, abnormal lung sounds, increased respiratory rate, fever or hypothermia, and abnormal white blood cell count. This metric to identify inappropriate diagnosis of CAP has been endorsed by the National Quality Forum.

A total of 17,290 patients were included in the study, and 12 percent were felt to have been inappropriately labeled as having CAP. A total of 88 percent received a full course of antibiotics. Patients who were inappropriately diagnosed with CAP were more likely to be older, suffer from dementia, or present with altered mental status.

Lower respiratory tract infection, including pneumonia, is the most common infectious cause of hospitalization in the United States. It is a common source of sepsis. It is reasonable to empirically treat it if pneumonia is initially a serious concern, but there are perils in not ruling out the condition if it is not actually present. A delay in ruling it out promptly can prevent recognition and appropriate treatment of another condition, which in many cases is really causing the signs and symptoms. Unnecessary antibiotic usage can result in adverse effects, allergic reactions, and development of antibiotic resistance.

The most common presentation was dyspnea and/or cough. Inappropriate diagnosis of CAP was also associated with being on public insurance, having decreased mobility on admission, or having had an inpatient hospitalization within the previous 90 days, in addition to the variables noted earlier. These patients were more often discharged to a skilled nursing facility (SNF).

The study speculated on why physicians might be prone to inaccurately diagnosing CAP. Some of their explanations are that common diagnoses are, well, common, so providers may just settle on the convenient CAP diagnosis; CAP symptoms are also nonspecific and can mimic and overlap with other cardiopulmonary conditions. Moreover, providers are trained to treat early to avoid falling out of historical quality metrics.

What can you do about any of this?

1. Share this article with your medical providers so they are aware it is a problem.

2. Perform clinical validation queries, when appropriate

   • Here are the clinical indicators that should make you suspicious that the respiratory issue is less likely to be pneumonia and more likely to be another condition: no fever, no cough, normal vital signs, normal lung examination, normal white blood cell count;

   • If there is no reading of imaging other than the emergency provider’s (i.e., no overread by radiology of outside films);

   • If the radiologist’s read indicates the lungs are clear or states “no infiltrate” or “no pneumonia;”If the diagnosis perpetually remains in an uncertain diagnosis format; and

   • If the diagnosis perpetually remains in an uncertain diagnosis format; and

   • If there is conflicting or contradictory provider documentation (e.g., the pulmonologist doesn’t include pneumonia in their impression list).

3. Reconcile CDI/coder Diagnosis Related Group (DRG) mismatches to ensure that patients with more than one respiratory condition documented end up in the correct DRG.

4. Your facility may want to set up a task force, system, or quality improvement project to try to reduce misdiagnosis of pneumonia.

Efforts to decrease the incidence of misdiagnosis are not just for clinical documentation integrity; they should improve the quality of care of patients.

And shouldn’t that be our ultimate goal?

What is Chronic Atrial Fibrillation, Anyway?

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

The American College of Physician Advisors’ CDI Committee (disclosure: I am Chair) has published materials on numerous CDI topics. Each set of materials consists of a document detailing the points that a physician advisor should be aware of enabling them to educate their medical colleagues, and another downloadable document of a CDI tip for dissemination to the medical staff with pointers aimed at the clinician.

We are currently revising the tip on atrial fibrillation and flutter, and I found some interesting updates for you.

In 2023, the American College of Cardiology and American Heart Association published clinical practice guidelines on the diagnosis and management of atrial fibrillation (link to article here). For our and my committee’s purposes, the important update was the definitions of the types of atrial fibrillation (AF).

AF is the most common sustained dysrhythmia, which is characterized by disorganized, chaotic wiggling of the upper chamber/s of the heart causing irregularly conducted beats in the ventricles. It is clinically significant because patients seek medical attention, and it is associated with increased risk of stroke, heart failure, and death.

• Paroxysmal AF terminates within 7 days or less of onset. It usually does not require intervention. It often is recurrent and intermittent.

• Persistent AF is atrial fibrillation which is continuous and lasts for at least 7 days. It requires intervention to convert to normal sinus rhythm. It may recur. The article recommends that if a patient starts off with persistent AF, they should continue to be characterized as persistent even if the pattern of the AF subsequently becomes intermittent and “paroxysmal.”

• Long-standing persistent AF is persistent AF that lasts for more than 12 months. The patient and provider have not yet given up the hope that someday this patient may be converted into normal sinus rhythm.

• Permanent AF is persistent AF of some duration wherein the provider and patient make a shared decision to abandon efforts to convert the patient into a normal rhythm. There is no inherent difference in the character of the AF; it is just a therapeutic choice. These patients are often given medication long-term to control the rate of their AF and anticoagulation to reduce the risk of stroke or other issues from blood clots.

The new guidelines advise that the expression, “Chronic AF” is historical and should no longer be used. They explain “it has been replaced by the “paroxysmal,” “persistent,” “long-standing persistent,” and “permanent” terminology.” In an American Hospital Association Coding Clinic from 2019, guidance for the diagnostic statement of “chronic persistent atrial fibrillation,” was given that the coder should only use I48.1, the code prior to 2020 for persistent AF because “chronic atrial fibrillation is a nonspecific term” that could be referring to that laundry list of AF.  

We’ll come back to this in a few moments.

When revising the materials, we delved deeply into the use of “history of” in the context of AF. As we know, providers and coders have different understandings of what “history of” means. To a coder, it means “old, resolved, in the past, no longer present.” To a provider, it means, “the past medical history includes,” and they do not really make a mental distinction between historical conditions and chronic conditions. The ICD-10-CM code used for verbiage of “history of AF,” Z86.79, is titled Personal history of other diseases of the circulatory system.” Can’t get more vague than that, and it bundles in with “history of” heart failure, coronary artery disease, or aortic aneurysm.

It is disconcerting to a provider to use verbiage indicating a current condition if it is not currently manifesting. This action will require explanation to them. They need to understand that if a patient has had AF in the past and they are still receiving any kind of work-up or treatment for it presently, the patient should be diagnosed with some type of AF. Compare it to diagnosing hypertension in a patient on antihypertensives whose blood pressure is 100/54. They still have hypertension, albeit chronic and controlled, not a “history of.”

On rate control for recurrent short-lived, self-terminating AF = paroxysmal AF. On antiarrhythmic to prevent recurrence of AF which required cardioversion after several months = persistent AF. What if the patient is on anticoagulation for AF, but they are not sure what the duration or type of AF it was, and you can’t access their records? That may be a situation where documenting “chronic AF, type unknown” would be clinically appropriate.

I do not recommend using “chronic AF” indiscriminately. Persistent, long-standing persistent, and chronic AF are all comorbid conditions or complications (CCs) whereas unspecified and paroxysmal AF are not. Using “chronic AF” for all AF could be interpreted as fraud or abuse, an attempt to capture a CC when it isn’t warranted.

Another point to teach your providers is descriptive diagnoses, although they feel like they are being specified, often result in an unspecified code. “Atrial fibrillation with a rapid ventricular response” and “new-onset AF” convey urgency and clinical significance to the practitioner, but to the coder, they mean I48.91, Unspecified atrial fibrillation. In the case of the new-onset AF, there may be no more specificity to be had yet, but the former term may have opportunity to specify.

