Congratulations to Dr. Baker and Dr. Kartchner for actually reading the June Editor’s Note and emailing me the regulation that initial observation service codes can only be billed by the physician who actually orders the observation service. This is certainly not a rule I ever knew existed and I can guarantee that when I was in practice I billed 99218-99220 even when the ED doctor or one of my partners wrote the order for observation. If any of you are thinking of blowing the whistle on me, I am sure the statute of limitations has expired. But if not, I prefer chocolate chip cookies for my prison visits but will settle for anything other than cookies with raisins. 

But the issue of physician coding and billing for observation is going away on January 1st. As Dr. Erica Remer describes in her article in this issue, the coding for hospital visits is changing dramatically as announced by the AMA in their CPT code definitions and the CMS OPPS Proposed Rule for 2023. But the AMA and CMS made a big mistake here. They repeatedly discussed “inpatient and observation status” as if those are the only options for hospitalized patients. But we physician advisors know that is not true as the post-operative outpatient staying overnight is neither. They are simply outpatient. As you would expect, I have already alerted the AMA and CMS of their error. I would expect that their intent is not that these visits be coded with the office visit codes but rather also use the hospital codes, but we will have to wait and see what they decide. 

Dr. Remer was busy last month producing content for this newsletter and I am personally grateful for her contributions. She also writes about functional quadriplegia and provides a summary of the presentation we gave at the Case Management Society of America’s national conference. Please indulge me a bit as I brag a bit about that presentation. We presented to a standing room only crowd! Every seat was taken (even the front row) and attendees were sitting on the floor and standing along every wall.  

Short stay audits are always a concern and in this issue Dr. Ritu Prasad reviews the QIO’s audit program. If you have not been audited, don’t feel neglected as your time will come. As Dr. Prasad notes, the focus is stays with an LOS of under two midnights but that doesn’t mean your doctors can just keep patients more than two midnights and you are off scot-free since two day inpatient stays are reported on the PEPPER and extending a stay simply to earn a DRG and avoid an audit is not a compliant tactic. 

Dr. Kristin Wallick writes about a flaw in the HAC reporting system related to central lines and pneumothoracies. If you read my writings, you will know I am not a fan of “quality” measures and this article supports my contention that we really have no idea on how to accurately measure quality care. Sure, we have to stop bad things from happening, like taking out the wrong kidney, but for many events that are measured, they are known complications that can happen even to the most skilled physician. Maybe one day we will stop measuring random events and calling them complications. 

Finally, there was a robust discussion in mid-July on RAC Relief about the patient who would not agree to transfer to a nursing facility. Dr. Steven Grant noted that his facility has a policy on such patients. His excellent summary of their policy is featured here. I am sure he would have loved to share the policy but, well, let’s just blame the lawyers for that. 

Have you thought about advancing your career to be just like Dr. Remer and submitting an article for the ACPA newsletter? Email me at [email protected] for the submission guidelines. I accept articles of any length and on any topic. 

Lessons from the Case Management Society of America (CMSA) Annual Conference 

Erica E. Remer, MD, FACEP, CCDS  

Member, ACPA Board of Directors

Co-Chair, ACPA Clinical Documentation Integrity Committee

On June 2, Dr. Ronald Hirsch and I had the pleasure of presenting in a packed room at the Case Management Society of America (CMSA) Annual Conference in Kissimmee, Florida. Our talk was entitled: Medical Necessity – A Team Effort: The Case Manager, the Physician, and the Physician Advisor. Ron handled the explanation of medical necessity, and my contribution was detailing how case managers can influence providers to do requisite supportive documentation.  

In mingling with the attendees, I was surprised to discover that there were case managers who didn’t know what CDI (clinical documentation integrity) is. Even though CMSA comprises case managers from the whole healthcare continuum, CDI has spread to the outpatient arena over the past years so I would have thought they all might be familiar with it. 

As I pondered this lapse, it occurred to me that different professionals read the record at different times during the encounter, and there is opportunity for synergy. Utilization/case management scrutinizes the emergency and admission documentation to see if medical necessity is met for the status and level of care to which the patient has been assigned.  

In contradistinction, CDI professionals usually do not perform their initial review until 24-48 hours after admission. This presumably gives the providers time to sort out the clinical situation and get their documentation ducks in a row. Coders (including professional fee coders) do not see the chart until after discharge. Quality, Compliance, Legal, and Physician Advisors may touch the chart anytime during or after the encounter. 

When I was a PA, I recognized that the critical care attestation being used in my organization was not compliant. It wasn’t in my purview, but it seemed like someone should care and act. If an encounter was escalated to me and I judged the documentation to be lacking in supporting medical necessity for status, I would address that deficit along with closing out the CDI query. It would behoove us to understand what other departments are looking for and keep it in mind whenever we are reading the record. 

It might be advisable for case management personnel to be introduced to CDI tenets, and CDI specialists to be versed on medical necessity criteria. They might approach their assigned tasks a little differently. The MCG criteria may specify “persistent confusion,” and that might be sufficient, but the case manager could educate the provider on potentially documenting “metabolic encephalopathy” to be more specific and maximally risk-adjusting. The CDIS who is doing a second-level review on sepsis cases might recognize a medical necessity documentation deficit and counsel their provider to spell out why an inpatient admission was warranted. They don’t need to be fully cross-trained but being introduced to key elements and knowing when referral is indicated could be quite helpful. 

