MOON requirement delayed in IPPS final rule: What next?
Hospitals got a last-minute reprieve from the Medicare Outpatient Observation Notice (MOON) notification requirement, which was set to go into effect August 6. Citing the need for additional time to revise the standardized notification form that hospitals will need to use to notify patients about the financial implications of being assigned to observation services, CMS moved back the start date for the requirement in the 2017 IPPS final rule to ‘no later than 90 days,’ after the final version of the form is approved (www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2017-IPPS-Final-Rule-Home-Page.html).
CMS released the new draft of the form (www.cms.gov/Regulations-and-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing-Items/CMS-10611.html?DLPage=1&DLEntries=10&DLFilter=10611&DLSort=1&DLSortDir=descending) August 1 and accepted public comments for 30 days. The MOON notification form is intended to be used to help hospitals comply with the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act. The Act requires hospitals to provide a verbal and written notice of outpatient status to any patient in observation who has been in the hospital for more than 24 hours, stipulating that hospitals must inform patients within 36 hours from the start of the service about their status. However, without a final version of the form ready for use, it would appear that hospitals cannot comply with the NOTICE Act at this time.
‘Hospitals should review the IPPS final rule that contains significant clarification on things like when and how the notice is delivered and finalize their own policies for delivering the notice pending the final version of the MOON being available,’ says Kimberly Anderwood Hoy Baker, JD, CPC, director of Medicare and compliance for HCPro in Middleton, Massachusetts.
CMS stated in the 2017 IPPS final rule:
We expect the final [Paperwork Reduction Act] PRA approval of the MOON around the time the implementing regulations are effective. Therefore, the implementation period for hospitals and CAHs will begin sometime after the effective date of this final rule and will be announced on the CMS Beneficiary Notices Initiative Website at: www.cms.gov/Medicare/Medicare-General-information/Bni/index.html and in an HPMS memorandum to MA plans. During this implementation period, hospitals and CAHs will have time to prepare for implementation, consistent with past implementation practices for beneficiary notices. Hospitals and CAHs will be required to deliver the MOON to applicable patients who begin receiving observation services as outpatients on or after the notice implementation date.
‘Hospitals should watch the Beneficiary Notice Initiative page, where CMS said they would announce implementation information, for more information on the finalization of the MOON and implementation time frames,’ says Baker.
Hospitals will likely not be required to provide the MOON notification form to patients until 90 days after PRA approval, which could mean compliance with the MOON and NOTICE Act is at least 120 days out from the final rule release date given that there is also a 30-day comment period on the revised form, according to Baker.
‘When the final version of the notice form is ready for use, hospitals should use the 90-day implementation period to develop a mechanism for the form to be in their EHR with a trigger to print the notice when the patient is registered as or has a status change to observation. This will allow for the form to be delivered by the designated individual to the patient immediately rather than attempting to do it at discharge,’ says Rose T. Dunn, MBA, RHIA, CPA, FACHE, chief operating officer for First Class Solutions, Inc.
The message should be delivered by hospital staff who are well versed in the purpose of the notice and how patient status may financially impact the patient. Dunn recommends that hospitals choose patient access staff, financial counselors, or utilization review/case management staff to deliver the MOON rather than patient care staff.
The role of HIM in MOON compliance
While many facilities plan to task departments outside of HIM with delivering the verbal and written notice to observation patients, that does not mean there isn’t a seat at the table for HIM when it comes to operationalizing this regulation.
At Via Christi Health in Wichita, Kansas, Sam Antonios, MD, FACP, FHM, CCDS, medical director of medical information and ICD-10 physician advisor, and his colleagues are working to ensure they understand the nuances of the MOON.
Antonios’ facility is currently building a daily report to help track patients who have been in observation 24 hours.
The report will help the facility ensure compliance with the NOTICE Act and MOON, but this may be a challenge for facilities that do not have the capability to create such a document in their electronic systems. But even with the right systems and alerts in place, relying on just one report may present challenges. ‘For example, you may have patients who don’t have the right trigger from the initiation of observation services,’ Antonios says. Remember, the MOON must be delivered 24?36 hours after the initiation of observation services, which is not always the time when the patient entered the hospital, especially for those in the emergency department, he says.
