Debbie Hill - WCFSC May 22 2015 FINAL

West Central Florida Stroke Council
May 22, 2015 1
FOCUSED STROKE CENTER STRATEGY
Lombardi Hill Consulting Group!
WHAT YOU NEED TO KNOW!
!
A CMS (Medicare) Update!
!
!Debbie Lombardi Hill, FAHA
St. Petersburg, Florida w May 22, 2015
Lombardi Hill Consulting Group! ©Copyright LHC 2015
Disclosures!
ª  Principal, Lombardi Hill Consulting Group
ª  Member, Gerson Lehman Healthcare Council
ª  Independent Contractor, American Heart Association/
American Stroke Association (AHA/ASA)

May 22, 2015 2
What You Need To Know!
ª Inpatient Prospective Payment System (IPPS)
•  Proposed Rule published April 17, 2015
ª Medicare Therapy Caps
•  PT/OT/ST Capped at $1900
•  Any Exceptions ??
ª Two-midnight Rule
•  Observation Unit vs. Short Inpatient Stay
CMS (Medicare) FY 2016!
ª  Proposed Rule published April 17, 2015
ª  Hospital Inpatient Quality Reporting Program
•  Stroke measures to be removed for FY 2018 payment
•  STK-01 VTE Prophylaxis
•  STK-06 Discharged on Statin Medication
•  STK-08 Stroke Education
ª Bundled Payments for Care Improvement Initiative
•  Stroke MS-DRGs
•  61, 62, 63, 64, 65, 66

May 22, 2015 3
CMS (Medicare) FY 2016!
ª  Readmission Reduction Program (HRRP)
•  Stroke included in hospital overall readmission rate
•  Stroke NOT separately evaluated
ª  Therapy cap exception process remains in effect until
December 2017
•  Legislative action
•  PT, OT, ST
ª  Two-midnight rule remains intact
CMS Two-Midnight Rule!
Emergency
Department
Physician
Office
or
Stroke
Clinic
Hospital
Inpatient
(Short Stays)
Hospital
Observation
Unit
Hospital Payment $ $2745 $4,029
Physician Payment $$$ $$ $
Patient Out-of-Pocket $ $6971 $1,2162
Example: TIA
APC 8009
plus Diagnostics
MS-DRG 69
GMLOS 2.2 days
1 If patient requires rehab, will not meet eligibility requirements for Medicare coverage
2 Annual IP deductible; doesn’t apply if deductible already met

May 22, 2015 4
….when the physician
expects the
beneficiary to require
a stay that crosses at
least 2 midnights and
admits the beneficiary
to the hospital based
on that expectation.
Source: 2014 IPPS Final Rule, p. 50944
What it says….
Surgical procedures,
diagnostic tests and
other treatments would
be generally
appropriate for
inpatient admission
and inpatient hospital
payment under
Medicare Part A…...
…..the services would generally be
inappropriate for inpatient
hospital payment ….regardless of
the hour of arrival or whether a bed
was used.
If the physician expects to
keep the beneficiary for a
limited time not to cross 2
midnights…
Conversely,
Source: 2014 IPPS Final Rule, p. 50944
OBSERVATION UNIT

May 22, 2015 5
•  The clock for the
rule starts when
“care is initiated”
after hospital
arrival
•  Prior time in ED,
observation or
procedure area counts
NO
Stroke OP
Clinic
Emergency
Department
YES
Inpatient Admission
NO
Observation Unit
Based on info available, physician decides: Will this patient
require 2 or more “midnights” of hospital services?
•  Hospital payment
requires:
•  a qualifying ED
visit
•  a stay in
observation unit
for > 8 hours
•  No
restrictions
ª  What are documentation requirements of a two-midnight
expectation?
•  Expected length-of-stay
•  Underlying need/complex medical factors
•  Patient history and comorbidities
•  Severity of signs and symptoms
•  Current medical need
•  Risk of an adverse effect
ª  Is bed location or monitoring justification for admission?
•  Two-midnight benchmark not based on level of care or
placement of patient within the hospital
FAQs!