Collaboration was also the theme in the afternoon when Dr. Ahmed Abuabdou (ACPA VP of Operations) and I participated in a panel with Amy Ehrich and Mary McLaughlin Davis as part of the affiliation between CMSA and ACPA. Our topic was the relationship between the case manager and physician advisor. Ahmed shared some PA successes from his institution, I harped on documentation as usual, Amy imparted some pearls from the payer side, and Mary gave the case management perspective from her large healthcare system. 



In conclusion, don’t operate in a vacuum. Introduce your case management staff to the CDI team. Have them see how they can cooperate and collaborate. Get to know Quality, Compliance, and the Revenue Cycle. As a PA, you can increase your value if you are able to promote your colleagues’ and other departments’ agendas, too. 

Dr. Erica Remer is the Founder and President of Erica Remer, MD, Inc., a CDI consulting firm in Beachwood, OH 

Hospital Acquired Condition 14 (HAC 14) 

Kristin Wallick, MD, FCCP 

Member ACPA CDI Committee 

Case: A 72 year old male with tracheobronchomalacia underwent a fiberoptic bronchoscopy, right thoracotomy, and tracheal bronchoplasty. Prior to surgery, he had a PICC line placed by intervention radiology due to poor venous access without complication. Postoperatively he developed a right pneumothorax requiring chest tube placement. A Hospital-Acquired Condition (HAC) 14, iatrogenic pneumothorax with venous catheterization was attributed to this patient.  

The HAC Reduction Program (HACRP) is a Medicare Value-Based-Purchasing (VBP) program that supports the Centers for Medicare and Medicaid Services’ (CMS’) effort to link Medicare payments to healthcare quality in the inpatient hospital setting. Under the program, CMS reduces overall Medicare payments for hospitals that rank in the worst-performing quartile of all hospitals on measures of Hospital-Acquired Conditions (HACs). On an annual basis, CMS evaluates overall hospital performance by calculating total HAC Scores based on the equally weighted average of scores of program measures. Hospitals with a total HAC score greater than the 75th percentile of all total HAC scores will receive a 1-percent payment reduction. This payment adjustment applies to all Medicare discharges for the applicable fiscal program year when CMS pays hospital claims. CMS uses the Total HAC Score to determine the worst-performing quartile of hospitals based on data for six quality measures. (1) 

Over the past three years, data analysis at our institution has demonstrated a lack of a temporal relationship and correlation between central venous catheterization and pneumothorax for HAC-14. Currently, HAC-14 only requires the presence of a diagnosis code of postoperative pneumothorax (J9.5811), not present on admission, with any of the central line procedure codes. There are no exclusions and no options to link or unlink the diagnosis code to the procedure code regardless of the temporal correlation of the procedure or etiology of the pneumothorax. If both codes are listed on the coding summary, the HAC will be triggered, even if no temporal or causal relationship exists. The intention of the HAC 14 is to track the incidence of iatrogenic pneumothorax from central line placement. The goal is to provide data to institutions to determine quality improvement opportunities associated with central line placements. There is no opportunity for any intervention to decrease the incidence of the HAC 14 in our patient as the etiology of the pneumothorax is not the central line.  For complication metrics to be impactful and accurate, the coding of this HAC-14 must have a clear association and etiology.  

The use of central venous catheters has become the standard practice for the administration of chemotherapy, vasopressors, intravenous fluid or blood products, and parenteral nutrition. Central venous catheters are common among critically ill patients. More than five million central venous catheters are inserted in the United States each year. (2). In the United States in 2014, over 15 million catheter-days/year were recorded in the intensive care unit alone. (3). The incidence of pneumothorax with central line placement ranges from 1-3% in the medical literature. (4,5).  

If an ICD 10 -CM code set does not exist, requests can be made through the ICD-10-CM Classification Team at the National Center for Health Statistics (NCHS) Centers for Disease Control and Prevention (CDC). We have requested new ICD 10 diagnosis codes under the J95.811 postprocedural pneumothorax with the intent to add a revision to the HAC 14 inclusion criteria with these diagnosis codes. These new codes would specify if the pneumothorax was due to a central line or vascular line placement. This approach would also require NCHS to update their inclusion codes to require one of these two new codes and remove the code J95.811 from the HAC 14 inclusion list. Currently an internal review and consideration are underway. 

References: 

1. Hospital-Acquired Condition Reduction Program | CMS 
2. Preventing complications of central venous catheterization. AU McGee DC, Gould MK SO N Engl J Med. 2003;348(12):1123.  
3. CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011 http://stacks.cdc.gov/view/cdc/5916/ (Accessed on February 06, 2014). 
4. Patel A R, Patel A R, Singh S, et al. (May 22, 2019) Central Line Catheters and Associated Complications: A Review. Cureus 11(5): e4717. doi:10.7759/cureus.4717. 
5. Reeson M, Forster A, van Walraven C. Incidence and trends of central line associated pneumothorax using radiograph report text search versus administrative database codes. BMJ Qual Saf. 2018 Dec;27(12):982-988. doi: 10.1136/bmjqs-2017-007715. Epub 2018 May 25.  

