News to Note – November 2023

• Hospital transfers have been getting some attention recently, along with the common myths associated with them.  Two points are regulated by the Centers for Medicare and Medicaid Services (CMS): 1) Who pays for the transportation to the second hospital, 2) How much each hospital gets paid for the services provided.
• The first myth is that inpatients can only transfer to another hospital if they need a higher level of care.  This is not correct, as there are no rules about who can or can’t transfer.  
• If the patient requires care not available at the first hospital, their transportation is billable under Medicare Part B by the ambulance company.  However, this only covers transportation to the nearest facility that can provide the necessary care.  If the patient wants to go to a more distant hospital, the ambulance should provide the patient an Advanced Beneficiary Notice (ABN) and charge the patient for the extra mileage. 
• If the patient is transferring for personal reasons or request, such as to be closer to home or where their primary doctor or specialist practices, the cost of transportation is solely the patient’s responsibility.
• The second myth involves payment to the hospitals.  
• The same rules apply whether the transfer was medically necessary or not.
• Beware a common misconception that the referring and accepting hospital split the final DRG!  This is not correct but is commonly referenced.
• While not all DRGs are adjusted, in those which are, Hospital A (the referring hospital) submits a claim for the services it provided with the diagnoses and procedures.  The claim needs to indicate the patient was transferred to another acute care hospital by use of a specific discharge status code which tells the claims processing system that an adjustment to the payment may need to be made.  This happens by noting the patient’s length of stay at Hospital A, the DRG assigned to the admission, and the geometric mean length of stay (GMLOS) for that DRG.  If the patient’s stay was more than one day shorter than the GMLOS, Hospital A will be paid a lower, adjusted amount.  If the length of stay is within one day or more of the GMLOS, then Hospital A gets the full DRG payment.  
• Hospital B (the accepting hospital) submits a claim for all the care they provided.  Their stay may have a different principal diagnosis and will certainly have different procedures.  Ultimately, Hospital B gets the full payment for their DRG with no reduction at all, unless of course they transfer the patient to yet another hospital or discharge to a Skilled Nursing Facility (SNF) or to home care.  If that happens, then the same adjustment applies as to the first hospital.
• Does this mean you should you resist transferring a patient to another hospital until they come within one day of the GMLOS?  Absolutely not!  Medical decisions about patient care should never be based on finances or reimbursement.  Always provide the care as the patients need it and allow the money to fall where it does. 
• The Office of the Inspector General (OIG) recently released a report on the CMS transfer payment adjustment system and determined that if CMS applied the transfer DRG payment reduction to every DRG instead of limiting it to specific DRGs, the Medicare Trust Fund would save about 350 million dollars per year.  But, there is some question about how they came to this conclusion as they found 109,000 admissions from 2017 – 2019 that would have had a payment adjustment based on length of stay compared to the GMLOS, and then randomly selected 100 claims for review to make their final determination.  Is that a statistically valid sample?  They also seem to have made a significant error that two months ago, they criticized hospitals for making.  The OIG found the claims they used in their review by looking at the DRG and the codes on the claim for the discharge destination.  However, they did not query the common working file to determine if the patient actually received that care.  As they pointed out in their previous audit of hospitals, patients are often referred to a SNF or for home care but never receive that service and the hospital claim is never corrected.  Fortunately, the OIG only makes recommendations and CMS has stated they are committed to performing their own analysis at some point in the future – but when that will happen remains to be seen.
• It bears repeating that the use of commercial criteria by Medicare Advantage (MA) plans is not prohibited by the CMS.  MA plans are welcome to use MCG or InterQual inpatient criteria to approve an inpatient admission.  But, when it comes to denying hospitalization or other care, using criteria as the final arbiter is not allowed.  
• Overall, criteria is not a bad thing.  Yes, every patient is different and no criteria set can encompass every possible patient/disease interaction, but common things happen commonly and criteria can do an excellent job sorting things out. 
• The other thing that criteria do is consolidate the medical literature. The standard of care should be judged on what is optimally done for a condition and not what is done in one facility.  Dr. Bill Rifkin of MCG has written extensively about facility variation and it is amazing how prevalent it is. 
• Ever see data from a hospital where 100% of their Medicare total knee arthroplasties are inpatient?  It’s out there and it turns out their physicians’ standard practice is to keep all patients hospitalized at least three days but is that appropriate?  As a review of the literature or MCG would tell you, the standard of care is same-day or next-day discharge.  A payer can rightfully use criteria to determine that this hospital’s doctors may not be practicing per the prevailing standard of care.  They cannot deny inpatient admission based on that criteria, but the payer and the hospital know which cases need secondary review.
• The same can be applied to patients with heart failure or pneumonia.  It needs to be established which patients require hospital care and for how long and which patients need that second midnight in the hospital.  It’s not what the doctors at St. Elsewhere do, it’s really about what the standard of care is. 
• Be sure criteria is used correctly. On hospital day two, a patient who passes observation criteria or fails discharge screening needs ongoing hospital care and that means inpatient admission, not extending “observation care” past the second midnight.