May 22, 2015 6
ª  What if the physician is unable to determine the need for two-
midnight, or longer stay, at time of patient presentation?
•  Admit for observation services and re-evaluate later
•  Observation time will count toward two-midnight benchmark
if admitted later
ª  Patient is admitted under a presumption of two-midnight stay
but leaves earlier. Is it paid as inpatient admission or other?
•  Paid as inpatient if expectation of two-midnight stay is justified
•  Patient transferred, left AMA or expired
•  Symptoms resolved/clinical condition improved
FAQs!
ª  For transferred patients, is pre-transfer time considered?
•  Pre-transfer time at the initial hospital can be considered for the
two-midnight rule
ª  When does observation billing begin?
•  Outpatient billing for observation time begins when patient is
admitted to the observation unit/bed
•  Not when “care is initiated”
•  Only applies to when the two-midnight rule begins
FAQs!

May 22, 2015 7
TIA Scenario #1!
ª Patient presents at 10 am
with stroke symptoms
•  Care initiated at 10:10 am
•  By 11:30 am symptoms
resolve
•  Symptoms return at 1:00 pm
•  ED physician re-evaluates;
admitting physician agrees to
admit for one day
•  LOS expectation based on
condition, treatment and risk?
§  1 midnight
§  Place in observation
ª Patient presents at 10 pm
•  Care initiated at 10:10 pm
•  By 11:30 pm symptoms
resolve
•  Symptoms return at 1:00 am
admit for one day
§  2 midnights
§  Admit as inpatient
Same patient, same presentation, same
expected LOS, different course
TIA Scenario #2!
resolve
admit for one day
§  1 midnight
•  Placed in observation, H&P done
•  Echocardiogram, MRI, MRA
done
•  Next day, hospitalist busy with
admissions, rounds at 8 pm,
patient feels better but asks to
stay the night
•  Hospitalist agrees to discharge in
am “if stable”
•  Keep patient on observation
status
•  Write off medically
unnecessary hours
§  1st night – medically necessary
§  2nd night –medically unnecessary

May 22, 2015 8
TIA Scenario #3!
resolve
admit for one day
§  1 midnight
•  Placed in observation, H&P done
•  Echocardiogram, MRI, MRA
done
•  Evening of first day, patient
worsens
•  MD writes order to admit
•  1st night – observation counts
toward two-midnight benchmark
•  2nd night – inpatient night counts
as second night
•  Patient admission meets two-
midnight rule and qualifies for
inpatient reimbursement
ª  Internal focus
•  Orienting staff to “midnight” clock
•  Developing tools to assist with documentation
•  Auditing documentation to support two-midnight stay
expectation
•  Providing feedback to physicians making the admit vs.
observation decisions
What Are Hospitals Doing Now?!

May 22, 2015 9
Get With The Guidelines!
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
2014
Nov
EMS (Home/Scene) 57% 57% 56% 55% 58% 50% 48% 46% 43% 46% 52%
Private Transport 36% 36% 36% 34% 34% 35% 34% 33% 31% 32% 37%
Hosp-Hosp Transfer 0% 0% 0% 0% 0% 5% 7% 9% 9% 10% 10%
Unknown 1% 1% 3% 6% 7% 9% 10% 12% 17% 12% 1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
PercentageofPatients
Year
Patient Arrival Mode
EMS (Home/Scene) Private Transport Hosp-Hosp Transfer Unknown
52%
37%
10%
FL Hospitals
ª  37% of stroke patients are ED “walk-ins”
ª  Inter-facility transfers of stroke patients are on the rise
Parting Comments…..!
Do a sweep of the ambulance
bay and the waiting room at
11 pm!

May 22, 2015 10
Debbie Hill
Debbie@LombardiHill.com
407-222-6106
Please feel free to contact me at:
QUESTIONS?!

Debbie Hill - WCFSC May 22 2015 FINAL

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