Kristin Wallick, MD, FCCP is Senior Medical Director Denials Management UCHealth and Physician Advisor Clinical Documentation, Case Management, and Utilization Management UCHealth 

Physician Advisors Guide to the 2023 Physician Fee Schedule Proposed Rule 

Erica E. Remer, MD, FACEP, CCDS  

Member, ACPA Board of Directors

Co-Chair, ACPA Clinical Documentation Integrity Committee

The unofficial, unpublished FY 2023 Physician Fee Schedule Proposed Rule (CMS-1770-P)) was posted on July 7, 2022 (Regulations.gov). The published version is set to drop on July 29, so by the time you are reading this, you will be able to see the official Rule. Comments will be taken at https://www.regulations.gov/search?filter=CMS-1770-p until September 6, 2022.  

January 1, 2021, the American Medical Association (AMA) revised the CPT Evaluation and Management (E/M) Guidelines for Office and Outpatient Visits (O/O Visits), Split/Shared Visits, and Critical Care Time billing, and CMS adopted these changes. The Proposed Rule I am reviewing here now addresses visits other than office and outpatient, referred to as “Other E/M.” The statistic is quoted that “E/M visits comprise approximately 40% of all allowed charges under the PFS” and the subset of Other E/M represents about 20%. 

CMS is proposing to mostly adopt the AMA CPT E/M codes and descriptions. It can be somewhat confusing when CMS deviates from CPT’s code-view, which affects several codes and concepts presented in the Proposed Rule. 

To view the specific guidelines as laid out by the AMA, go to http://www.ama-assn.org/cpt-evaluation-management. They are almost the same as the ones established for the O/O Visits. Emergency Medicine E/M level is solely MDM based; the only situation where time is used in the ED is for Critical Care billing. All other E/M will either be leveled by MDM or time-based. 

Here are the high-level points from the CPT E/M guidelines: 

• The definition of new and established has not changed. 
• Services reported separately cannot be double dipped in Medical Decision Making (MDM). For example, if a provider bills for an echocardiogram, they may (and should) document the results in their note, but they can’t take credit for the echo in their MDM calculation for the E/M visit. 
• There are no longer mandatory elements of the history or physical examination (PE). 
• History and PE should be done as “medically appropriate.” 
• Isn’t Social History (SH) always relevant? 
• Good riddance, gratuitous Review of Systems (ROS)! 
• Do the right thing for your patient – H&P may not be required for billing purposes, but they are still clinically useful and medicolegally significant. 
• MDM 
• There are four levels of MDM: straightforward, low, moderate, and high. 
• There are three elements which are judged as to their level of complexity, and the compilation of the three elements constitutes the final E/M level. Two out of three elements must be met or exceeded to establish the level of MDM. 
• Number and complexity of problem/s that are addressed during the encounter 
• The problem must be addressed. Just existing in the patient’s problem list is not adequate. Was it worked up or treated? Is there monitoring? Is it contributing to the need for nursing care? 
• It isn’t only about the final diagnosis – the presenting signs/symptoms may drive this element. 
• If you are deferring all management to another healthcare provider, you can’t take credit for addressing the problem. 
• There are pretty specific definitions of the category of problem (e.g., stable/exacerbated, chronic/acute, uncomplicated/complicated) 
• Amount and/or complexity of data to be reviewed and analyzed 
• You take the point when you order the test. Analyzing the result is expected and included. 
• Multiple results of the same test being trended only count once (e.g., comparing serial hemoglobin or serum creatinine) 
• External means from another practice or institution. Reviewing your own notes doesn’t count here. 
• Independent historian is giving additional story for confirmation or completeness. Language interpretation doesn’t count. 
• Independent interpretation requires interpretation although it need not be a formal report. Saying, “The Xray looked good to me,” isn’t an interpretation. Instead: “The CXR doesn’t demonstrate an infiltrate or evidence of heart failure. Normal.” 
• Risk of complications and/or morbidity or mortality of patient management 
• Includes management options discussed, considered but not undertaken. For instance, discussion with family and decision to make patient comfort care only is considered high risk. 
• Social Determinants of Health (SDoH) are considered moderate risk but only if they “significantly limit diagnosis or treatment.” Consider making this a macro. 
• Drug therapy requiring intensive monitoring for toxicity is high risk. The monitoring is not for therapeutic efficacy but to assess for toxic adverse effects. Obvious ones are aminoglycoside levels, monitoring for pancytopenia in context of chemotherapy, digitalis monitoring. Routine levels (e.g., electrolytes, glucose, creatinine) are not counted, but the same laboratory studies can count IF they are time-sensitive in a risky scenario (e.g., treating AKI, severe hypoglycemia). 
• Parenteral controlled substances has been added to high risk. This was not originally found in the Office/Outpatient matrix. 
• Not all examples are applicable in every setting. For instance, if a patient is inpatient, decision to admit may not be applicable but decision to escalate hospital-level of care, such as transferring the patient to the ICU, may. 

It is very important to detail the thought process, especially now that MDM is the SOLE component. You do not want to leave determining the complexity to the auditor’s imagination. Think in ink! Why are you ordering that test? What are you concerned about? How are you addressing that comorbidity? 