In general, HIM should aid in the creation of reports listing any admission for Medicare beneficiaries in observation. Records for patients who have been in observation for more than 24 hours should be flagged when the report is run, which should ideally be done twice daily and be sent to the team tasked with delivering the MOON, Antonios says.
HIM must play a role in deciding what to do with the MOON when it is completed and how to track verbal notification of observation status, Antonios says. Should HIM scan the MOON forms immediately for inclusion in the patient’s medical record, or should scanning be completed at the end of the patient’s hospital stay? Deciding which option is best may depend on the needs of your facility and staffing patterns.
‘HIM professionals should ensure that the form is properly signed and scanned into the appropriate section of the medical record where it can be consistently found during an audit,’ says Edward Hu, MD, CHCQM-PHYADV, system executive director of physician advisor services at UNC Health Care system in Chapel Hill, North Carolina, and president of the American College of Physician Advisors. In addition, HIM will also play a role in ensuring the CMS-approved MOON is given to observation patients, Hu says.
In an era when hospitals are increasingly using electronic methods of documentation and communication, it may be tempting to create an electronic version of the MOON for patients to read and sign. However, Hu notes that if this practice is implemented the patient must still receive a paper copy of the form. ‘Hospitals must provide a signed paper copy of the MOON to the beneficiary, even if he or she reviews and signs on an electronic pad,’ he says. ‘The hospital must provide the MOON on paper for the beneficiary’s review if the beneficiary asks to review a paper version.’
Tracking and delivering the MOON is one hurdle to overcome, but so too is ensuring that patients understand the information presented to them. Language barriers can present a challenge when delivering the MOON. While it may be relatively easy to obtain a copy of the notice for patients who speak more common languages like Spanish, it is a bit more difficult at Antonios’ facility where patients speak a variety of languages that the form is not available in. In turn, staff may have a difficult time verbally notifying patients of observation status during off hours when a translator is unavailable, he says.
Hu notes that HIM can play a role in ensuring the Spanish-language version of the MOON is made available to patients and staff when it is approved by CMS. ‘Hospitals also have an obligation to provide the information on the MOON in a language and manner that the patient understands. Although this does not mean the MOON must be translated into every language, it does mean that the hospital has an obligation to ensure understanding by beneficiaries with limited English proficiency,’ he says.
The ups and downs of MOON
Complying with the NOTICE Act and operationalizing MOON has presented a significant challenge for healthcare organizations. Some are unsure of how to deliver the form and little is known about the impact it will have on patient relations and hospital staffing.
The verbal and written notice to observation patients should be given between 24 and 36 hours of the patient being placed in this status, which has many wondering whether they should actually wait 24 hours to deliver the notice since it can be challenging to ensure the notice is given before the 36-hour mark, says Antonios. ‘It leaves you with an open window of only 12 hours of actually being able to deliver before missing the deadline,’ Antonios says. Failure to deliver the notice within the given time frame can result in noncompliance.
While Antonios points out that CMS stated in the 2017 IPPS final rule that facilities can deliver the MOON prior to 24 hours of observation care, this may not always be the best option?especially since CMS noted that it discourages this practice. Delivering it before the 24-hour ma=rk as a proactive measure to ensure observation patients in need of the notice are not overlooked?or even delivering it on time?can present challenges since an observation stay can often become an inpatient stay based on a physician’s finding during the early hours of patient care, Antonios says.
Whether you decide to wait 24 hours or deliver the MOON as soon as observation status is initiated, there will be pros and cons.
Not waiting for the 24-hour mark may mean the verbal and written notice were given but not needed and could result in patients who are confused about their status and the financial implications of it. ‘It’s so early in the process that you may have people switched to inpatient before 24 hours and then you would have wasted the little bit of energy and resources to do a task that you didn’t need to do, because if you switch someone before 24 hours you don’t have to give them anything,’ Antonios says.
Delivering the MOON to all patients when they are first assigned to observation makes it easier to capture these Medicare beneficiaries before the 24?36-hour window passes, he says. It lends a fair amount of standardization and automation to the process of complying with the NOTICE Act and MOON, Antonios says.