The last addition to our materials relates to atrial fibrillation as a potential sepsis-defining organ dysfunction. Clinicians are aware that new-onset AF may be heralding serious pathology, such as sepsis or diabetic ketoacidosis. The literature supporting this stance can be found here.

ACPA has many excellent benefits for the physician advisor member including the CDI resource materials (https://www.acpadvisors.org/). I strongly recommend you/your physician advisor check us out.

CMS Focuses on SDoH, BH in Proposed 2025 OPPS Ruling

By Tiffany Ferguson, LMSW, CMAC, ACM

In a move to support individuals at high risk of suicide or overdose, the Centers for Medicare & Medicaid Services (CMS) is proposing changes in the payment structure and services to expand telehealth options for care management and the inclusion of social determinants of health (SDoH) risk factors in outpatient treatment programs. These changes aim to provide better financial backing for practitioners who deliver critical interventions and follow-up care for at-risk populations.

Among the proposed changes, CMS is introducing separate payments for safety planning interventions. This new payment structure, GSPI1, will compensate practitioners for developing and implementing safety plans, which are vital for individuals identified as having a high risk of suicide or overdose. This code is in addition to or separate from the evaluation and management (E&M) visit or psychotherapy services.

Additionally, post-discharge follow-up contacts will now have separate payment, ensuring continuous care and support during a critical recovery phase. The proposal is looking to create a monthly billing code to provide post-discharge follow-up contacts that are performed in conjunction with a discharge from the emergency department for a crisis encounter. This would be a bundled service describing four calls in a month, each lasting between 10-20 minutes, GFCI1, pricing would be a direct crosswalk with principal care management - 99426.

CMS is also focusing on the integration of telehealth into more behavioral health treatment services. The new payment and coding proposals will facilitate the use of technology to enhance treatment delivery. This initiative is part of a broader effort to modernize and improve access to behavioral health services. The proposal is specifically looking at the expansion of telehealth for General Behavioral Health Integration, 99484 and Principal Care Management, 99424-99427, as well as potential reimbursement for FDA-approved digital mental health treatment (DMHT) devices (See page 377).

CMS is proposing updates for Opioid Treatment Programs (OTPs). In relation to SDoH, CMS is making efforts and opening comment for inclusion of the health-related social needs tool for those with opioid use disorder in OTPs. Although the reimbursement for providing the SDoH risk assessment was added last year, there is a recommended expansion to include this same add-on for OTP inclusive in the bundled intake. The enhanced payments will support a more thorough assessment of patients’ needs, including health-related social needs, harm reduction interventions, and recovery support services.

These proposed changes by CMS represent a proactive approach to addressing some of the most pressing issues in behavioral health and opioid treatment. For further details see the 2025 OPPS proposed ruling, starting around page 606.

Sepsis 2.5

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

In the old days, you walked into a patient’s room, visually surveyed them, and exclaimed, “(Spicy expletive deleted!) This patient is septic!” and then you rushed out to start aggressive treatment and transfer to the intensive care unit. The reason the pundits tried to specify what constituted sepsis in the 1990s was to avoid missing cases and incurring deaths.

The problem that we have with sepsis right now is that all the attempts to codify and operationalize it left out the most important characteristic. The patient is sick. I don’t mean sick like with a cold or a stomachache; I mean SICK, in all-caps.

I believe sepsis is part of the progression of non-self-limited untreated infections. It doesn’t happen with an adenoviral upper respiratory infection. It also isn’t present in every elderly patient with cystitis.

Sepsis is the penultimate stop prior to dying from an infection. When I used to present at mortality conferences, if I saw a patient who died from an infection, but sepsis was never recognized or explicitly documented, I referred the case to quality for education of the clinical personnel.

But how to recognize it? The general criteria of the systemic inflammatory response syndrome (SIRS) of fever/hypothermia, tachycardia, tachypnea, and abnormal white blood cell count was a start. These were a cue that something was amiss, but they were too nonspecific. Zillions of conditions could result in abnormal vital signs or an abnormal white blood cell count.

“Life-threatening organ dysfunction caused by dysregulated host response to infection” was closer. In writing this, I realized the problem is in the construction of this phrase. The organ dysfunction doesn’t really have to be immediately life-threatening. The condition of sepsis is what is life-threatening; we recognize it is present by the organ dysfunction it has caused.

Howard Rodenberg et al. published an article called, “Sepsis-2.5: Resolving Conflicts Between Payers and Providers,” on behalf of the Society of Critical Care Medicine. Putting aside the fact that I wish they had invited me to be a co-author, because I have been preaching what they wrote for a long time now, I really like their no-nonsense conceptual definition of sepsis:

Sepsis is present when a patient with infection exhibits evidence of organ dysfunction at a site external to the seat of infection, or more than what is routinely expected from a localized infection.

Septic shock is present when a patient with sepsis exhibits persistent hypotension following initial fluid resuscitation.

I used to say that sepsis is when a patient is sicker than the average patient with that underlying infection, heralded by organ dysfunction. A colleague disagreed with the sicker-than-average characterization – he pointed out that if a patient is in the ICU, an intensivist might not have the same definition of “sicker than average,” because the intensivist’s patients are all sick. I mean sicker than all others with that same underlying infection of pneumonia or cellulitis or UTI, not only in the cohort of patients for whom you are caring personally.

They propose that sepsis is identified by “an ill-appearing patient, documented or suspected infection, and evidence of organ dysfunction.” I like it!

I am not sure where some of the specific guidelines stem from (e.g., hyperlactatemia being > 3.0 mmol/L); had I been a co-author, I would not have set strict criteria. Hypoxia may be sufficient; does it have to meet the threshold of acute hypoxic respiratory failure? I would not endorse a specific change from the baseline. If someone normally has platelets of 120,000 and they have thrombocytopenia of 70,000 in the proper setting, I don’t think it is reasonable to reject that as clinically significant thrombocytopenia because the decrease from baseline is less than 50 percent.

I don’t want providers to have to tick off checkboxes and grab their calculator to see if a patient qualifies. I know this was crafted with payor input, but not all payers play by the same rules. I always think that a competent provider using sound clinical judgment should be able to make a diagnosis without being pigeonholed into a specific level or change from a baseline.

Their conceptual definition does explicitly resolve the issue of organ dysfunction involving the infected system. It says “or more than what is routinely expected from a localized infection.” Acute hypoxic respiratory failure is not routinely expected in pneumonia. Acute kidney injury is not typical for urinary tract infection.

The other thing that doesn’t sit well with me is the name. I don’t like “Sepsis-2” or “Sepsis-3” or “Sepsis-2.5.” That implies that the condition of sepsis has been changing and evolving. It has not! Sepsis has always been and will continue to be a real medical condition. The only thing changing is the words we use to describe and characterize the condition.

How about “life-threatening progression of infection identified by causing organ dysfunction?” I propose we don’t give clinicians more hoops to jump through making sure the patient meets specific thresholds and rigid criteria, but let’s allow providers to make the diagnosis and treat the patient, aggressively and with alacrity.

Is this Sepsis-3.1?

Should it be?

Social Admissions: Differences Using ABN and Preadmission HINN

By Tiffany Ferguson, LMSW, CMAC, ACM

There seem to be variances, particularly regionally, regarding the use of the preadmission Hospital-Issued Notice of Non-coverage (HINN) and the Advance Beneficiary Notice of Non-coverage (ABN). Both notices serve essential roles in informing patients about potential non-coverage by Medicare, but they differ significantly in their application and implications, especially in the context of social admissions.