The alternative to MDM-based billing is time-based billing. The emergency department is excluded from this section. Here are points about time-based billing: 

• The patient must be seen face-to-face (F2F) by the healthcare provider (or surrogate, e.g., split/shared visit in hospital – the NPP can do the F2F portion even if the physician is billing), but each moment of time counted does not have to be F2F. 
• This is now TOTAL time. There is no “>50% spent in counseling and/or coordination of care.” 
• The time should occur in the same calendar day, however, if a continuous service spans two calendar dates (e.g., patient encounter is begun prior to midnight and concludes the next calendar day), it is considered a single service and all the time is applied to the reported date of service. 
• The number of minutes must be met or exceeded. 
• These are the activities which count for time-based services: 
• Preparing to see the patient (e.g., review of tests, reading consultants’ notes or transfer documents) 
• Obtaining and/or reviewing separately obtained history 
• Performing a medically appropriate physical examination 
• Counseling and educating the patient and/or patient/family/caregiver  
• Ordering medications, tests, and/or procedures as medically necessary 
• Referring to and communicating with other health care professionals (assuming not being separately billed) 
• Documentation 
• Independent interpretation of non-separately reportable tests and discussing the results with the patient/family/caregiver 
• Care coordination (as long as not claiming it as a separately billable service) 
• Excluded time: 
• Time spent performing services which are separately reportable and billed (no double dipping!) 
• Travel 
• General teaching that doesn’t specifically benefit the patient 

For a patient admitted in the hospital, either inpatient or outpatient status for observation services (OBS), there will be a combined code set now. Initial care would be reported with 99221-99223, and subsequent care is 99231-99233. Discharge services will be billed under 99328-99239 or 99234-99236 for admission and discharge on the same day for either inpatient or OBS.  

You only get one initial E/M; if a patient is first placed in OP with OBS services and a bill for initial hospital care is submitted, and then the patient is admitted inpatient, the first IP claim would be for a subsequent visit, not initial. This is not considered a new stay. Only one bill can be submitted in a day, so if a patient is seen in the morning as OBS and transitioned to IP in the afternoon, only one 99221-99223 service would be submitted for that date. 

As the proposed code sets stand presently, for consultations: 

• Inpatient or OBS 
• Medicare (does not use the consultation code set):  
• Initial: 9922-  
• Subsequent days: 9923- 
• Commercial insurers who accept consultation codes: 
• Initial: 9925-  
• Subsequent days: 9923- 
• Outpatient without OBS services  
• Medicare:  
• Initial: 9920-  
• Subsequent days: 9921- 
• Commercial insurers who accept consultation codes: 
• Initial: 9924-  
• Subsequent days: 9921- 

For general comparison, here is a table with the highest level of E/M and their corresponding work RVU with 2022 values. 

One potential comment that you might consider making depends on whether you think a patient who is hospital outpatient in bed, not OBS (e.g., patient in for OP joint replacement who is staying overnight for whom a hospitalist is requested to manage medical conditions), should be billed as O/O or they should change the Inpatient/OBS code set to include all patients seen in the hospital setting. I defer to your clinical experience as to which code set seems more appropriate to you. Under the current RVU schema, it doesn’t seem to make a difference moneywise. 

Patients seen in the ED throw a little wrinkle into this coding scenario. If the patient is admitted to the provider who sees the patient in the ED (whether IP or OBS), they should bill an initial hospital IP/OBS code. If the provider is requested to see the patient for evaluation by the emergency physician but the patient is not admitted, then CMS proposes that the other HCP also use an ED E/M code. If the insurer were not CMS, then the latter scenario might warrant a consultation code; remember, CMS does not recognize consultation codes. 

Circling back to the Proposed Rule, CMS plans to retain the “8 to 24-hour rule.” The concept is that they don’t want providers to game the system by extending a stay over a midnight just to accrue a second day’s billing. 

• Less than 8 hours of IP or OBS, only bill initial IP/OBS care code (9922-) 
• 8-24 hours, same-day discharge code (i.e., 99234-99236), even if the stay spans across a midnight. These codes account for the increased resources to perform admission and discharge services. 
• > 24 hours, bill initial IP/OBS (9922-) for date of admission and hospital discharge day management (99238-99239) for date of discharge 

CMS is not adopting CPT’s prolonged total time code (993X0). They are proposing their own G-code, GXXX1, to describe a prolonged service, which is always and only applied to the highest level of service in a code set (If there is an “X” character in a code like this, it means they haven’t settled on the final code; the X is a placeholder). I can’t even begin to explain this section to you because, although I am pathetic at math, (meeting or exceeding) 75 minutes base for 99223 plus 15 minutes prolonged services equals 90 to me. I don’t understand CMS’ explanation of adding an additional 15 minutes on to start prolonged services at 105 minutes for 99223. I think you should read this section from page 313-318 yourself and send in comments. If you spend inordinate amounts of time with a patient, you want to be appropriately compensated. They want 15 minutes for free. Discharge services are not eligible for prolonged services add-on because that is already built into “more than 30 minutes.” 

When split/shared (a service performed conjointly by a physician and a non-physician practitioner) got revamped, CMS wanted to establish their definition of “substantive portion,” which defined who was entitled to bill for the service, as being the individual who expended more than half the total time. There were so many objections (including mine and Dr. Ronald Hirsch’s) that they tabled this pending more discussion. Until January 1, 2024, they are going to continue using one of the three key components (history, physical exam, or MDM) or more than half the total time spent as the substantive portion. After that, they are planning on solely basing it on who spends more than half the time. Isn’t that always going to be the NPP?! If you use them effectively, it will. 

They are giving us an opportunity to give more feedback. I implore you to add your voices. If we do not get this changed, there will never be an advantage to performing a split/shared visit, because the provider will expend their time seeing a patient and the encounter will be paid at the NPP’s rate. My assertion is that the substantive portion is the MDM. Furthermore, why would the history or physical establish the substantive portion if they aren’t even going to be factors in selection of the E/M level of service?  