However, ensuring that staff who are educated on completing the written notice and verbally explaining observation to patients are available at all times is not an easy task. While emergency departments (ED) are often well staffed during nights and weekends, other areas of hospitals may not have the same coverage, which could result in noncompliance if the MOON delivery window is missed. The ED?be it registration or other staff?may be the ideal setting for delivering the MOON if it is done routinely prior to the 24-hour mark. ‘Staffing on the floor goes down significantly after hours. It goes down significantly during the weekend, but the ED typically still has staff,’ Antonios says. ‘People receive paperwork in the ED anyway. It’s part of the process.’
Ready CDI teams for CMS’ proposed expansion of mandatory ortho episode payment models
by Shannon Newell, RHIA, CCS, an AHIMA-approved ICD-10-CM/PCS trainer
If your hospital resides in one of the 67 metropolitan statistical areas (MSA) required to participate in the Comprehensive Joint Replacement Model (CJR), you will also be required to participate in a new orthopedic payment model called ‘SHFFT’ (surgical hip and femur fracture treatment) if an August 2 proposed rule is finalized. The impact? The following assigned MS-DRGs will no longer define hospital reimbursement:
- Major Joint Replacement or Reattachment of Lower Extremity (MS-DRGs 469, 470)
- Hip and Femur Procedures Except Major Joint (MS-DRGs 480, 481, 482)
MS-DRGs 469 and 470 are included in the CJR, which we have discussed in prior articles. Let’s take a look at the proposed SHFFT episode payment model (EPM), which involves the other three MS-DRGs, and see what role the CDI program can play as reimbursement shifts to episode-based payments.
Model overview
The episode of care defined for the SHFFT EPM begins with an admission to a participating hospital of a fee-for-service Medicare patient assigned MS-DRGs 480?482. This admission is referred to as the anchor hospitalization. The episode continues 90 days post-discharge from the hospital, and payments for all related Part A and Part B services are included in the episode payment bundle. CMS holds the hospital accountable for defined cost and quality outcomes during the episode and links reimbursement?which may consist of payment penalties and/or financial incentives?to outcome performance.
This is a mandatory EPM for hospitals already impacted by the CJR; the SHFFT model will apply to the same 67 geographic MSAs. The EPM is proposed to begin July 1, 2017, and will last for five years, ending in December 2021.
Cost outcomes
CMS will initially pay the hospital and all providers who bill for services during the episode using the usual fee-for-service models. Thus, the SHFFT EPM will not impact the revenue cycle at first. However, at the end of each performance period, which typically represents 12 months (January through December), CMS will compare or reconcile the actual costs with a preestablished ‘target price.’
CMS will set target prices using an approach that will phase in a blended rate of hospital to regional costs. In recognition of the higher costs associated with discharges in MS-DRGs with an MCC or CC, CMS has developed an algorithm to adjust the target price for this subset of the patient population.
If the reconciliation process indicates that the costs to deliver services for the episode were higher than the target price, CMS will require repayment from the hospital. If, however, the costs to deliver care for the episode were lower than the target price, CMS will provide additional payments to the hospital for the provided services. To receive additional payments, however, performance for defined quality outcomes must meet or exceed established standards.
Quality-adjusted target price
To receive any earned financial incentives, the hospital must meet or exceed performance standards for established quality outcomes. CMS therefore adjusts the target price based on quality performance, referred to as the quality-adjusted target price.
The SHFFT EPM uses the exact same quality outcomes as those defined for the CJR:
- Patient experience. This is the HCAHPS measure also used in the Hospital Value-Based Purchasing Program (HVBP). The source of information for this measure is the HCAHPS survey.
- Patient-reported outcome data. As with the CJR, the hospital can collect and submit patient-reported data elements and at present will earn quality composite points for submitting the data. These data elements are collected both before and after the procedure and will be used by CMS to create a functional status measurement tool.
- THA/TKA complication rates. This is the Hospital-Level Risk Standardized Complication Rate (RSCR) following the THA/TKA measure. This measure already impacts financial performance under the HVBP. Like the CJR, performance for this measure is weighted the heaviest in the quality composite comprising 50% of the composite score.
