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Rule for conditions acquired at hospital
Ensure full documentation for each patient
Now that the Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule that would prohibit payment for healthcare-acquired conditions for Medicaid beneficiaries, it's more important than ever that case managers work with physicians to ensure that conditions that are present on admission are clearly documented in every patient's chart, says Deborah Hale, CCS, president of Administrative Consultant Services, a health care consulting firm based in Shawnee, OK. (For information on accessing the proposed rule, see resources, below.)
The proposed rule, mandated by the Patient Protection and Affordable Care Act, would require states to develop rules to reduce provider payment for healthcare acquired conditions that would otherwise result in an increase in payment. The rule would require states, at a minimum, to use the Medicare list of hospital-acquired conditions for which providers are not paid and gives them the option to add other conditions to the list. CMS has set a target of July 1 for implementation.
"Medicaid's adoption of payment reduction for hospitals for certain hospital-acquired conditions isn't surprising given the current national focus on value-based purchasing and pay-for-performance, Hale says. Commercial payers are likely to follow suit, she adds.
Case managers can help protect the hospital's reimbursement and quality report cards with attention to adherence by developing performance improvement initiatives and ensuring that patient records have the proper documentation to help coders distinguish between the conditions that were present on admission and those that developed during the hospital stay, Hale says.
The proposed rule, when implemented, means case managers must give the same attention to documentation in the charts of Medicaid beneficiaries as they give those of Medicare patients, says Joanna Malcolm, RN, CCM, BSN, consulting manager of clinical advisory services for Pershing, Yoakley & Associates in Atlanta. "It's important that all documentation be standard, not matter who the payer is," Malcolm says. "All payers are moving in the direction of reducing reimbursement for hospital-acquired conditions, and that means that case managers need to make sure the physicians' documentation includes hospital-acquired conditions."
The documentation must be completed when the patient is still in the emergency department or is being admitted, she says. Case managers should work with the physicians who assess patients on admission and prompt them to document correctly so the hospital can prove that the condition was present on admission, Malcolm says.
Be sure that patients who are transferred from another hospital or nursing home are assessed for conditions that are present on admission, she adds. Pressure ulcers and urinary tract infections are fairly among the common among nursing home patients, Malcolm points out. "CMS has stringent requirements for documentation of pressure ulcers," she says. "Case managers have to make sure that the nurse has clearly documented the size and depth of the ulcer during the admission assessment so the hospital can get paid. If the patient is bed-bound or very elderly and the case manager doesn't see the documentation, he or she should query the nurse to ensure that the patient was assessed for pressure ulcers on admission."
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