Medical Necessity
Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI
Manager
Accretive Health
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Medical Necessity
• Medical Necessity
– Fundamental to Medicine
– Integral to Revenue Cycle
– Basis for healthcare delivery transformation
• Right care
• Right time
• Right reason
• Right place
• Right documentation
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NEW PEPPER Target Areas
TARGET AREA
Full and Abbreviated Title
TARGET AREA DEFINITION
Two-day Stays for Medical DRGs
(2DS Med)
*new as of the Q1FY14 release
N: count of discharges for medical DRGs with a length of stay equal to two days
(“through” date minus “admission” date = 2 days), excluding patient discharge
status codes 02, 20, 07, 82
Two-day Stays for Surgical DRGs
(2DS Surg)
*new as of the Q1FY14 release
D: count of discharges for medical DRGs
N: count of discharges for surgical DRGs with a length of stay equal to two days
(“through” date minus “admission” date = 2 days), excluding patient discharge
status codes 02, 20, 07, 82
One-day Stays for Medical DRGs
(1DS Med)
*new as of the Q1FY14 release
D: count of discharges for surgical DRGs
N: count of discharges for medical DRGs with a length of stay equal to one day
(“through” date minus “admission” date = 1 day), excluding patient discharge
status codes 02, 20, 07, 82
One-day Stays for Surgical DRGs
(1DS Surg)
*new as of the Q1FY14 release
D: count of discharges for medical DRGs
N: count of discharges for surgical DRGs with a length of stay equal to one day
(“through” date minus “admission” date = 1 day), excluding patient discharge
status codes 02, 20, 07, 82
D: count of discharges for surgical DRGs
N: count of discharges for medical DRGs with “admission” date equal to
“through” date, excluding patient discharge status codes 02, 20, 07, 82
Same-day Stays for Medical
DRGs
(Same DS Med)
D: count of discharges for medical DRGs
*new as of the Q1FY14 release
Same-day Stays for Surgical DRGs N: count of discharges for surgical DRGs with “admission” date equal to
(Same DS Surg)
“through” date, excluding patient discharge status codes 02, 20, 07, 82
*new as of the Q1FY14 release
D: count of discharges for surgical DRGs
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Two-Midnight Rule
• “When a patient enters a hospital for a surgical
procedure not on the inpatient only list, a diagnostic
test, or any other treatment and the physician expects
the beneficiary will require medically necessary
[emphasis added] hospital services for 2 or more
midnights (including inpatient and pre-admission
outpatient time), the services are generally
appropriate ...”
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Two-Midnight Rule
• “Documentation in the medical record must support a
reasonable expectation of the need for the beneficiary
to require a medically necessary stay lasting at least
two midnights.”
• The entire medical record may be reviewed to support
or refute the reasonableness of the decision, but
entries after the point of the admission order are only
used in the context of interpreting what the physician
knew and expected at the time of admission
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Clinical Documentation
Improvement
Today
• Principal Diagnosis
• Secondary Diagnosis
• Present on Admission
• Query Process
Today
• Holistic Documentation
–
–
–
–
What
Why
Where am I?
Where am I going
• Complete and Accurate
Medical Record
Documentation
– Hospital
– Physician
– Patient
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Medical Necessity
• What is Medically Necessary Care?
– Care that needs to be provided during a stay at the hospital
– Medically necessary for diagnosis & treatment (Social Security
Act §1862(a)(1)(A))
• Documentation to establish medical necessity
– Clinical status of the patient
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Medical Necessity
• Not just a “hospital thing”
• Information used by Medicare is contained within the
medical record documentation of history, examination
and medical decision-making.
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Medical Necessity
• Medical necessity of E/M services is based on the
following attributes of the service that affected the
physician’s documented work:
– Number, acuity and severity/duration of problems addressed
through history, physical and medical decision-making.
– The context of the encounter among all other services
previously rendered for the same problem.
– Complexity of documented comorbidities that clearly
influenced physician work.
– Physical scope encompassed by the problems (number of
physical systems affected by the problems).
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Physician Engagement
Physician Engagement
Getting physicians’ Attention
Getting physicians’ Involved
Getting physicians’ Committed
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Physician Engagement
• An engaged physician is directly proportional to the
degree of satisfaction with his/her profession and
specific situation
• Engaging physicians
– Improving their outlook and viewpoint on documentation
– Query process
• “Burden” vs. “Benefit”
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Clinical Documentation
Improvement
• Expanded CDI Chart Review
– Real documentation improvement opportunities
– Severity of illness congruent with intensity of service
• H & P-context of admission
• Progress notes
• Discharge summary
– Documentation mutually beneficial
– Services that are reasonable and necessary
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CERT Resource
• Documentation Improvement Opportunities abound
• Read the report of findings WPS Medicare CERT Error
Summary-1st QT 2014
– http://www.wpsmedicare.com/j5macparta/departments/cert/j
5mac-1st-qtr-error-summary.shtml
– http://www.wpsmedicare.com/j5macparta/departments/cert/j
5nat-1st-qtr-error-summary.shtml
• Identify your facility opportunities
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Thank you. Questions?
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