In conclusion, there are major changes coming to professional fee billing January 1, 2023. Any clinically practicing colleagues will need to understand the new system and what they need to document to bill the appropriate level of service. And we can offer our comments to hopefully shape the Final Rule. Don’t forfeit that opportunity. 

Dr. Erica Remer is the Founder and President of Erica Remer, MD, Inc., a CDI consulting firm in Beachwood, OH 

No Way Out: How to Manage Declined Discharges 

Steve Grant, MD, FHM, ABQAURP

Member, ACPA 

Among the many nightmares we face as Physician Advisors, managing patients who refuse to discharge from the hospital is one of the most draining.  We all want the best for our patients.  At the same time, hearing “no” is more than frustrating; it’s a patient safety issue.  Chances are you have acutely ill Emergency Department boarders, urgent day of surgery cases, and pending outside transfers in desperate need of your beds.   Delaying the care of those patients because your patient won’t leave can have dire consequences.    

Judging from the traffic this topic generated on RAC Relief, this is a common scenario.  At the University of Vermont Medical Center, it happens often enough that we needed a clear plan to help us balance patient centered care with the wise allocation of inpatient beds.  Unfortunately, there was little in the literature or the Utilization Management community to guide us in making a policy.  So we made our own. 

We convened a multidisciplinary team that included nurses, physicians, advanced practice providers, residents, case management, utilization management, quality, compliance, legal, risk management, ethics, finance, medical psychology, palliative care, spiritual care, diversity, equity, and inclusion, and patient-family advisors.  We spent months developing a policy that was approved by senior leaders. 

Several key principals frame the policy: 

• A clear discharge plan that is consistently communicated to patients and families goes a long way to prevent declined discharges.   
• We offer all patients a reasonable discharge plan. We define reasonable as any location that meets the patient’s medical needs at the time of discharge.   
• We are committed to the precepts of Patient and Family Centered Care.  This does not equate to honoring all patient/family requests, particularly if granting a request for one individual could harm others. 
• Declined discharges should never be accepted without further inquiry.  Prior to the policy, refusal was often accepted with few questions asked. 
• Time is of the essence, as discharge options can disappear quickly.  Each step in the policy has a clear timeline. 

Using this framework, we created a three-step management protocol (see Figure 1 below). 

• Step 1: Explore and Respond.   
• Reflect on your own response: hearing “no” can trigger negative reactions.  Before engaging with the patient, take a moment to reflect on your response and put yourself in a calm frame of mind. 
• Explore the reasons for refusal, identify and address barriers: approach the discussion with curiosity and compassion, consider the principles of trauma-informed care, and work with others in your system to resolve barriers where possible. 
• Defer payment issues to Case Management:  while Physician Advisors have the expertise to have these discussions, many front-line clinicians do not. 
• Respond based on discharge location:  details vary depending on the discharge location.  If the discharge is to a non- hospital setting, this is the time to discuss the risks of remaining hospitalized, such as hospital acquired conditions.   It’s also when we emphasize the safety risk their refusal poses to other patients.   
• Explain that remaining hospitalized will not be the default option and that further discussion will follow. 
• Re-evaluate if the discharge plan is still reasonable: after inquiry we sometimes agree that the proposal is no longer appropriate. 
• If still appropriate, then re-attempt discharge. 
• Step 2: Escalation 
• If the patient continues to decline discharge, we escalate the review to Case Management Leadership.  If they agree that the discharge plan is reasonable, then the patient is given the option of accepting the discharge plan or discharging to self-care. 
• Throughout Steps 1 and 2, we move forward with discharge planning.  We set a date, arrange transportation, and complete all discharge tasks. 
• The timeline for Steps 1 and 2 combined is 24 hours. 
• Step 3: Adjudication 
• If the patient declines both options, the primary team disagrees with the escalation decision, or an administrative discharge to self-care appears unrealistic then the case is sent to the Adjudication team (see Figure 1), who make the final decision. 
• The timeline for Step 3 is one business day 

Concurrent with these steps we follow payer-specific processes of important messages, notices of non-coverage, and beneficiary appeals.  These exist in a separate policy but aside from traditional Medicare cases don’t typically influence outcomes and if applied too bluntly can stifle collaboration. 

The policy has been active for a year.  At first it represented a real culture change but has gradually become part of our daily practice.  Clinicians particularly appreciate the backing of a policy, something they could point to as “the rules” when the going gets tough. 

To date, most declined discharges resolve in Step 1, demonstrating yet again the power of good communication. As best as well can tell, Step 1 discussions occur several times a month, but it’s hard to distinguish between refusal and strong preference.   Six cases have gone to escalation and two to adjudication, with all but one resulting in discharge. To be mindful of potential bias, we track age, race, gender, and payer for cases that go to escalation. 

Bringing this policy to life was a difficult endeavor, but one perfectly suited to Physician Advisors, melding administrative and clinical expertise with strong communication skills, teamwork, and innovation.  For years we have relied on guidance from the ACPA community and we hope, in turn, you find this helpful. 

Dr Grant is ACMO for Care Coordination and Patient Transitions at University of Vermont Medical Center, Burlington, Vermont 

Introducing Functional Quadriplegia 

Erica E. Remer, MD, FACEP, CCDS  

Member, ACPA Board of Directors

Co-Chair, ACPA Clinical Documentation Integrity Committee

My first day of orientation as a CDI physician advisor my patients became instantly sicker. The director of CDI taught me about certain conditions which I didn’t previously recognize or document in the ED. These included encephalopathy, malnutrition, and today’s topic, functional quadriplegia. 