The regulations surrounding HINNs, particularly the preadmission HINN, were last revised as Version 508 in April 2012, before the implementation of the Two-Midnight Rule and the Medicare Outpatient Observation Notice (MOON) in October 2013. This historical context may explain why preadmission HINNs were once more commonly used and may still be used more frequently in certain regions.

A preadmission HINN is issued by hospitals when they determine that an admission is not medically necessary, is inappropriate, or is custodial in nature. The primary purpose of a preadmission HINN is to notify the patient that the hospital, typically the utilization review committee (URC), does not consider inpatient admission to meet the criteria for Medicare coverage. This occurs when the attending physician supports inpatient admission; however, there is concern that the inpatient admission may not be medically necessary, is inappropriate, or can be considered custodial care. This notice is issued before or at the time of admission. The hospital (URC) is not required to obtain concurrence from the patient or the attending physician before issuing a preadmission HINN. This also applies to direct admissions to swing beds and in situations in which the hospital determines that skilled nursing facility (SNF) services are not needed.

An ABN, on the other hand, serves a broader function. In the case of custodial care, there are nuances to recognize, particularly since ABNs are provided when the hospital intends to provide care in the outpatient setting. The ABN is intended to inform Medicare beneficiaries in advance that Medicare may not cover certain items or services. The notice allows healthcare providers to shift financial liability to the beneficiary if Medicare denies the claim. An ABN must be provided before the service is rendered, giving the beneficiary time to make an informed decision about whether to proceed.

ABNs are used in a wide range of scenarios, typically involving services that may be deemed not reasonable and necessary under Medicare guidelines (or considered custodial care).

When considering social admissions made primarily for non-medical reasons, such as convenience or social support, the differences between using an ABN and a preadmission HINN become particularly relevant. The preadmission HINN focuses on the hospital’s assessment that the inpatient admission does not meet Medicare’s criteria for medical necessity or appropriateness. This notice serves to inform the beneficiary of their right to appeal to their Quality Improvement Organization (QIO) should they disagree with this decision.

The QIO will either concur with the member or the hospital on the medical necessity of the inpatient status. Should the QIO side with the hospital, the patient is financially liable for their Part A services.

If the hospital instead provides the patient with an ABN, the hospital is making a decision to keep the patient in an outpatient designation. The patient must provide a signature of acknowledgement prior to the services, if the hospital intends to bill the patient for any outpatient services that may be rendered while bedded.

Reviewing the use of the preadmission HINN, it appears to be most common in the Northeast, specifically New York. According to Livanta’s 2023 annual report, Region 2, which includes New York, New Jersey, Puerto Rico, and the Virgin Islands, reviewed the preadmission HINN 174 times, with an 81-percent concurrence rate with the hospital. The breakdown is interesting: 167 HINNs were given in New York, while only seven were given in New Jersey, and none in Puerto Rico and the Virgin Islands. In fact, New York last year provided significantly more notices than any other region. In Region 3 (Maryland, Delaware, Pennsylvania, and Virginia), this preadmission HINN was reviewed seven times by Livanta. In Region 5 (Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin), it was reviewed a total of six times, and in Region 7 (Iowa, Kansas, Missouri, and Nebraska), it was reviewed once in the entire year. The trends were similar in Acentra Health’s (formerly Kepro’s) annual reports for 2023. The highest number of preadmission HINNs, at 22, was found in Region 1 (Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont).

This disparity suggests that New York hospital policies pertaining to utilization review seem to define the delivery of a preadmission HINN as the standard of practice for social admissions, with a decision to place patients in inpatient care, while other hospitals across the country are either not providing the preadmission HINN appropriately or choosing up front to keep patients in an outpatient designation.

In writing this article, I reached out to the Centers for Medicare & Medicaid Services (CMS) for clarification on why certain hospitals use the preadmission HINN versus the ABN for social admissions. I requested that the instructions for the HINNs be updated to reflect more current standards of practice, given that they are over 10 years old.

The response I received stated: “Thank you for your suggestion to clarify. We will take this into consideration with the next manual change.” One can only hope! 

Preadmission Screening Annual Resident Review (PASRR) and Long Hospitalizations

By Tiffany Ferguson, LMSW, CMAC, ACM

One thing I was never taught in my master’s in social work (MSW) program was the hospital requirement to complete a PASRR screening for every patient discharging to a skilled nursing facility (SNF).

The Preadmission Screening and Resident Review (PASRR) was created as part of the Omnibus Budget Reconciliation Act of 1987. PASRR requirements, added to the statute as sections 1919(b)(3)(F) and 1919(e)(7) of the Social Security Act, required states to create a system to assess the needs of individuals with mental illness or intellectual disability applying to or already residing in Medicaid-certified nursing facilities.

This system ensures that individuals are not being placed in such facilities unnecessarily or without adequate supports.

PASRR requires that Medicaid-certified nursing facilities:

• Evaluate all applicants for serious mental illness and/or intellectual disability;

• Offer all applicants the most appropriate setting for their needs (in the community, a nursing facility, or acute-care settings); and

• Provide all applicants with the services they need in those settings.

PASRR is an important tool for states to use in rebalancing services away from institutions and towards supporting people in their homes. To comply with the 1999 U.S. Supreme Court decision in Olmstead vs. L.C., under the Americans with Disabilities Act, individuals with disabilities cannot be required to be institutionalized to receive public benefits that could be furnished in community-based settings.

In brief, the PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have a serious mental illness or intellectual disability. This is called a “Level I screen.” Those individuals who test positive at Level I are then evaluated in-depth, called “Level II” PASRR. The results of this evaluation result in a determination of need, determination of appropriate setting, and a set of recommendations for services to inform the individual’s plan of care. Although this process is a federal regulation, it is managed through each state agency, often in different ways in each state.

In 2020, the PASRR regulations opened for public comment in efforts to acknowledge and attempt to reduce some of the inefficiencies. The most common compliant was about the time delay; patients are required to remain hospitalized for 7-9 business days while they await Level II evaluations. This means that every patient in a hospital awaiting a Level II PASRR evaluation must remain in the hospital during that time until they are approved for discharge to a SNF and/or nursing home facility. This process had become so burdensome that in California, Medicaid will cover administrative days for the hospital while patients wait for their Level II PASRR evaluation.

The conundrum I have with this regulation is multifaceted. It is unclear why, with technological advances and such a high focus on nursing home requirements, the proposed ruling has never been finalized or revised – and thus remains untouched since 2020. It is difficult to understand, with today’s staffing limitations and lack of hospital beds, how it can be considered perfectly acceptable for patients to sit in the hospital an additional 7-9 days while they wait for an outside evaluation.

The final argument is that this law misses the mark on the intention of inappropriately housing individuals in a care setting when a community setting would be more appropriate. This raises concerns about the growing number of patients who remain in the hospital for custodial reasons, often for extended lengths of time.

By PASRR standards, this would be greater than 30 days. Per PASRR requirements, an evaluation must be completed if the patient is going to a nursing home or SNF for more than 30 days with a serious mental illness or intellectual disability diagnosis. However, that same patient could remain in the hospital for months to years, without such evaluation or support from the state, for community-based services.