• What if criteria are not met?  CMS makes it clear that these tools alone cannot be used by MA plans to deny care.  If care is going to be denied, it must be reviewed by a physician or other health care professional.  More importantly, CMS requires the person have “expertise in the field of medicine or health care that is appropriate for the service at issue.”  A pediatrician is welcome to approve an inpatient admission but cannot deny inpatient admission for an adult unless they have cared for hospitalized adults.  An internist that has never cared for patients in an Inpatient Rehabilitation Facility (IRF) cannot deny an IRF admission.  Starting in January, if you get a denial, feel free to ask for the physician’s qualifications and if they refuse, escalate the issue however you can.
• If your hospital performs carotid artery stents or your doctors want to perform them, you must go online and get the new National Coverage Analysis that outlines when CMS will cover the procedure. There are significant changes to the coverage that may broaden use while also imposing new requirements. 
• First, CMS used to require facilities to register and be approved to perform the procedure.  This will no longer be required. 
• Next, in the past, only patients at high-risk for carotid endarterectomy could be considered for stenting.  CMS is now removing that requirement, allowing standard risk patients to have this procedure covered.
• Finally, and most importantly, CMS is adding a requirement for a shared decision-making visit between a health professional and the patient.  This discussion must include the options of endarterectomy, stenting, and optimal medical therapy, the risks and benefits of each of those options, what the clinical guidelines state, and the patient’s preferences and priorities.  While requiring shared decision-making is not new, in this case, it is the first procedure where there are not any published tools that can be used as there are for defibrillators or the Watchman device.  This means you will need to either develop your own tool, or count on your doctors to document all the required elements.  Remember, auditors thrive on denying due to technical omissions, so don’t ignore the new requirements.
• If you are looking for the document, you can use the link above or search Google for document CAG-00085R8.
• The CMS discharge planning conditions of participation were updated in 2019 but after four years, we still don’t have interpretive guidelines.  CMS stressed increased patient choice and honoring their goals of care but did not offer many specifics on what that looked like.  Now, there may be upcoming guidance about patient choice, at least.  
• The Federal Register seems to suggest that CMS wants patients to be offered the choice of any post-acute provider in their desired area that could provide the care needed for the patient.  For example, if a patient on dialysis requires care at a SNF, the patient’s choice would be limited to facilities that provide dialysis.  However, most patients do not have such needs.  Most have needs that any SNF can provide but many, if not most, want a 5-star SNF with private rooms, good staffing, and great food.  But, most 5-star facilities don’t have open beds when patients need them.  This led to the question – when offering a patient a list of facilities, must you include those which do not have an open bed?  At the current time, following a private communication from CMS to an ACPA leader, the answer is no.  The list you provide the patient only has to include facilities that can meet their medical needs AND have an available bed.  
• You have to include the most recent quality and resource use data from CMS Care Compare at a minimum, but you can also indicate which facilities accept their insurance, which may be trusted partners or participate in any applicable bundled payment programs, along with any additional data you may have such as readmission rates or outcomes data.
• What if there is an open bed at a facility but the patient refuses it?  Be sure the follow up IMM has been given and let the patient appeal their discharge and if they don’t appeal, give the HINN 12 that day.  When the QIO sees that you have a safe discharge plan for the patient and an accepting SNF, they should rule in your favor.  
• Last month, CMS announced they have withdrawn the National Coverage Determination (NCD) for amyloid PET scans used to diagnose and monitor response to treatment of Alzheimer’s disease.  The NCD allowed one PET scan for patients who were participating in clinical trials which became a problem when CMS approved payment for Leqembi outside of clinical trials.  Patents needed a PET scan to see if the drug was right for them, but could not get Medicare to pay for it.  Having the NCD completely withdrawn is both good and bad news.  The good news is that there are no specific requirements from CMS to obtain a PET scan for this purpose.  The bad news is that it leaves coverage to the discretion of the Medicare Administrative Contractors (MACs).  Will the MACs place specific requirements on coverage?  Will each MAC come up with their own requirements, creating a patchwork of coverage depending on the state where the patient resides?  If your facility is performing these scans, ensure the documentation to support performing each scan is present in the medical record. 
• The American College of Rheumatology and American Academy of Hip and Knee Surgeons recently met and developed clinical guidelines related to the timing of elective joint replacement surgery.  They concluded the timing should be a shared decision between the patient and the surgeon and that there is no role for specific time frames for trials of conservative therapy but several MACs have Local Coverage Determinations (LCDs) mandating a three-month trial of conservative care.  What will happen with this?  The two MACs should revise their LCDs but time will tell if this ultimately happens – and when.
• Last month, Livanta’s newsletter included the story of a patient who was hospitalized with a stroke and sent home with home care.  The daughter called Livanta because a week following discharge from the hospital, no one from home care had shown up and her calls to the agency were not answered.  Livanta contacted the hospital, the case manager contacted the home care agency, and the agency told the case manager they declined the patient due to understaffing.  A few points to take away from this case:
• Hospitals should not refer a patient to a home care agency without confirming they accept the patient. 
• Home care agencies should not accept a patient, then decline the patient without notifying the hospital. 
• In an instance like this, the hospital has to recode their claim since home care did not begin within three days of discharge.