I had never heard of this condition before because it is essentially a coding construct. The term indicates a patient who is completely immobile due to severe disability or frailty without physical injury or damage to the brain or spinal cord. Examples of patients with functional quadriplegia are advanced dementia patients who need assistance for all of their activities of daily living and super obese patients (BMI ≥ 50) who are unable to ambulate and care for themselves. 

There are folks in the CDI world who think this is just a made-up diagnosis and is a grab to procure a major comorbid condition or complication. I disagree. I always knew this type of patient was sicker, more complex, and/or required more nursing care than other patients with similar underlying conditions without functional quadriplegia. I just didn’t have a way to indicate this in diagnoses or codes. Personally, I welcomed the terminology. 

The ACPA CDI Committee recently created information on functional quadriplegia for the physician advisor and a CDI tip for the provider. You can access it on the CDI Resource Page under MDC 1. It would be extremely unlikely to ever be the principal diagnosis establishing the Diagnosis Related Group (DRG), so it is just for ease of locating it that we posted it under the Nervous System.  

Please check it out! If you have any CDI topics for which you would like materials created, please reach out to us at [email protected]. We are always looking for our next project. 

Dr. Erica Remer is the Founder and President of Erica Remer, MD, Inc., a CDI consulting firm in Beachwood, OH 

Physician Advisors and Case Managers: Collaboration in Learning and Practice 

Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM

Sr. Member, ACPA Advisory Board,

Past President CMSA

Physician Advisors and Case Managers have a long history of collaboration to meet common goals. The American College of Physician Advisors (ACPA) and The Case Management Society of America (CMSA) have worked together as partners since 2017. During this time, we have attended and presented at each organization’s conferences, and participated in the shared work of both organizations. 

The pandemic slowed the momentum of the relationship, but in no way did it end it nor did our respective members cease participating in our respective virtual conferences.  

This year both conferences were live and the CMSA President, Melanie Prince attended the ACPA Conference. Drs. Ahmed Abuabdou, Ronald Hirsch, and Erica Remer represented ACPA and presented at the CMSA Conference.  

Drs. Hirsch and Remer discussed the importance of Clinical Documentation in supporting the medical necessity of hospitalization for patients. Case managers learned how best practice documentation mitigates avoidable days and denials. Physician Advisors and Case Managers agree the electronic medical record is the patient plan of care and care coordination is a subset of the plan.  

Dr. Remer defined the Grand Unified Theory of Documentation detailing how Clinical Documentation Integrity (CDI) is the foundation to support a hospital and the mission, vision, and values it promulgates. It creates the bridge between the care, treatment, and management of patients and the adherence to quality and compliance metrics. CDI justifies patient status, medical necessity for treatment, and communication between the internal consultants and treatment teams.  

Case studies are impactful for the learner and Dr. Remer used examples from her family to describe the value of using succinct clinical terminology to describe why a patient needs an inpatient level of care, and specifically, in her case, an inpatient rehabilitation level of care. She stressed that physicians must document accurately to justify the cost/value/benefit ratio of the level of care they are ordering for their patient. 

Dr. Hirsch described to the case manager audience the difference between the Centers for Medicare and Medicaid (CMS) definition of medical necessity and the commercial insurance’s definition.  Private payers will not approve a higher level of care if they feel the patient will have the same outcome in a lower level of care. This resonated with the hospital case managers in the audience. They have faced denials to move patients to an acute rehabilitation unit/hospital or an LTAC, and the explanation of why this occurs will help them refocus on the patient’s expected outcome rather than focusing on criteria. The ACPA physicians connected CMSA’s key standard, advocacy, to how documentation from all members of the interdisciplinary team supports a patient’s care, site and hospital status.   

Drs. Ahmed Abuabdou and Erica Remer joined CMSA case managers Amy Ehrich and myself on a panel titled; Supporting Patient-Centered Care with Interpersonal Collaboration: The Case Manager and Physician Advisor Relationship.  

The panelists discussed the role, function, and responsibilities in the case manager and physician advisor relationship. Dr. Abuabdou and I described the roles in hospitals and hospital systems and Amy discussed her relationship with the Medical Directors at a large national managed care organization. Dr Remer described how accurate clinical documentation supports every aspect of the physician advisors’ and the case managers’ service.  

All agreed that cohesion between the physician advisors and the case managers is essential to achieve excellence in status determination, CDI, quality and performance improvement, managing expedited and long-term denials, compliance at every level, high-level revenue cycle practices, and coordination of care.   

CMS is proposing health equity-focused measures for adoption in the Hospital Inpatient Quality Reporting Program. This entails a process to capture screening and identification of patient –level, health-related social needs, such as food and housing insecurity, transportation needs, utility difficulties and interpersonal safety, https://www.cms.gov/newsroom/press-releases/cms-proposes-policies-advance-health-equity-and-maternal-health-support-hospitals. The Physician Advisors informed the audience that case manager documentation of patients’ Social Determinants of Health is allowable under the CMS proposed rule and could affect hospital reimbursement. This is an excellent opportunity for hospital case managers to advocate for their patients and for their hospitals in detailing why discharges are delayed for a seemingly noncomplex DRG.  