There are many arguments for why the hospital is not the best setting for custodial patients. These include risk of exposure to infections, the impact on other patients receiving medically necessary care by holding beds, and staff burnout. There is also a lack of socialization, sunlight, physical activity, and rehabilitation for the mind and body.

Hospitals are not built or trained to care successfully for patients with long lengths of stay, especially for patients without medical needs, and thus these patients are often neglected and ignored, isolated in their hospital rooms.

It appears that this is a void in our medical system and federal regulations, where prolonged custodial hospitalization is a tolerated practice, often due to lack of alternatives; however, transitioning to a SNF requires extra red tape because of federal and state attention.  

Why Medicare Advantage Denials for Patients with 2MN Still Exist

By Juliet Ugarte Hopkins, MD, ACPA-C

It has nearly been six months since 42 CFR 422.101(b)(2) within the Code of Federal Regulations was officially set into motion on Jan. 1, obligating Medicare Advantage (MA) plans to follow the Medicare Two-Midnight Rule and Medicare Inpatient-Only (IPO) lists when it comes to patient status.

Have all the postulated outcomes come to fruition? Hardly. Let’s consider two of them:

1. Denials from MA plans for inpatient-designated hospitalizations will drop precipitously. This most certainly has not happened, even anecdotally, because the Two-Midnight Rule does not simply involve passage of a second midnight in the hospital. It involves medical necessity of that second midnight. As much as it seems we have been talking about medical necessity since October 2013, when the Two-Midnight Rule was introduced by the Centers for Medicare & Medicaid Services (CMS), many continue to apply It inappropriately. More on this in a bit. While CMS made it clear in 2023 that MA plans must utilize the Two-Midnight Rule, they did not include any consequences or penalties if they do not. While some have recommended filing complaints to CMS about violations of the federal regulation by sending an email to your CMS regional office with the number of cases and the payors involved, this is only a suggestion, and not a formal notification or grievance process established by CMS. As such, there is technically nothing – at this point – to stop MA plans from electing not to comply with the Two-Midnight Rule.

2. Scores of MA plan medical directors will lose their jobs on Jan. 1 due to the simplicity of status determination related to application of the Medicare Two-Midnight Rule and subsequent decline of MA plan denials. Once again, application of the Two-Midnight Rule for hospitalizations covered by MA plans has not resulted in fewer denials. As such, there likely has been no decline in employment opportunities for MA plan medical directors. In fact, a cursory review of LinkedIn, and other job search engine sites results in plenty of postings for this type of position.

Let’s get back to the point about the passage of two midnights with medical necessity.

The problem is the term itself – “medical necessity.” In actuality, the concept is “medically necessary care which can only take place in the hospital setting.” Physical and occupational therapy services (including initial assessments), administration of oral medications, and assistance with activities of daily living (ADLs) and ambulation can all take place outside of the hospital. As such, none of these patient needs qualify as “medically necessary,” in the context of the Two-Midnight Rule.

This does not mean they are not necessary.

They most certainly are, and the lack of any of these services could very well lead to a disastrous or even deadly outcome for the patient. This conflict of concepts escalates the struggle clinicians and case/utilization management staff experience when making patient status decisions. 

Passage of a second midnight related to a delay in care also does not fit the bill for “medical necessity.” However, this can be trickier to assess. If discharge is delayed today because the hospitalist is waiting for cardiology to read the echocardiogram, which was performed yesterday – that’s a no-brainer.

Same goes for the patient who is hospitalized Friday and remains hospitalized Monday, because the hospital doesn’t perform stress tests on the weekends. But what if a patient with appendicitis presents to the emergency department at noon, an uncomplicated laparoscopic appendectomy takes place the following day at 4 p.m., and the patient discharges at 7 a.m. on the third day following an unremarkable recovery? Was the passage of two midnights medically necessary? It depends. Was there a medical condition that needed to be addressed or corrected before the surgery could take place, pushing it back to later in the day on the second day? Or was the patient ready for the procedure the afternoon of the first day, but there was no room in the surgical schedule until the following afternoon?

If the documentation is not clear about which was the case, you can be sure the payer will assume there was simply a scheduling delay and deny inpatient status.

Finally, let’s talk about urinary tract infections (UTIs). Maybe not just urinary tract infections – let’s utilize UTIs as a general stand-in condition when considering medical necessity.

You know the drill: “IV Ceftriaxone until urine culture and sensitivities return” is the common history and physical plan refrain, followed by a statement indicating that two midnights are expected.

Why? Because it generally takes at least two midnights, sometimes three, for a urine culture to demonstrate the infective pathogen and its sensitivities to various antibiotics. But why can’t the patient be placed on an oral antibiotic and discharged with follow-up on the urine culture results by their primary care provider? Is there a history of complicated UTIs for anatomical or instrumentation reasons, or has the patient suffered from highly resistant organisms in the past?

If these points are not applicable or are not documented in the record, medical necessity of two midnights cannot be assured as proven. 

It is imperative for clinicians, physician advisors, utilization managers, and yes, MA plan medical directors and case managers to understand the Medicare Two-Midnight Rule.

While a much simpler approach, I believe applying the Rule to any patient who remains hospitalized for at least two midnights is a non-compliant practice.

Don’t create confusion and frustration for your medical staff and utilization/case management colleagues. Utilize the Rule correctly, request additional clinician documentation when warranted to support medical necessity, and find other ways to address discharge delays in your hospital – other than attempting to pass them as appropriate inpatients.

CY25 Proposed Updates to ESRD Prospective Payment System (PPS)

By Tiffany Ferguson, LMSW, CMAC, ACM

On June 27, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update payment rates and policies for renal dialysis services for Medicare beneficiaries.

The updates, effective from Jan. 1, 2025, include changes to the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS), with most notable adjustments being made to support acute kidney injury (AKI) dialysis payment rates, as well as the operationalization of oral-only drug inclusion in the ESRD PPS.

Here are some key highlights from the proposed rule:

1. ESRD PPS Base Rate Increase: Understanding that this population continues to rise in number, as does the corresponding cost of care, CMS is preparing for another year of influx. CMS has projected that for the 2025 calendar year (CY), Medicare will be paying $7.2 billion to approximately 7,700 ESRD facilities for renal dialysis services. CMS proposes increasing the ESRD PPS base rate to $273.20, up by $2.18 from the current $271.02. Total payments to all ESRD facilities are projected to rise by approximately 2.2 percent. Specifically, hospital-based ESRD facilities will see a 3.9-percent increase, and freestanding facilities will see a 2.1-percent increase.

2. Wage Index Changes: CMS proposes using a new methodology for the ESRD PPS-specific wage index that would be used to adjust ESRD PPS payment for geographic differences in area wages. By combining data from the Bureau of Labor Statistics and freestanding ESRD facility cost reports, CMS hopes to replace the existing hospital wage index values in this payment methodology.

3. Outlier Policy Updates: CMS proposes to expand the existing list of ESRD outlier services to include more drugs and biological products that traditionally have been included in the composite rate prior to establishment of the ESRD PPS. CMS is also proposing some slight technical adjustments in methodologies for calculating fixed-dollar loss (FDL) and Medicare allowable payment (MAP) amounts. For CY 2025, the FDL amount for pediatric beneficiaries would increase, while the amount for adults would decrease.