Hospital (accountable party), collaborators, and Advanced Payment Models
The hospital is held accountable for episode cost and quality outcomes and all associated financial risks/rewards, even though a variety of providers deliver services and impact performance. As with the CJR, the hospital has been designated as the accountable party because CMS believes the hospital is best positioned to influence coordinated, efficient delivery of services from the patient’s initial hospitalization through recovery.
CMS permits the hospital to enter into collaborative arrangements with physicians and other providers to support and redesign care delivery across the episode and to share financial gains and/or losses. The proposed rule expands the list of collaborators defined in the previous CJR final rule to include other hospitals and Medicare Shared Savings Program accountable care organizations.
The proposed rule also provides an Advanced Payment Model (APM) track for the EPMs, an important step that will further incentivize collaborator participation.
CDI program opportunities
There are five key ways that clinical documentation and reported codes across the continuum impact SHFFT performance:
- Identification of patients included in the EPM. The assigned MS-DRG impacts which discharges are included in the cohort. As one example, consider a patient who would fall into the EPM (MS-DRGs 480?482) unless he or she has a bone biopsy. If reported, the bone biopsy would result in assignment of different MS-DRGs (477?479) and the discharge would not be included in the EPM.
- Establishment of target costs. The capture of the MCC and/or CC impacts establishment of the episode target price.
- Determination of related costs. The costs for hospital readmissions within the episode are included in episode costs if the readmissions are related. The assigned MS-DRG for the readmission determines whether the readmission is related.
The costs associated with Part B claims are included in episode costs if the services are related. The primary diagnosis for each visit determines whether the visit is related.
- Reported complications. Assignment of ICD codes for the following conditions are counted as complications when those conditions result in inpatient readmission:
- Complication risk adjustment. As with other hospital-centric measures such as risk-adjusted readmission and mortality rates, comorbidities reported for the 12 months prior to the anchor hospitalization are used to assess case-mix complexity. The CMS risk adjustment module uses defined comorbidity categories to identify conditions that impacted predicted rates of complications for the THA/TKA cohort.
The capture of at least one condition for each of the 28 comorbid categories over the 12-month period will strengthen risk adjustment and RSCR performance. RSCR performance contributes to 50% of the quality composite score, which, in turn, impacts the quality-adjusted target price.
Summary
Together the CJR and SHFFT models cover all surgical treatment options (hip arthroplasty and fixation) for Medicare beneficiaries with hip fractures. These MS-DRGs typically represent one of the largest inpatient surgical volumes for most short-term acute care hospitals.
As hospitals and collaborators assess and refine the management of patients to achieve or exceed the quality-adjusted target price, the data we submit on claims will be used to assess our performance. The CDI program in the inpatient and ambulatory setting must be positioned to promote and support the capture and reporting of impactful documentation.
Additional information on the proposed rule can be located at https://innovation.cms.gov/initiatives/epm.
Editor’s note
Newell is the director of CDI quality initiatives for Enjoin. Her team provides CDI programs with education, infrastructure design, and audits to successfully and sustainably address the transition to value-based payments. She has extensive operational and consulting expertise in coding and clinical documentation improvement, case management, and health information management. You can reach Newell at 704-931-8537 or shannon.newell@enjoincdi.com.
How coders can build a successful relationship with their physicians
by Sue Egan, CPC, CCD
All coders know that working with physicians is not always a positive experience.
It can be tough providing them education or getting responses from queries. Conversely, providers are busy and typically do not like anything to do with coding. When they hear coding they often take that to mean more work on their part.I have been working with providers for many years and the one thing coders always ask me is, ‘What is your secret for getting along so well with doctors and engaging them to change behavior?’
Building a relationship with your providers can make both of your lives easier. Outlined are a number of ideas that can facilitate building a strong relationship with your physicians.
- Documentation clarification inquiries for the hospital are likely to support physician billing. Communicate to the physicians that if the hospital is asking for documentation it will better support their billed services as well. Complete and accurate documentation will hold up to increased scrutiny by payers.
