The news cycle never seems to rest. First, a bill has been introduced in Congress to once again try to get observation days to count for the three-day stay requirement for Part A skilled nursing facility (SNF) coverage by Medicare.
Similar bills have been proposed for over 10 years and never get anywhere, so I have little faith that this one will be different. In addition, it makes no sense to limit it to counting observation days. Many Medicare beneficiaries would benefit from SNF care without any hospital stay.
We simply need Congress to realize that medical care in 2023 is not the same as in 1965, and the whole three-day inpatient stay requirement needs to go away.
I also have an update on the Livanta memo about short inpatient stays that I have been discussing for the last two weeks. I was looking through my files and noted that in March 2023, Livanta released a report on their short-stay inpatient audits that they had performed up to that time. And to my amazement, they reported that they had denied 11 short inpatient stays with the diagnosis of melena and 11 with a diagnosis of gastrointestinal hemorrhage. That’s the exact circumstances of one of the case examples in their memo.
In addition, they denied 10 cases with non-ST elevation MI, 10 admissions with ventricular tachycardia, and amazingly, 10 with complete heart block. Those results from earlier this year are in complete opposition to what the memo outlines as acceptable inpatient admissions. It is hard to argue that a patient with ventricular tachycardia or complete heart block is not at high risk of an adverse event. Of course, there are no case details, simply the primary diagnosis, but if they allow inpatient admission for a patient with resolved angioedema, how could they deny complete heart block?
But the bigger news is that on Friday afternoon, Aug. 8, Nina Youngstrom’s newsletter, the Report on Medicare Compliance, reported that the Centers for Medicare & Medicaid Services (CMS) confirmed to her in writing that they had reviewed the Livanta memo prior to publication.
That is huge.
If CMS did not support the case examples, they would not have let Livanta release it.
Now, the talk on discussion groups is that most don’t trust Livanta to abide by this, and I am also mildly skeptical, but knowing CMS reviewed this should go a long way to reducing hesitation at least about admitting all emergent cholecystitis and appendicitis as inpatient, if nothing else. Get a copy of her article and read it.
This new information from Livanta also brings up a fascinating proposal relayed to me by a hospital revenue cycle leader. Over the last year, they have had more than a few Medicare patients who were admitted as inpatients for cholecystitis or appendicitis and had a one-day stay, whereby the hospital then self-denied and rebilled to Part B. This person is considering refunding the Part B payment, then filing a corrected claim based on the inpatient order. That will get them the DRG that Livanta states is the appropriate payment and get an additional $7,000+ per case. In fact, now that Livanta has provided these examples, maybe everyone should go back and look at their short stays that were self-denied after discharge. Now, what is unclear is how this would be viewed. If you followed the requirements for self-denial with utilization review (UR) committee scrutiny and patient notification, what’s the process to reverse that? I honestly don’t know.
One last topic for today. I was contacted by a hospital asking how CMS calculates length of stay (LOS). The concern was that her hospital leaders calculate it from the start of care to discharge, then compare that to the Medicare GMLOS for the DRG.
Well, CMS uses the date of the inpatient admission for LOS calculations and ignores any outpatient or observation days: exactly the opposite of what her leaders do. As I told this person, measuring something this way is statistical malpractice. The only way they can have an LOS better than the GMLOS is to discharge unstable patients, which would be medical malpractice.
I hope this person can resolve this; it’s really senseless.
Literature is ripe with classic phrases that seem timelessly apropos. For example, take the partial federal government shutdown. For days, the phrase repeated in the
As I discussed recently, we have a go-live date for the Medicare Change of Status Notice of Feb. 14. Before reading on, stop and take
Please log in to your account to comment on this article.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Join Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, as she presents effective strategies to strengthen collaboration between CDI, coding, and quality departments in acute care hospitals. Angela will also share guidance on implementing cross-departmental meetings, using shared KPIs, and engaging leadership to foster a culture of collaboration. Attendees will gain actionable tools to optimize documentation accuracy, elevate quality metrics, and drive a unified approach to healthcare goals, ultimately enhancing both patient outcomes and organizational performance.
Optimize your outpatient clinical documentation and gain comprehensive knowledge from foundational practices to advanced technologies, ensuring improved patient care and organizational and financial success. This webcast bundle provides a holistic approach to outpatient CDI, empowering you to implement best practices from the ground up and leverage advanced strategies for superior results. You will gain actionable insights to improve documentation quality, patient care, compliance, and financial outcomes.
Enhancing outpatient clinical documentation is crucial for maintaining accuracy, compliance, and proper reimbursement in today’s complex healthcare environment. This webcast, presented by industry expert Angela Comfort, DBA, RHIA, CDIP, CCS, CCS-P, will provide you with actionable strategies to tackle complex challenges in outpatient documentation. You’ll learn how to craft detailed clinical narratives, utilize advanced EHR features, and implement accurate risk adjustment and HCC coding. The session also covers essential regulatory updates to keep your documentation practices compliant. Join us to gain the tools you need to improve documentation quality, support better patient care, and ensure financial integrity.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Healthcare organizations face complex regulatory requirements under the No Surprises Act and Price Transparency rules. These policies mandate extensive fee disclosures across settings, and confusion is widespread—many hospitals remain unaware they must post every contracted rate. Non-compliance could lead to costly penalties, financial loss, and legal risks. Join David M. Glaser Esq. as he shows you how to navigate these regulations effectively.
Protect your facility from unwanted audits! Join Becky Jacobsen, BSN, RN, MBS, CCS-P, CPC, CPEDC, CBCS, CEMC, and take a deep dive into both the CMS and AMA guidelines for reporting post operative pain blocks. You’ll learn how to determine if the nerve block is separately codable with real life examples for better understanding. Becky will also cover how to evaluate whether documentation supports medical necessity, offer recommendations for stronger documentation practices, and provide guidance on educating providers about documentation requirements. She’ll include a discussion of appropriate modifier and diagnosis coding assignment so that you can be confident that your billing of post operative pain blocks is fully supported and compliant.
During this RACmonitor webcast Dr. Ronald Hirsch spotlights the areas of the OIG’s Work Plan and the findings of their most recent audits that impact utilization review, case management, and audit staff. He also provides his common-sense interpretation of the prevailing regulations related to those target issues. You’ll walk away better equipped with strategies to put in place immediately to reduce your risk of paybacks, increased scrutiny, and criminal penalties.
Copyright © 2024 RACmonitor. Powered by MedLearn Media.
Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