4. Low-Volume Payment Adjustment (LVPA): CMS is proposing to modify the LVPA policy to create a two-tiered system, in efforts to better align payment methodology with resource utilization. The two-tiered system designates that facilities with fewer than 3,000 treatments will receive a 28.3-percent adjustment, and those with 3,000 to 3,999 treatments will receive an 18.0-percent adjustment. Tiering is based on the median treatment count over the prior three years.

5. Inclusion of Oral-Only Drugs: CMS will include oral-only renal dialysis drugs in the ESRD PPS bundled payment, starting Jan. 1, 2025. This is expected to increase access to these drugs, particularly benefiting those without Medicare Part D coverage.

Updates for AKI Dialysis: CMS proposes extending Medicare payment for home dialysis for AKI patients, allowing them more choices in their treatment. ESRD facilities will be able to bill for home and self-dialysis training for AKI patients. The proposed payment rate is set to be equal to in-center dialysis treatment.

The provision for AKI dialysis treatment in ESRD facilities was first released in CY 2017; however, in-home treatment was excluded due to the nature of AKI typically being of a short duration, and the work for set-up and training raised concerns at that time. However, since 2020, there have been significant efforts to promote home peritoneal and hemodialysis for patients, rather than in-center.

Currently, CMS feels there is enough data to expand this to AKI patients. The expansion of ESRD facility conditions for coverage to include home dialysis for AKI is an intentional approach to increase home dialysis access and utilization, while also promoting greater opportunities to increase AKI treatment and management in the outpatient setting. 

The proposed rule by CMS introduces several updates aimed at improving payment rates and policies under the ESRD PPS for CY 2025. Key proposals include increasing the base payment rate, revising the wage index methodology, updating outlier policies, and extending Medicare payments to home dialysis for AKI patients.

These changes reflect CMS’s commitment to enhancing patient care, expanding access to essential medications, and ensuring that payment adjustments align with the resource use of low-volume facilities.

Warding off Clinical Validation Denials with Better Documentation

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

Clinical validation (CV) denials are plaguing us lately. When I work on projects entailing medical record review, I must admit that it is not unusual for me to agree with the payer. However, if a legitimate diagnosis is denied, the blame often stems from the documentation.

I recently had an epiphany as to a methodology for providers to put “mentation” into their documentation and ward off denials.

I recommend a macro in the setting of sepsis. It goes like this:

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

If the coder can’t identify an infection, either the provider is not documenting it properly (e.g., “decubitus ulcer” is not equivalent to “an infected decubitus ulcer with surrounding cellulitis”), or there is no sepsis. There has to be an infection in order to progress to sepsis.

If the practitioner can’t provide any organ dysfunction in that field, either they missed the organ dysfunction (organ dysfunction is not only SOFA, Sequential Organ Failure Assessment), there is no sepsis, and/or there is increased risk of denial.

When I thought about it, I realized that this sentence composition works for lots of conditions, and could be prophylactic against other CV denials:

• Acute-on-chronic hypoxic and hypercapnic respiratory failure due to severe exacerbation of chronic obstructive pulmonary disease (COPD) as evidenced by oxygen saturation in mid-80s and increased CO2 with pH of 7.32. Placed on BiPAP, steroids, nebulizers, and antibiotics. Will monitor closely.

• Pneumonia, probably aspiration, as evidenced by fever, cough, shortness of breath, elevated WBCs, and RLL infiltrate. Was known to have vomited in NH two nights prior. Being treated with antibiotics and supplemental oxygen.

• Severe malnutrition due to cachexia from pancreatic CA as evidenced by BMI 14.7, loss of weight of 10 percent in last month, and muscle wasting. Appreciate dietitian consult. Will implement appetite stimulation and dietary supplementation.

The elements of this construction are:

1. The condition being diagnosed affirmatively or uncertainty (e.g., possible, probably, suspected, likely, etc.);

2. The etiology, using linkage (e.g., from, due to, caused by, as a result of, etc.);

3. The manifestations (clinical indicators); laboratory, imaging, or other supporting evidence (e.g., as evidenced by…); and

4. Plan of treatment.

Maybe they should think about it as: condition…due to…as evidenced by…treated with…

The provider doesn’t need to do this every time they are discussing the diagnosis (i.e., it doesn’t need to be copied and pasted from day to day). It needs to be done upon the initial diagnosis. From that point on, the practitioner just needs to document whatever is relevant that day. Is it getting better? Did some of the manifestations resolve? How is the plan changing? Did the diagnosis evolve from uncertain to definitive? Having multiple mentions of the ongoing condition will demonstrate that it is a clinically valid and significant diagnosis. A best practice is to have it reappear in the discharge summary as well.

Teach this to residents and onboarding providers, and when you are educating service lines on best practice. If you give feedback, use this construction to model good documentation practice.

Some of you might be thinking, “but the payers have specific, ridiculous, unattainable criteria that they demand for the diagnosis of that condition.” That is a different problem. If that is baked into your contracts, address it. If they are just quoting silly criteria to justify unjust denials, fight it. Good documentation doesn’t completely eliminate denials, but it does help the person responsible for appeals, and helps me assess clinical validity when I perform audits.

Have your provider practice good medicine and produce good documentation, expressing what they thought and why they did what they did. It won’t make all denials go away, but it should decrease the number of them. As a bonus, this pattern of construction may help the clinicians organize their thoughts and communicate their thought process to their colleagues.

And that might just improve the quality of care delivered to your patients!

2024 Q1 Coding Clinic Reinforces “As Many Codes as it Takes” Notion

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

I am overdue to give my comments on the 2024 American Hospital Association (AHA) Coding Clinic published for the first quarter. I really appreciate this Coding Clinic, because it gives reminders of general coding rules.

One of the things I have always loved about ICD-10-CM reflects my mantra: “as many codes as it takes.”

• The revisions to the ICD-10-CM Coding Guidelines include the following:

  • The additions of “other surgical site” for post-procedural and obstetrical surgery in the context of sepsis. This means that there should be at least four codes for sepsis in the setting of a procedure:

    • A code for the site of infection, specifying the area involved, like superficial or deep incisional surgical site;

    • The code to specify that there is post-procedural sepsis, T81.44 or O86.04;

    •  A code to identify the infectious agent, if possible;

    • R65.2- for severe sepsis, because all sepsis is now “the condition formerly known as severe sepsis;” and

    • And at least one code to detail what the sepsis-related organ dysfunction was.

• The answer to a question about how to code “acute prostatitis and cystitis” reminds us that you need both the code for prostatocystitis, which establishes the site, and N41.0, Acute prostatitis, to establish the acuity.

• On page 20, the guidance explains that a postprocedural intra-abdominal abscess would take 2 codes – T81.43XA, Infection following a procedure, organ and space surgical site, initial encounter, and K65.1, Peritoneal abscess – to fully flesh it out.

There were several recent questions that arose regarding what “other” or “other specified” codes are meant for conditions for which the provider gives details and often linkage, but with no specific code for the etiology. For instance, chorioamniotic separation goes to O41.8X30, Other specified disorders of amniotic fluid and membranes, third trimester, not applicable or unspecified; and E27.49, Other adrenocortical insufficiency, is one of the codes needed to capture the condition of hypothalamic pituitary adrenal axis insufficiency.

