Confusion from CMS Statement, DME Audits Loom, Documenting AMA Discharges

The Centers for Medicare & Medicaid Services (CMS) sent a giant wave of panic through the industry this past week, when they announced that the Medicare Administrative Contractors (MACs) have been instructed to hold payment on almost all claims because of the federal government shutdown.

But the next day, they clarified their statement to indicate that what they meant is that the MACs were instructed to hold all claims only for services that were no longer approved because of a lapse in legislation, such as telehealth services and Hospital at Home.

It’s strange, because everyone already knew that telehealth claims were not going to be paid, and Hospital at Home was not permitted, but perhaps since the MACs are required to pay clean claims within 14 days, CMS felt they needed to issue a notice on Day 15 of the shutdown.

But it sure would have been nice if they did it without getting the facts wrong…

Changing subjects, last week Cotiviti, everyone’s favorite Recovery Audit Contractor (RAC), announced that it was going to start its audits of durable medical equipment (DME) claims across the nation. Now, I doubt that any DME suppliers are reading this, but many of you probably help physicians with ordering DME, and you’ll want to ensure the documentation to support medical necessity is complete to help the DME supplier avoid a denial. The three items that are pertinent to hospital discharge planning are home oxygen, continuous positive airway pressure (CPAP) devices for sleep apnea, and home ventilators.

As a quick review, home oxygen for a hospital patient being discharged is indicated if the pulse oximeter reading within two days of discharge is at or below 88 percent, or 89 percent if the patient has heart failure, pulmonary hypertension, or hematocrit over 56. CPAP requirements are too long to review here, but you can read them in NCD 240.4.

And home ventilator indications are described in NCD 240.9, where there are 11 specific criteria that must be met. But for patients being discharged from the hospital with a home ventilator, it is covered when the patient has acute-on-chronic respiratory failure due to chronic obstructive pulmonary disease (COPD) if the patient’s needs exceeded the capabilities of a non-invasive method of ventilation like CPAP – and if the patient required usage of a ventilator within the 24-hour period prior to hospital discharge, as long as the treating clinician determines and documents that the patient is at risk of rapid symptom exacerbation or rise in PaCO2 after discharge.   

I am sure your DME suppliers would be thrilled if you helped them out by ensuring that the necessary documentation is in the hospital medical record to help them avoid having to fight Cotiviti for their payment. And there are few things in life as rewarding as denying a RAC their contingency fee.

Finally, last week I talked about how hospitals should be coding discharges as against medical advice (AMA) more frequently, to avoid the penalties and lack of payment for readmissions that may occur after such a discharge. One Monitor Mondays listener noted that they no longer use the term AMA, but call it a “patient-directed discharge” to avoid any negative connotation. And that’s great, so I want to add to that by suggesting use of the term “insurance-directed discharge” when, for instance, the medical team determines discharge to an inpatient rehabilitation facility (IRF) is appropriate, but the payer will only approve skilled nursing facility (SNF) care.

And of course, be sure your billing staff knows to look for those terms and then codes the discharge as 07-, against medical advice. You can read more in my article about this expanded use of AMA discharge coding here.