Mary McLaughlin Davis is the Director of Care Management Cleveland Clinic Main Campus and Akron General

QIO Short Stay Audits and the CMS IPO List 

Ritu Prasad, MD, CHCQM-PHYADV 

Member, ACPA Government Affairs Committee

Every year CMS puts out the Inpatient Only list, also known as the IPO list, which dictates which procedures must be performed as hospital inpatient status.  With each release, CMS will update the IPO list, often removing some procedures and occasionally adding back procedures that were previously removed.  

Over the last 2 years, there have been numerous changes to the CMS IPO list, especially for orthopedic surgery.  These changes to the IPO list have occurred during the COVID surges, leaving overwhelmed health systems scrambling to update their surgical service lines and patients.  In the face of the COVID pandemic, keeping track of these changes has been a challenge.  Fortunately, with each set of changes, CMS allows for an “audit-free” window to allow health systems to incorporate and rollout these updates.  Now that CMS audit activity has resumed, following are a few thoughts to keep in mind if a short stay procedure is pulled as part of a short stay audit. 

First, let’s start with the basics: What is a short stay audit? 

Quality Improvement Organizations (QIOs) are contracted by the Centers for Medicare and Medicaid Services (CMS) to improve the quality and efficiency of healthcare for Medicare beneficiaries.   

Quality Improvement Organizations (QIO) are resuming short stay reviews to determine if medical services are medically necessary, compliant with the 2 midnight rule, and follow IPPS and OPPS guidelines for Medicare patients.  The focus of these reviews is reviewing cases with a length of stay (LOS) under 2 midnights to see if the 2 midnight rule is being correctly appliedi.  

What are the potential consequences / risks of these audits? 

After conducting the audit, the QIO will send a determination letter for any denied cases.  (No letter is provided for approved cases.) The letter will detail the case reviewed, dates of service, and the QIO’s determination, along with case information to provide a brief rationale for denial. The hospital Is provided an opportunity to respond, typically 20 days.   If no response is received from the hospital in that time, the proposed denial becomes the final determination.  The MAC and the beneficiary will be notified of the denial.  

It is important to review the cases pulled for review to ensure the utilization review processes in your hospital are working correctly in regards to following the 2 midnight rule as well as the CMS IPO list.  It is also a good opportunity to assess your audit risk and determine if education, process improvement, or internal audits are needed at your institution. 

As the QIO resumes short stay audits for medical necessity and compliance with the 2 midnight rule, what should you do if they pull a surgical case for audit that was recently removed from the IPO list?  

In 2021, CMS removed 290+ procedures, many orthopedic, from the IPO list and advised that these procedures would be exempt for audit for compliance with the 2 midnight rule. In 2022, many of those procedures were placed back on the CMS IPO list, and the “audit free windows” are discussed below: 

In the CY 2021 OPPS/ASC final rule, CMS established a policy in which procedures removed from the IPO list beginning January 1, 2021 would be indefinitely exempted from certain medical review activities related to the two-midnight policy. This policy change was made to accommodate the unprecedented number of procedures being removed from the IPO list beginning in CY 2021 due to the elimination of the IPO list. For CY 2022, because CMS is finalizing the proposal to halt the elimination of the IPO list and to return the majority of services removed in CY 2021 back to the list, CMS is also finalizing the proposal to revise the exemption for procedures removed on or after January 1, 2021 from the IPO list to the exemption period that was previously in effect, that is, a two year period.ⁱⁱ 

So now you’re thinking, shouldn’t a surgical case just recently removed from the IPO list not be pulled in a short stay audit?  What does the audit free window actually mean?   

QIOs are still able to audit for the purposes of providing education, but not for the purpose of rescinding payment or referring to RAC. 

So, what to do next?   

The CMS changes to IPO list have been rapid and dynamic over the last five years, as many of the changes have been quickly rescinded.  It’s hard for all parties involved to keep track of the updates, let alone track all the audit free windows for these procedures.  If you see an orthopedic surgery pulled for a short stay audit, it may be worth reviewing the timeline of when the procedure was removed from the CMS IPO list to determine if it is still in the audit free window. 

In addition, consider formulating an appeal that explains the IPO list, the CY 2021 changes, and the audit free window that is well outlined in the CMS fact sheet.  And of course, make sure to submit your additional info in the allotted 20 day timeframe! 

Dr. Prasad is Senior Physician Advisor and Medical Director of Observation Services at MedStar Union Memorial Hospital 

NPAC 2022 Don’t Miss Out 

It is no secret, or surprise, the field of physician advisory continues to grow year after year  within the U.S. healthcare system. Depending on the particular program, a physician advisor may interface with departments such as Revenue Cycle, Payer Strategy, CDI, Compliance, Care Coordination, and Quality Assurance; as well as liaise with the executive suite and medical staff for a given facility.  

The American College of Physician Advisors (ACPA) has distinguished itself as the primary physician-led authority and resource for supporting physician advisors, of all levels, in this growth. Over the past several years, ACPA has developed a variety of educational and information-sharing offerings for physician advisors through its newsletters, specialized articles, town halls, and more. Noteworthy is ACPA’s yearly premier event, the National Physician Advisor Conference (NPAC). Whether held in person or virtually, each NPAC has been abundant with content useful, if not essential, for the physician advisor. And, NPAC 2022 was no different.  

NPAC 2022, Exploring the Spectrum: Leadership through Collaboration and Diversification, built upon classic conference themes with the addition of new concepts from the frontier of physician advisory.  