A question on page 17 regarding the coding of the verbiage “rheumatoid arthritis with inflammatory polyarthropathy” points out to me that you need to take into consideration where in the classification a code appears. M06.4, Inflammatory polyarthropathy, lives under the umbrella of M06, titled Other rheumatoid arthritis. It probably would have been better if it were titled Inflammatory rheumatoid polyarthropathy. However, I (not Coding Clinic) would also suggest that if the provider had specified “rheumatoid factor positive RA with inflammatory polyarthropathy,” the more accurate code would be M05.79, Rheumatoid arthritis with rheumatoid factor of multiple sites without organ or systems involvement.

There was a set of questions regarding dural tears that I am sure is driving some of you crazy. My experience is that some quality and clinical documentation integrity (CDI) teams try to get their providers to perform contortions to get out of triggering patient safety indicators and complications. They think that the magic words to preclude a complication from being considered a complication are “inherent to” or “integral to.” However, on pages 20 and 21, Coding Clinic is pointing out that regardless of whether the circumstances would have led to a dural tear for anyone performing that procedure, or whether there is thinning, scarring, adhesions, or stenosis, the condition is clinically significant and should be documented and captured as an accidental puncture or laceration. I agree with their assessment.

Pages 23-24 posed an interesting question. A patient presented to the ED with an exacerbation of asthma and did not have access to their albuterol inhaler. Coding Clinic explained that you don’t use an underdosing code for as-needed medications. The code they recommend is Z91.198, Patient’s noncompliance with other medical treatment and regimen for other reason. It makes me think that I might have been using the wrong code for underdosing of antipyretics (to reduce fever). It is still clinically significant and should be recorded (it might be the reason that mom dragged the baby out in the middle of the night – giving too low a dose of acetaminophen), but since it isn’t a long-term drug or prescribed course, like 10 days of antibiotics, it isn’t a “medication regimen.”

There was also a question about transaminitis and hyperbilirubinemia being documented as “acute liver injury due to metastatic liver disease and chemotherapy.” The indexing of “acute liver injury” goes to a trauma code in S36. The coder recognized that this is not correct. Coding Clinic advises using K71.8, Toxic liver disease with other disorders of liver and then codes for the metastasis and adverse effect of the antineoplastic drugs. Since the etiology is known and there is no distinct combination code, K71.8 is indicated, not K71.9, Toxic liver disease, unspecified. The next question also tackles the use of a trauma code – if there is no trauma, you shouldn’t use a trauma code (an S-T code). Medical intervention misadventures are not considered “trauma.”

The next one is a head-scratcher to me. On page 28, a patient with coronary artery disease and a bypass graft (CABG), presents to the ED with chest pain over three days and is diagnosed with a non-ST-segment elevation myocardial infarction (NSTEMI), likely from the stenosis of a vein graft. They recommend I24.4, NSTEMI, as the principal diagnosis and I25.10, Atherosclerotic heart disease of native coronary artery without angina pectoris, as the codes. Their reasoning is that “it would be inappropriate to assign a code for angina in the setting of an MI.”

Am I to infer that if the patient hadn’t suffered an MI, you would have used the code indicating “of CAD graft” with “unstable angina pectoris?” What if the patient had chronic stable angina prior to the MI? Are you not allowed to include that information in the coding? I think what they were trying to convey is that the NSTEMI was the progression of the atherosclerosis of autologous vein coronary artery bypass graft with unstable angina, and that once you had the MI, it superseded the CAD in that distribution. In addition, the patient was found to have other CAD, which was not felt to be the etiology of the chest pain.

I know that coding is based on documentation. We want the codes to reflect the conditions the patient has, so if the coding based on documentation doesn’t tell the story accurately, either the documentation or the coding must be adjusted. And…with as many codes as it takes.

As always, I recommend you read the Coding Clinic in its entirety on your own.

Programming Note: Listen live to Dr. Erica Remer as she reports this story during today’s Talk Ten Tuesdays broadcast at 10 a.m. EST.

It Takes Failure to Have Respiratory Failure

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

I have been performing a lot of chart reviews in my consulting capacity, making clinical validation determinations. Whether I am hired by the payor or the provider, I assess the clinical course and documentation and try to make a fair appraisal. One of the conditions that is particularly irksome is acute hypoxic respiratory failure.

For the newly updated pediatric sepsis definition, a survey of practitioners was undertaken to suss out what the consensus was for the medical condition. A scenario was posed, and the respondents weighed in on whether they thought it constituted sepsis or not. I decided to try that approach with acute hypoxic respiratory failure.

I posted this case on LinkedIn:

O2 sat of 89 percent on room air. 2L by n/c gets pulse ox to 95 percent. PE: No acute distress. Not toxic appearing. Exacerbation of COPD.

Do you think this is acute hypoxic respiratory failure?

Almost all of those who responded gave me a resounding “no.” A couple of people wanted a little more information, to try to determine if the patient had chronic respiratory failure. One person cited Pinson & Tang’s position that a pO2 < 60 mmHg (SpO2 < 91 percent) on room air was sufficient to conclude hypoxemic respiratory failure.

This highlighted the fact that in clinical documentation integrity (CDI) practice, we often depend on dogma put forth by respected individuals in the field (including me!) We teach our providers and create internal clinical guidelines to support our positions. If there is established evidence-based literature, great! If not, we sometimes fall back on expert opinion. One of the pitfalls of this is we sometimes spurn common sense and rely too heavily on medicine by checkbox.

I believe I have sorted out why this condition unsettles me and causes us all such grief. I am going to try to lay it out for you all, clinicians, coders, and payers. Please note that I am specifically honing in on adult respiratory failure.

The ICD-10-CM code J96.01 is titled “Acute respiratory failure with hypoxia.” Why is it written that way, and not “acute hypoxic respiratory failure?” Let’s deconstruct this.

I posit that first, you need to determine if there is acute respiratory failure.

Acute respiratory failure implies a rapidly developing, severe, and life-threatening impairment of the body to intake or absorb adequate oxygen – or to expel sufficient carbon dioxide. If left untreated, the individual is at high risk of dying from inadequate oxygenation of tissues (e.g., heart or brain) or profound acidosis, which is incompatible with life.

Chronic respiratory failure is more insidious. It often develops more gradually, so the body has time to compensate. The patient learns to deal with shortness of breath if they walk too fast or to stop exerting themselves before ischemia gives them chest pains. If the person comes to equilibrium in chronic respiratory failure, they will have a chronically reduced oxygen level, persistently elevated carbon dioxide level, or both, but their pH will be near-normal. Their status is tenuous, and a new stressor can disrupt the delicate equilibrium, setting off the same life-threatening cascade of events as acute respiratory failure. This is termed acute and (or on) chronic respiratory failure.

The second part of the title is “with hypoxia.” Having a pO2 of < 60 mmHg constitutes hypoxemia, a reduced oxygen level in the bloodstream. Hypoxia is defined by Merriam-Webster as “a deficiency of oxygen reaching the tissues of the body whether due to environmental deficiency or impaired respiratory and circulatory organs.” Hypoxia is the life threat, although it often follows and is heralded by hypoxemia. This is why the code isn’t “with hypoxemia.” Practically speaking, however, we use the terms interchangeably.

In order to have acute hypoxic respiratory failure, you need to have all components: acuity, low oxygen delivery to tissues, and the threat to life.