- Demonstrate why. When you ask a physician to change the way he or she documents in the medical record, show them why it matters. Show how accurate and complete documentation enables appropriate risk adjustments for the patients a physician treats. Remind physicians that good documentation can prove that the patients he or she treats really are sicker than others. This approach is more effective than stating the hospital will get a higher paid DRG.
- Knowing when to step away will help you keep a positive relationship with a provider.
- Regardless of how important the material is you want to educate the provider on, if he or she has a patient that has just passed away, now is not the time to share?they won’t remember what you tell them. Let the provider know you recognize the situation and will reschedule.
- If you know a physician is overwhelmed or is having a really bad day, then recognize that now may not be a good time and offer to reschedule.
- Be available. When approaching a physician for one-on-one education, be flexible in your availability. This could mean coming in early to meet with a doctor before his or her first case. If the physician can meet at lunch, do it. Recognizing the physician’s workload demands and being flexible will yield many benefits to the relationship.
- Be prepared. Physicians will ask you a question once, maybe twice, where you can say, ‘I don’t know,’ but chances are they won’t ask a third time. Be creative in your response. Instead, try saying, ‘You know, I just read something about that, let me go back and make sure I am giving you the most updated information,’ or ‘I just saw something on this, I am not sure if it was CMS or carrier directed. Let me find it and get back with you.’ Once you lose a physician’s trust, it is very difficult to regain it.
- Don’t waste their time. One of the biggest complaints I have heard from doctors is related to queries they deem as a waste of time. Make sure the query or question you are asking is
- Addressed to the right physician/provider
- Relevant to the patient care being provided
- The information you are basing your query on is accurate
- Walk in their shoes for a day. Offer to round with them, where you can provide live audit and education to the provider. See how their days really are. In most cases, you will be amazed at how much they get done.
- Be a better listener. Some coding and documentation guidelines are not clinical in nature and providers can get frustrated by being asked to document things that aren’t clinically significant (e.g., family history for the 85-year-old patient). Sometimes your provider may just need to vent this frustration and while you may not have a resolution to offer, listening and understanding can go a long way in building rapport.
- Ask questions. Ask your provider how they translate a patient visit into medical record documentation. Questions that might solicit opportunities for improved documentation may include:
- What questions are they asking when interviewing the patient?
- What concerns do they have?
- What is the patient experiencing? You can utilize this information to point out how the documented note can better demonstrate the patient’s current condition and treatment plan.
- Share the good as well as the bad. When a physician is doing a really great job documenting timely, accurately, and completely, give them a shout out. Or, when they answer queries timely, let them know. A quick note with a smiley face or even a gold star will be very much appreciated. Positive recognition given to one physician and not another often results in the physician inquiring how he or she can get recognition.
- Sports and (other interests). While engaging physicians in discussions such as sports is completely unrelated to coding and documentation, it can pay off significantly. Many providers are very loyal to their alma mater’s college football and basketball teams. Relationship building can be accelerated when you engage physicians in areas of personal interest. Gaining an understanding of a physician’s college coach, conference, and team standing, and discussing this information with a physician can go a long way to building a relationship. But sports isn’t the be-all, end-all. If you know a doctor has a particular interest (cooking, piano, horror movies, or painting) learning a little about that interest can go a long way. Expanding your knowledge is a good thing and building your relationship with that provider is a great thing.
- Empathy. It is important to remember that physicians are busy with competing priorities. Providers often get interrupted while they are dictating and/or documenting their notes, and when they leave something out of their notes, it is not intentional.
Recognizing that one of our major responsibilities as coders and documentation specialists is to make the physician’s job easier and their data as accurate as it can be is essential.
Avoid approaches that make them feel like they have done something wrong. Let providers know your job is ‘to make you look as good as you are.’
Editor’s note
Egan is an associate director with Navigant Consulting and has been working with providers, of all specialties, for more than 25 years. She works with providers to improve documentation as well as provide education and training related to CPT coding. Sue has lived in Charlotte, North Carolina, for the last 23 years, enjoys traveling with friends, and relaxing at home with a good book and her cats. Opinions expressed are that of the author and do not represent HCPro or ACDIS.