The newly added category, Evolving Roles for Physician Advisors, proved to be popular among conference attendees. As one could imagine, the breadth of topics under Evolving Roles was expansive. Dr. Erin Boyd’s presentation, “Reviewing the Behavioral Health Case with Significant Medical Issues”, was a standout for guiding physician advisors through cases for patients with behavioral health issues. Dr. Scott Ceule showed us the impact of physician advisors on transfer centers through his presentation, “Transfer Centers -Physician Advisors Should Lead the Way!”.  And Dr. Christopher Boyle’s presentation, “Skilled Nursing Facilities and Discharge Planning-Physician Advisors and Population Health”, as well as Dr. Christine Palermo’s presentation, “Healthcare Reform, Wayne Gretzky, Strategy and Success-An Integrated Physician Advisor Program” shared ideas for under-tapped opportunities within Population Health and Revenue Integrity, respectively.  

NPAC 2022’s Professional Leadership category also drew a lot of attention from attendees interested in collaborating with executive leaders while pursuing their own executive path. Drs. Emeric Palmer and Alexander Ogedegbe, walked everyone through a comprehensive model for engaging the C-suite with “It’s A Kaleidoscope-The Evolution of a Physician Advisor Program”.  This presentation was further complemented by Dr. Ada Offurum and Tiffany Ferguson’s presentation, “Leading as a Physician Advisor-Elevating Your Role”. 

“Fight like a Lawyer” presented by Dr. Barbara Adams and “The Medicare Fee for Service Appeals Landscape-Utilizing Decisions to Guide Compliance and Prevent Denials” presented  by Jessica Gustafson, esq also offered unrivaled legal perspectives under categories for both Financial and Regulatory Strategy.  

Among a number of presentations addressing Clinical Documentation Integrity (CDI), Drs. Ronald Hirsch and Erica Remer treated conference attendees to their co-presentation of “Sick or Not: Only the Documentation Knows for Sure”. This was a delight along with presentations from other ACPA “fan favorites” such as Dr. Edward Hu with his presentation of  “Emergency and Post Stabilization Services” and Dr. Howard Stein with his presentation of “Closed Observation Units”. 

Just a sample of the many phenomenal presentations from NPAC 2022, these presentations with the others are now available for viewing through NPAC 2022 Encore. And, up to 25.5 CME credits can be earned from the over 30 on-demand presentations included. Individual pricing, as well as discounted group pricing for purchase is available via the ACPA website.  

For anyone unable to attend NPAC 2022 in person, NPAC 2022 Encore is the next best thing. If you listen to feedback from the in-person attendees, it will not disappoint.  

August 2022

President’s Note: Summer truly is in full swing but some of us are focused on Fall and an exciting new educational opportunity for our membership. I am thrilled to introduce ACPA’s newly-elected TLC (The Learning Center) Champion, Dr. Benjamin Kartchner, by featuring his long-awaited news about an in-person event geared specifically for new physician advisor on-boarding. Welcome, Ben! 

- Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, FABQAURP

Like most professional organizations, the American College of Physician Advisors (ACPA) has both a mission and vision statement. Full disclosure, I can’t recall if I had previously looked at them before today. I’m sure everyone reading this has looked and knows them by heart so I may have just outed myself as a horrible member in my first article as TLC Champion. Nevertheless, I looked to confirm what I already knew; education, promotion, and advancement of the physician advisor is foundational to the ACPA. 

We are making great progress in these endeavors which is why I am incredibly excited to announce a new educational offering from the ACPA called Essentials & Fundamentals to be held October 17, 2022, at the Loews Chicago O’Hare Hotel.  This one-day event will cover the basics of utilization management, care management, and clinical documentation integrity (CDI) and has been designed specifically for new physician advisors or those looking to brush-up or expand their knowledge base. Focus will be on basic, core principles every physician advisor should know, and aims to enable attendees to become full spectrum physician advisors. 

Topics will cover patient status determination, regulatory compliance, chart review, denials management, and peer to peer basics as they relate to Medicare, Managed Medicare, and commercial payers.  Attendees will also learn about the Medicare Severity Diagnosis Related Group (MS-DRG) system and how clinical documentation affects not only payment, but Centers for Medicare and Medicaid Services (CMS)-reported quality metrics.  Our speakers are knowledge experts and thought leaders within each respective topic with a cumulative experience of over 50 years in active physician advisor practice.   

The in-person venue will allow ample opportunities for your specific questions to be answered, leading to greater understanding and ability to apply the principles in your specific organizations.  A smaller, more personal educational setting will also allow for more interaction with the speakers during breaks and in-between presentations. If you are a new physician advisor, are looking to start a second career, or want to expand your physician advisor program to support areas such as CDI and care management, this is the ideal event to attend. I encourage you to socialize the event in your institutions as an opportunity to onboard new physician advisors. Registration is available on the ACPA website and you do not have to be an ACPA member to attend. 

Work continues on The Learning Center (TLC) with plans to reorganize the current content by topic and add more subject matter in 2023. There will be more information to come on this in the future but, in the interim, please let us know if there are specific topics you want to see with more content. I am committed to making the ACPA the primary source for physician advisor education and development. I also want to encourage everyone to share your knowledge via the various committees and this newsletter. I’m absolutely convinced that there are ACPA members and non-members out there who have brilliantly found solutions to problems and better ways of doing things. The rest of us are just waiting for you to share it. 

Ben Kartchner, MD, CHCQM-PHYADV

The Learning Center Champion, ACPA

Essentials & Fundamentals Chair, ACPA

Dr. Kartchner is an Associate Medical Director of Care Management, INW Region, Multicare Health System