People are (mis)interpreting Pinson and Tang’s guidance to mean that simply having a pO2 < 60 (SpO2 < 91 percent) or a P/F ratio of less than 300 is adequate to diagnose acute respiratory failure with hypoxia. Even with the caveat that one cannot apply the criteria to patients with chronic respiratory failure, this is not sufficient. This level of oxygen establishes hypoxemia, but more is needed to satisfy the acute respiratory failure piece.

Acute respiratory failure is symptomatic and requires substantial treatment. The symptoms/signs may be pulmonary in nature, like shortness of breath, tachypnea, or intercostal retractions. They may relate to the consequences of the hypoxia or hypercapnia, like anxiety, lethargy, or confusion. These patients typically appear acutely ill.

Treatment is necessary. When I practiced clinically, there were patients on whom I would toss a nasal cannula at a couple of liters per minute. I was trying to make them more comfortable, but I didn’t necessarily think they would succumb without it. Patients in acute respiratory failure need treatment to survive.

For hypoxia, they need significant oxygen supplementation. Most pundits expect to see four or more liters per minute (whatever you consider “high-flow”). A patient does not need to be intubated, but if they are intubated to address air exchange defects (as opposed to “airway protection”), they are in respiratory failure.

Let us remember that when we are reviewing records, we are not assessing the patient directly, but the documentation. It makes it so much easier if the provider produces good documentation to arrive at a valid conclusion. Here are the things I look for:

• A history describing development over a short period of time;

• Signs or symptoms of respiratory distress (e.g., shortness of breath, tachypnea or bradypnea, air hunger, supraclavicular/intercostal/subcostal retractions, accessory muscle use, abnormal vital signs and/or findings on lung exam) or end-organ dysfunction from hypoxia/hypercapnia (e.g., restlessness, anxiety, reduced level of consciousness, metabolic encephalopathy, diaphoresis, dysrhythmias);

• Consistency in documentation;

  • The history of present illness depicting a patient in distress with symptoms consistent with etiology. Description of baseline status if pertinent;

  • A general description including some degree of distress, ill-appearing, or in extremis (e.g., “in no acute distress, non-toxic, not ill-appearing” would be inconsistent);

  • Re-evaluation of the patient’s condition at reasonable intervals;

  • The declaration of an impression of acute hypoxic respiratory failure at the time (e.g., not days later for the first time, when the patient is no longer exhibiting the signs and symptoms). I expect it to be high on the impression list, not number 9 as an afterthought;

  • If the diagnosis is prompted by a query, it better be supported with the thought process by the provider. I don’t want to see a random diagnosis just pop up without clinical support and only appear once;

  • The diagnosis carried throughout the record by all providers. When the condition resolves, it should be resolved in the impression list. It can even be removed if the length of stay is prolonged, but it should reappear in the discharge summary; and

  • No unresolved conflicting documentation amongst clinicians.

• Critical care time being claimed in the ED, the drawing of an arterial blood gas, a pulmonary consult, and/or admission to the ICU are supportive (but not necessary) clinical indicators; and

• Treatment suggesting the diagnosis is clinically valid and significant

  • E.g., high-flow oxygen, CPAP, BiPAP, intubation; and

  • Aggressive treatment of causative conditions (e.g., antibiotics, pulmonary toilet, steroids, respiratory treatments as indicated).

How about that case? The patient meets criteria for hypoxemia, but is in no acute distress, nor is toxic-appearing. They have a reasonable etiology (COPD), but they only need 2 L/min by nasal cannula. These clinical indicators do not seem to support acute or acute-on-chronic respiratory failure with hypoxia. I would diagnose this as “acute exacerbation of COPD with hypoxemia.” If I were the documenter, I would also have discussed the patient’s baseline to support chronic respiratory failure, if I felt they had it.

Clinicians, if a patient has a life-threatening respiratory issue, think acute or acute-on-chronic respiratory failure. Document the historical and physical points and data that support the diagnosis. Specify whether it is hypoxic, hypercapnic, or both. Be precise and consistent in your documentation. Don’t downplay it or attribute the signs and symptoms solely to alternate diagnoses.

I would recommend linking the acute or A/C respiratory failure to the underlying etiology. I also like linking the manifestations. Detail your thought process and make it hard for the payor to deny the existence of the condition:

Acute-on-chronic hypoxic respiratory failure from pneumonia complicating acute exacerbation of COPD, with pO2 86 percent on baseline home O2 2 L demonstrating air hunger, accessory muscle use, and diffuse wheezing.

If the patient has a low oxygen level, but is not exhibiting signs of respiratory failure, and only requires low-flow oxygen supplementation, call it hypoxia or hypoxemia. If they have acuity, and severity, and require sufficient treatment, call it acute respiratory failure with hypoxia.

Payers do not misinterpret this article and cite that the documentation has to have all of the elements above, or else acute respiratory failure is ruled out. There is always an underlying condition, but there are very few diagnoses in which acute respiratory failure is considered inherent (e.g., acute respiratory distress syndrome, ARDS). Don’t try to gaslight the provider that acute respiratory failure is inherent to pneumonia or heart failure. Clinicians must take in all the facts and data and use their clinical judgment to render a diagnosis.

If you are going to take anything from this article out of context, don’t use it at all!

Physician advisors, bookmark this article and send it to your providers when you discover opportunity in your medical staff’s documentation of respiratory failure. Feel free to condense it and make a tip sheet for them.

Finally, CDI specialists, don’t try to force the provider to use the diagnosis of acute respiratory failure because it is a major comorbid condition or complication (MCC). Our job is to make sure the medical record is accurately depicting how sick and complex the patient is. They need to look as sick in the EHR as they do in real life: no less, but no more.

(For more education on optimal documentation practices, check out Dr. Remer’s Documentation Modules with CME).

Reference: Richard Pinson, Cynthia Tang, Acute Respiratory Failure – All There Is To Know, Pinson & Tang, September 5, 2023.

Navigating the Complexities of Outpatient in a Bed (OPIB)

By Tiffany Ferguson, LMSW, CMAC, ACM

The implementation of outpatient in a bed (OPIB) classifications in hospital settings presents unique challenges, particularly regarding billing, patient care, and regulatory compliance. These challenges may vary across hospitals, depending on electronic medical record (EMR) classifications and internal hospital bylaws or policy guidelines for managing this population.

With the looming continued aging of baby boomers requiring more healthcare services and increased social awareness of patient healthcare needs, compounded by provider moral distress, and the administrative pressures of doing more with less, social hospitalizations are continuing to rise.

Understanding and Documenting OPIB

OPIB is defined as an outpatient medical record designation that identifies a patient bedded in the hospital who initially or no longer warrants medically necessary services, from a billing perspective. These patients are often placed in the hospital setting because their social situation leaves them with no other alternative, or they remain in the hospital until an alternative location can be secured, despite the completion of observation services. To date, the Centers for Medicare & Medicaid Services (CMS) has not recognized this level-of-care designation in hospitals.

Since these patients are outpatients, the full admission requirements for hospital inpatients are not required. Thus, documentation requirements should fall to the hospital bylaws and internal policies and procedures.

Extended Observation versus OPIB

It is rare and unusual for a patient receiving observation services to remain in the hospital for a prolonged period. Since observation is a service, the review of medically necessary observation services is either completed, and the patient’s continued stay is due to social considerations, or the patient’s condition warrants hospital admission. For patients who remain purely for custodial reasons, they should be notified that observation services have ended.

