Compliance teams get nervous when rules are not followed. And when an expired form is used, they get really nervous.
Thankfully, there is one fewer expired form to worry about. The Centers for Medicare & Medicaid Services (CMS) has released the updated MOON (Medicare Outpatient Observation Notice). As I have noted in previous articles, the new MOON is actually more patient-friendly, removing some of the superfluous notes. But it still requires indicating why, in a patient-specific way, inpatient admission is not warranted – and a mandated verbal explanation is still necessary.
To help hospitals comply, I have posted a MOON version with checkboxes and suggested information to include in the “additional information” section on my website, where you can also find a video that can be shown to patients to meet the verbal explanation requirement. And then we wait for the new Advance Beneficiary Notice of Non-coverage (ABN), Important Message from Medicare (IMM), and Detailed Notice of Discharge (DND).
As all of you know, the Program for Evaluating Payment Patterns Electronic Report (PEPPER) has returned. And it appears that CMS has increased access to the report, so your quality teams should now be able to download it as they used to be able to. As I had noted in earlier articles, the new report is little-changed from the old version, and CMS still has a few bugs to work out.
But I must give credit to Dr. Sonya Siu, the physician advisor at Pennsylvania Hospital. She was reviewing her PEPPER and noted that one measure didn’t make sense. The measure, single Complication or Comorbidity (CC) or Major CC (MCC), measures the percentage of inpatient admissions that have only one CC or MCC on the claim. This measure was not new; it was reported on the old PEPPER.
But the problem was that in the old PEPPER, the 80th percentile for all hospitals was around 50 percent, meaning half of the Diagnosis-Related Groups (DRGs) had only one CC or MCC on the claim, and the new PEPPER has the 80th percentile at about 5 percent. I compared some hospitals for which I have old and new PEPPERs, and it was an abrupt change, not attributable to any gradual change in coding or diagnosis capture.
Now, I have to suspect that the new contractor has somehow miscalculated the measure. And honestly, I don’t know if the correct rate is 5 or 50 percent, so I would be hesitant to act on that measure. But then again, if they miscalculated it the same way for every hospital, I would think you could still tell if you are an outlier, and act on that as warranted. I have asked CMS to look into this, so we will see what they find.
Next, I have a quiz for you. This case was relayed to me by Dr. Mark Safalow, a longtime friend and physician advisor at Hartford Health and UConn Health – and co-owner of the Blue House Bagel Company in Canton, Connecticut, where his wife is co-owner, the head baker, and in charge of operations.
This was a Medicare patient with chronic hypertension who checked their blood pressure at home in the evening and determined it was markedly elevated, with a systolic blood pressure of 195. They called their physician’s office and were told to go to the emergency room.
As a smart consumer, knowing it was flu season and that ERs are busy, they waited until late at night, when the ER would be less crowded. The triage nurse got his history and immediately checked his blood pressure, documenting that it was measured at 11:56 p.m. As you might have guessed, it was markedly elevated, and he was taken back to a room and his evaluation continued, looking for end-organ injury with an EKG, and blood tests all done after midnight. He ended up being hospitalized.
So, the question for all of you is: considering that the patient’s blood pressure was checked in response to his presenting complaint, and it was performed before midnight, would you consider that blood-pressure check as simply the normal triage that all patients get, or would you count that first midnight for determining his admission status?
Under the Two-Midnight Rule, Medicare states that midnight counting begins when care or evaluation begins, in response to the patient’s presentation. I will admit that in the 4,528 days since the Rule went into effect, I have never faced this question. But I do think it meets the standard for counting.
Now, whether this patient even required hospitalization is a decision that would require more clinical information.
While the coverage of telehealth is definitely a good thing, it has caused needless confusion. I would like to address a little of that today.
In the Centers for Medicare & Medicaid Services’ (CMS’s) ongoing attempts to conquer fraud, waste, and abuse, it launched the WISeR (Wasteful and Inappropriate Service
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