Unexpectedly, some hospitals have reported Quality Improvement Organizations are making records requests for cases dating as far back as May 2015. They are also requesting charts for inpatient-only surgeries, which was also not expected.
This article appeared in the February, 2016 issue of Case Management Monthly.
When Quality Improvement Organizations (QIO) took over the role of education and enforcement for the two-midnight rule on October 1, 2015, many anticipated that the reviews would only look at records from that date forward.
But some hospitals have reported QIO records requests zeroing in on cases as far back as May 2015, says Ronald Hirsch, MD, FACP, CHCQM, vice president, Regulations and Education Group for AccretivePAS in Chicago.
"It caught everybody off guard. No one expected them to audit any [records] earlier than October 1," he said. "But audits are starting hot and heavy and it's important for organizations to understand that it's permitted and that the QIOs can request charts going back six months."
In another unexpected turn, QIOs are requesting charts for inpatient-only surgeries, says Hirsch.
This is because auditors can't determine which cases are inpatient-only because CPT® codes aren't listed on claims. The auditor is supposed to look at the ICD codes on the case and translate them to figure out if it is inpatient-only, he says. If it is, auditors know not to request the chart.
But it appears that's not happening. Auditors aren't translating the codes and instead are just requesting charts, which makes a lot more work for the hospital, says Hirsch.
Currently, there are only two QIOs to serve the whole country: KEPRO and Livanta. The short-stay reviews the QIOs took jurisdiction over in October 2015 will use the current two-midnight policy until January 1, 2016, when the companies will switch to the version of the rule outlined in the 2016 OPPS final rule.
Ensuring Compliance
With reviews already underway, it's too late for hospitals to do anything about this. "If hospitals knew that they were in an audit period, they may have been more diligent about looking at short-stay admissions," says Hirsch.
But compliance shouldn't just happen under the threat of review. "Hospital case managers should always assume that their work will be audited," says Jackie Birmingham, RN, MS, vice president emerita, clinical leadership, for Curaspan in Newton, Massachusetts.
"Today, yesterday, or five months ago—always document as if the auditors are at the door. This is why The Joint Commission started doing unannounced accreditation visits. This is why you should always keep your house in shape so that when guests arrive, you're ready."
Ultimately, she says, it's really not the auditors you should worry about, but the patients whose status may be in question. "It's no fun being the patient at the other end of the audit," says Birmingham.
So how do hospitals make sure they're prepared?
Hirsch recommends that every short-stay admission—those between zero and one day in duration—be reviewed prior to billing. Case managers should also look to see that every patient's status is appropriate up front, he says.
The biggest mistake an organization can make is to simply trust that physicians understand the two-midnight rule and that they are applying it correctly. Case managers should review the chart of every patient that goes upstairs. "If they have a question, there needs to be a process in place to review it," says Hirsch.
The physician advisor (PA) also needs to step in to ensure compliance. "The regulations are changing constantly," says Hirsch. The PA needs to ensure that the case managers and the physicians are educated about these changes and know how to comply.
Current cases should be reviewed to make sure they comply. If they don't, a PA should be involved to make sure the case meets one of the exceptions under the two-midnight rule. Cases that don't meet the exception should be changed prior to discharge using Condition Code 44.
In instances of cases that are found to be non- compliant after the patient has already been discharged, it's important to self-deny the claim and resubmit it. It's far better for the hospital to find the error than have it uncovered by an auditor, says Hirsch.
CMS has indicated that hospitals may be subject to Recovery Auditor scrutiny if they have too many short-stays that don't comply with the two-midnight rule. What's not clear is what error rate triggers a review, says Hirsch.
"My hope is that if a hospital does not do well on the first QIO audit, hopefully they will be allowed a second audit to allow time for remediation," he says.
Understanding the Audit Process
In September 2015, Kepro, one of the two QIOs performing two-midnight audits, released more details about its audit process, stating that the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) will conduct the initial review of short-stay claims using the familiar InterQual® standards.
Kepro also provided additional details about how the audit process will work:
- The process will mirror what KEPRO currently does for hospital-requested higher-weighted DRG reviews.
- CMS will provide KEPRO with sample claims and KEPRO will then request records from the hospitals.
- Unlike hospital-requested higher-weighted DRG reviews, hospitals will have 45, not 30, days to send in the records.
- Starting January 2016, CMS will provide monthly claims to KEPRO for short-stay reviews.
- It's likely that small hospitals will need to submit no more than 10 claims every six months; large hospitals 25. CMS has yet to define what size constitutes a large hospital.
- After identifying the claims it wants to review from those sent by CMS, KEPRO will send a request to the hospital for medical records within five days of the claim selection.
- A hospital has 45 days to respond with the record and may receive a denial if it doesn't meet the deadline. KEPRO will send reminders.
- Hospitals need to submit records in any CMS-approved format, including hard copy, but KEPRO officials prefer digital or electronic files. Formats that are approved include encrypted CD's, fax transmissions, or esMD.
A Kepro official said that auditors looking at short-stay claims need to see two components: documentation of medical necessity and application of the two-midnight rule.
Reviewers will also look for quality-of-care issues and will validate coding associated with the claims.
The first review will be performed by a non-physician using InterQual®. A physician review will follow if the case fails the initial review, and the review will be based on his or her medical judgment.
The physician reviewer will be looking at:
- Acuity of the patient's signs and symptoms
- Medical predictability of adverse events
- Need for diagnostic studies
Another concurrent review will also look at physician documentation to ensure that the patient needed hospital-level care and that the admission was not for social, custodial, or convenience services.
Ultimately when it comes to QIO reviews, the message is to stay on top of this issue and make sure physicians are assigning patients to the proper status—and have the documentation to back up their decisions.
This article appeared in the February, 2016 issue of Case Management Monthly.