News to Note – February 2023

• The Centers for Medicare and Medicaid Services (CMS) proposed a new rule to be effective in 2024 that codifies several provisions that apply to the Medicare Advantage (MA) plans. CMS is putting into federal regulations the policies that it feels are already in place but which the MA plans have been ignoring or abusing, such as limiting access to inpatient rehab. Very importantly, they are codifying the applicability of the Two Midnight Rule to MA plans.
• CMS announced that they are raising the fees for filing a dispute related to the No Surprises Act from $50 to $350. Why was this necessary? The fees that CMS collects are supposed to cover the costs of administering the program but while it has cost them $4.9 million to run it, they have only collected $89,000 in fees. The other interesting thing is that of all the cases submitted for dispute resolution, only one-third were actually eligible to proceed.
• The Office of the Inspector General (OIG) released a report of Cigna’s Hierarchical Condition Category (HCC) submissions for one of their subsidiaries and they found a lot of unsubstantiated codes were submitted. Cigna claimed that many of the codes they submit to CMS are simply codes taken directly from office visit claims submitted by doctors and there is no possible way they can validate every single one of these. While some feel this supports the idea of Clinical Documentation Integrity (CDI) teams in the outpatient physician offices, the benefit or value is not entirely clear. While employed doctors have access to the resources of their employer, be it a health system or even an insurer, there are still many doctors in private practice who can barely afford a receptionist and a medical assistant, much less a CDI specialist. They are not involved in any value-based programs where HCCs matter and just take care of their patients as best they can. Their payment is not at all linked to diagnosis codes so why would they spend time and effort sorting through all the coding rules to know when the code for a heart attack changes from acute to history of? They just know the patient had a heart attack and they are treating them to prevent another one so they put the code on the claim. 100% chart review for every submitted code is not feasible. What’s the solution? That remains unclear.
• Last month, Choosing Wisely and the Society of General Internal Medicine released five new recommendations. The list includes: 1) Asymptomatic healthy adults do not need a yearly physical exam and labs; 2) Routine pre-op labs before low-risk surgeries are not necessary; 3) Cancer screening should not be performed for patients with a life expectancy of under 10 years; 4) PICC lines should not be used for patient or physician convenience; and 5) Type 2 diabetics not on insulin do not need to perform daily home blood glucose monitoring. We all have a role in ensuring the medical care we provide patients is appropriate and this can serve as additional ammunition for your efforts within your health systems. Millions of dollars are spent on these low value and potentially harmful interventions, money that can be better spent on improving health equity, reducing food insecurity, and so much more.
• A few words about Emergency Department (ED) “boarders”:
• CMS and other organizations in reference to ED throughput consider “boarding” a measure of the time from the decision to admit to the transportation of the patient to that location. Patient boarding in itself not an intrinsically bad thing, but extensive boarding is problematic.
• Reduction efforts involving ED boarding is related to patient safety. Several studies have shown an increase in medical errors and mortality with increased ED boarding times and patient volume. An ED nurse with 10 other patients should not also be caring for an inpatient being managed by the hospitalist.
• While ED boarding time may be a quality measure, from a billing standpoint, ED boarding does not exist. An ED patient’s care is billed as ED care up until the point they either are admitted as inpatient, begin receiving observation services, or are transferred out of the ED to the pre-op area, another hospital, or even to a floor for custodial care. If none of these scenarios happen, the patient remains an ED patient.
• ED boarding is not billed as a status or service. Payer policy can be viewed as location-agnostic. If the patient is formally admitted as inpatient, then they are an inpatient, regardless of whether they are boarding in the ED, in an inpatient bed, or receiving care in a makeshift inpatient unit in a tent in the parking garage. Likewise for observation care. Of course, the patient should have their care transferred to the accepting physician from the ED doctor.
• Unlike facility charges for inpatient or observation or surgery, all of which are billed by units of time (minutes, hours, or days), ED facility billing is based on services provided to the patient without any regard to time. One ED visit, be it four hours or four days, generates one unit of ED care.
• Patients requiring inpatient psychiatric care are also frequently boarded in the ED awaiting transfer. They cannot be admitted inpatient as they will lose their place in line for transfer. But, they can start receiving observation services to allow the hospital to bill for the additional charges that come along with many hours or days waiting for transfer.
• Prolonged ED boarding is intrinsically a bad thing because of the adverse effects on patient safety and quality and the staff stressors resulting from caring for many more patients than is safe. But, remember it is not a status and does not affect how the care is billed.