Tuesday, January 24, 2017

Discharge Planning as Part of Community-Based Care Transition Program (CCTP) and Medicare: What is a Duplicate?

CMS encourages Home Health Agencies, Hospices, Hospitals, Inpatient Psychiatric Facilities, Long-Term Care Facilities, and Swing Beds to review the guide on “Discharge Planning”(ICN 908184) found in the Medical Learning Network section of CMS. 

This 20 page publication provides valuable detailed information for any provider of service involved in the patient discharge process.

CMS data suggests almost 20% of hospitalized Medicare patients are readmitted within 30 days of their discharge. This amounts to approximately 2.6 million beneficiaries being affected and costs the Medicare program an estimated $26 billion every year.

Increase medical costs

In an attempt to curb this expense, the CMS Innovation Center established by the Affordable Care Act has created the Community-Based Care Transition Program (CCTP).  The ACA has earmarked up to $500 million for the CCTP that was launched in 2011 and will run for 5 years.

Community-Based Care Transition Program

The program starts with the basic principle that the healthcare community should work together to improve quality of patient care.

Reduced healthcare costs

The goal is to ultimately reduce hospital readmissions by a minimum of 20 % which would translate to a savings of $5.2 billion a year.  This represents a significantly larger amount than the initial cost to CMS for the program.
Data for 2012 suggests the program is already working by preventing an estimated 70,000 readmissions.
Enrolled participants, referred to as Community-based organizations (CBOs) now numbering over 100, will work with hospitals to coordinate patient care transitions.  If you would like to see who is participating in your area, you can select this link to access the CMS interactive map: http://innovation.cms.gov/initiatives/map/index.html?modelPass=CCTP

Care transition

Care transitions as referred to in this program, relate to hospital inpatients that are being discharged to their home, a nursing home, or other care facility.  CBOs will use care transition services to identify risk factors that produce readmissions and coordinate the necessary actions to lessen the effect of those factors.

patient education

CBOs will be requred to provide:

Care transition services that begin no later than 24 hours prior to discharge

Timely, culturally and linguistically competent post-discharge education to patients

NOTE:This education is crucial so that patients understand potential additional health problems that may develop or a deteriorating condition.

Timely interactions between patients and post-acute and/or outpatient providers

Patient centered self-management support and information specific to the beneficiary’s condition

A comprehensive medication review and management

NOTE:This includes any appropriate counseling and self-management support.                          

The CBOs will be paid an all-inclusive rate per eligible discharge based on the cost of care transition services provided at the patient level and of implementing systemic changes at the hospital level. CBOs will only be paid once per eligible discharge in a 180-day period of time for any given beneficiary.      

Performance and effectiveness of the CBOs will be gauged by the evaluation contractor and the implementation and monitoring contractor.  Quality and utilization measures will consist of 30-day all cause readmission rates, and will also monitor 90-and 180-day readmission rates, mortality rates, observation services, and emergency department visits.  

One major goal of the CCTP is to develop effective approaches to care interventions that will improve the quality of care while decreasing readmissions.  This transparency of the COB’s should ensure accurate evaluations of both successes and shortcomings of this program.

Please follow this link to the CMS site for full details on this program:

Medicare: What is a Duplicate?

Each Medicare claims processing system contains criteria to evaluate all claims received for potential duplication.  The claims can be placed into two categories: exact duplicate or suspect duplicate.  Each category is processed uniquely by the Medicare contractor.

CMSCMS has recently updated the Medicare Claims Processing Manual, Chapter 1, Section 120: “Detection of Duplicate Claims” based on change request (CR) 8121.

Duplicate claims : An exact duplicate claim is denied or rejected, if missing applicable modifiers, automatically by the claims processing system.

 For exact duplicate denials, professional providers do have appeal rights, but institutional and DME providers do not.

suspect duplicateIf a claim is deemed suspect by the initial system review, the claim is suspended for further review by the Medicare contractor.

 If suspect duplicate is denied after review, all providers have right to appeal.

Due to the nature of the service, some claims may only appear to be duplicates.  Proper coding of the service with the applicable condition codes or modifiers will identify the claim as a separate payable service, not a duplicate.  An example could be modifiers “LT” and “RT” for bilateral procedures.

By utilizing an advanced Medical Practice Management Billing Software like Iridium Suite from Medical Business Systems, duplicate claims submissions are easily prevented.  A configurable Claim Scrubber as found in Iridium Suite will check each service entered and alert the user immediately if the same service is already on record. 

This gives the user the opportunity to determine if the service is a true duplicate or if the service qualifies for an appropriate addition of a modifier.

See the information below for details on the process Medicare utilizes to identify duplicate claims.

Provider of Service duplicate claimsExact Duplicate suspect duplicate 

Suspect Duplicate

Institutional institutional claims Claim matches identically on the following data:

1. Health insurance claim (HIC) number 
2. Type of bill 
3. Provider identification number  
4. From date of service 
5. Through date of service
6. Total charges (on the line or on the bill)
7. HCPCS,  CPT-4, or procedure code/modifiers Claim matches on the following data:

1. Beneficiary information
2. Provider identification
3. Same date of service or overlapping dates of service

Professional professional claims

1. HIC number
2. Provider number
3. From date of service
4. Through date of service
5. Type of service
6. Procedure code
7. Place of service
8. Billed amount

The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers vary according to the type of billing entity, type of item or service being billed, and other relevant criteria.

DMEDME supplies Claim matches identically on the following data:

1. HIC number
2. From date of service
3. Through date of service
4. Place of service 22
6. Type of service
7. Billed amount
8. Supplier

The criteria for identifying suspect duplicate claims submitted by physicians and other suppliers vary according to the type of billing entity, type of item or service being billed, and other relevant criteria.

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