There should also be a clear transition documented in the EMR, with an end to the observation services ordered or a change in the EMR encounter type to indicate that observation hours have been completed. This will help avoid confusion regarding any changes or decrease in services due to the patient’s lack of medical necessity.

Key Considerations for OPIB Classification

• Defining Outpatient Classification: Clearly define what constitutes an outpatient classification. This involves setting clear criteria and guidelines for when a patient is placed in the hospital for an OPIB designation. Consider incorporating this into the patient classification guidelines to guide the utilization review and physician advisor team in reviewing these patients.

• Documentation Requirements: If this designation is a part of your hospital’s EMR, then it will be helpful to ensure that policies and procedures reflect the standards for provider and clinical staff documentation.   

• Acceptance and Decision Tree: Develop an acceptance or decision tree protocol for determining when a patient qualifies for OPIB. This protocol should outline specific criteria and decision points for healthcare providers to ensure that medical necessity does not exist or has ceased. This decision tree should also include review of alternative locations that may be better-suited for these individuals, rather than the hospital.

• Patient Communication: Inform patients about their OPIB classification, including how it affects their care and billing. Clear communication helps manage patient expectations and reduces confusion regarding their treatment plan.

• Billing and Ancillary Services: Determine if and how the hospital plans to charge for services rendered to OPIB patients, particularly ancillary/professional services. Establish transparent billing practices to ensure that patients are aware of potential costs. Should the hospital determine that they are not going to bill the patients, it will be key to maintain appropriate reporting (see Dr. Ronald Hirsch’s comments and articles on A2970).

• Internal Tracking and Reporting: Implement a system to track OPIB cases internally. This tracking is crucial for future prevention strategies, charity reporting, and maintaining compliance with regulatory standards.

Avoiding Social Admissions

To prevent social admissions, consider leveraging agreements with hospital-owned or community partners. This might include post-acute care facilities, community housing settings, or other properties the hospital owns or partners with. Establishing a fast track from ED to post-acute care may be a lower-cost alternative to taking up medically necessary resources in the hospital (which is likely a whole other article as to why the hospital is not the best fit for social care).

Effectively managing OPIB classifications requires clear definitions, documentation, and proactive communication with patients. Acknowledging the new norm and creating internal guidelines for addressing this population, hospitals can navigate the complexities of OPIB, maintain regulatory compliance, and provide appropriate care while managing resources efficiently.

Properly implemented, these strategies will help avoid legal challenges and improve overall patient satisfaction and outcomes.

NIH Study Finds Link between Treatment-Resistant HTN, SDoH

By Tiffany Ferguson, LMSW, CMAC, ACM

A recent study published in the Journal of the American Medical Association (JAMA) and funded by the National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health (NIH), has found that adverse economic and social conditions significantly increase the likelihood of developing treatment-resistant hypertension.

Such hypertension is defined as blood pressure that remains above 140/90 mmHg despite optimal use of three antihypertensive medications of different classes, including a diuretic. This condition significantly raises the risk of stroke, coronary heart disease, heart failure, and all-cause mortality.

The study analyzed data from 2,257 Black and 2,774 white adults participating in a larger study that includes over 30,000 Americans. Approximately half of these participants reside in the “Stroke Belt” in the southeastern United States, where stroke mortality rates are higher than the national average.

The social determinants of health (SDoH) factors in the study examined education level, income, social support, health insurance status, and neighborhood conditions. The study identified that several of these factors were linked to an increased risk of developing treatment-resistant hypertension, such as having less than a high-school education, a household income under $35,000, lack of social interactions, absence of someone to provide care during illness, lack of health insurance, residing in a disadvantaged neighborhood, and living in states with poor public health infrastructure.

Over a span of 9.5 years, the study observed that 24 percent of Black adults developed apparent treatment-resistant hypertension, compared to 15.9 percent of white adults. While adverse SDoH increased the risk for both groups, Black adults were disproportionately affected by these adverse conditions, leading to a higher incidence of the condition.

The researchers suggest that addressing the SDoH could mitigate the racial disparities observed and subsequently reduce the higher risks of stroke and heart attack among Black Americans. Effective interventions suggested included improving access to education, increasing household income, enhancing social support networks, expanding health insurance coverage, improving neighborhood conditions, and bolstering public health infrastructure.

In response to these findings, the NINDS Office of Global Health and Health Disparities is developing strategies to promote health equity. In August 2023, a supplement featuring 10 manuscripts was published, providing recommendations for addressing SDoH.

Furthermore, the NINDS’s Mind Your Risks® campaign, launched in 2016, highlights the link between high blood pressure and dementia, particularly targeting Black men ages 28-45. This campaign offers strategies for preventing and managing high blood pressure to improve brain and cardiovascular health.

Although the SDoH risk factors will take more than publications, manuscripts, and educational campaigns to change, this research is significant in acknowledging these disparities for future opportunities of targeted funding to high-risk communities.

Understanding Billing Requirements for Caregiver Training Services

By Tiffany Ferguson, LMSW, CMAC, ACM

As part of the Jan. 1, 2024 Outpatient Prospective Payment System (OPPS) guidelines, caregiver training services (CTS) codes were listed as billable services if provided by physicians and non-physician practitioners (NPPs).

I thought I would revisit these codes with greater specificity, as I am seeing some questions come up related to lack of provider awareness, and some confusion regarding providing support in an individual versus a group setting. The intent behind this ruling was to provide practitioners with the opportunity to be reimbursed for their time in providing treatment planning and supporting services to caregivers who support the management of their patients. 

Pursuant to the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act of 2017, a caregiver is defined as an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation. This includes family members, friends, or neighbors who provide unpaid assistance to a person with a chronic illness or disabling condition.

CTS will be reimbursed when provided by qualified practitioners, including but not limited to: physicians, nurse practitioners, clinical nurse specialists, certified nurse-midwives, physician assistants, clinical psychologists, and therapists (to include physical therapists, occupational therapists, and speech-language pathologists).

CTS is covered for patients under an individualized treatment plan or therapy plan of care, even when the patient is not present. Patient or representative consent is required for the caregiver to receive CTS, and this consent must be documented in the patient’s medical record.

The CPT codes for CTS include the following:

• 96202: Initial 60 minutes of multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by a qualified healthcare professional, without the patient present;

• 96203: Each additional 15 minutes of multiple-family group behavior management/modification training;

• 97550: Initial 30 minutes of caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community;

• 97551: Each additional 15 minutes of caregiver training; and

• 97552: Group caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community, with multiple sets of caregivers.

It is important to note that the CPT codes are broken down into appropriate group codes or individual codes based on the number of patients represented for caregiver training.

For instance, if the clinician is working with a patient’s daughter who is providing in-home support to her father with dementia, and the clinician and the daughter discuss the diagnosis and regularly review care plan needs and medication concerns to support the patient’s health condition, then CPT codes 97550 would be appropriate. However, if the clinician is hosting a dementia education and support group with caregivers, the code would be 96202.

It is important to note that if multiple caregivers are present for the same patient in the group setting, the time is still the same for the individual patient. Thus, the codes are based on training time related to the patient, not the number of caregivers.

The Centers for Medicare & Medicaid Services (CMS) provides these coding guidelines under Health Equity Services, to support providers for the time they are spending not only to care for patients, but also to support their natural support system. CTS provides holistic support and recognizes the time providers spend talking to family members and caregivers regarding their patients.