Checks and balances keep denials low

CMs cover ED 24-7, assess patients in PACU

By taking a proactive approach to patient status and instituting a series of checks and balances, Good Samaritan Hospital in Dayton, OH, keeps denials at a minimum.

The 577-bed hospital has care managers covering the emergency department 24 hours a day, seven days a week; requires an order for patient status before the hospital's electronic medical records system will allow patients to be placed in a bed; and requires physician offices to fill out a pre-admission form that includes patient status before a patient can be scheduled for surgery, according to Teresa I. Gonzalvo, RN, MPA, CPHQ, LNC, director of integrated care management.

"We have many access points and have created standardized admissions procedures with a goal of getting patient status right the first time and diminishing the errors. Every patient who is admitted to the hospital is reviewed by a case manager for admission status, regardless of their access point or payer," Gonzalvo says.

Having case managers cover the emergency department 24-7 has been a major factor in reducing denials, Gonzalvo says.

"About 70% of our patients come through the emergency department. By being on site, our case managers are able to accurately capture medical necessity before patients leave the emergency department," she adds.

The case managers have access to a patient tracking board that includes a case management component.

"They are able to intervene as soon as they have the laboratory work, radiology results, or other diagnostic information. Since they are physically in the emergency department, they can talk to the patients and physicians if they need additional information," she says.

If patients are placed in outpatient status with observation services, the case managers give them a brochure explaining what observation means, how it may affect their copay, and their eligibility for a nursing home stay if they are Medicare beneficiaries.

The case management department worked with the surgery schedulers, the director of surgery, and the nurse manager of the post-anesthesia care unit to develop a system for making sure patient status is correct before and after surgical procedures.

The hospital has created a pre-admission form that physician offices must fill out before they can schedule patients for surgery. The form includes a list of the appropriate choices for patient status after surgery including "inpatient," "outpatient," or "post-procedure recovery" along with the CPT codes.

"Physician office staff must fax that form with all the information completed before they can schedule the surgery. When the surgery is scheduled, we know what the patient status will be after the procedure," she says.

Once a patient is transferred to the post-anesthesia care unit (PACU) after surgery, the nurse checks to make sure the status is still accurate. If the patient's stay in the PACU exceeds the expected post-procedure recovery period, the nurse brings it to the attention of the surgeon.

The unit-based case managers take turns rotating through the post-anesthesia care unit between 2 p.m. and 4 p.m. to determine admission status for patients who are in recovery following surgery. If the unit case manager who is assigned recovery room responsibility has a big caseload on his or her regular unit for that particular day, another unit case manager or the manager takes over the process, Gonzalvo says.

The case managers assess which patients potentially may stay overnight and whether they are meeting observation or inpatient criteria.

If the patient had a procedure with the option of inpatient, outpatient, or post-procedure recovery, the case manager reviews the record for medical necessity and calls the surgeon or attending physician if he or she feels the order does not place the patient in the appropriate status, Gonzalvo says.

If the case manager and the admitting physician can't agree on a patient status, the medical director for case management intervenes.

"It's more efficient to get these patients admitted in the right status if someone goes to the recovery area, rather than trying to manage the admission status when the patients get to the floor," Gonzalvo says.

The team created a user-friendly manual for Medicare's Inpatient Only list to ensure that patients who receive surgical procedures on the list are admitted to the hospital as inpatients.

Surgery schedulers use the manual as a reference to determine if patients should be admitted as inpatients. The case managers re-evaluate the patient status while they are in the recovery room.

The medical record has patient status as a required field and includes order sets specific to the procedures on the Inpatient Only list.

If a procedure is on the Inpatient Only list, the physician does not have the option to order any other status, Gonzalvo says.

The hospital has established what it calls a QWIK bed procedure for patients who are being directly admitted from a physician office or transferred from another hospital.

When a hospital or a physician office calls to admit a patient, the QWIK bed referral management nurses assess the patient's medical necessity status in advance.

"The referral management nurses in this area have access to medical necessity criteria, but if they aren't sure, they collaborate with the emergency department case manager," she says.

Patients who are transferred from outlying hospitals are likely to meet inpatient admission status, Gonzalvo points out.

However, it's sometimes difficult for the admissions nurse in the QWIK bed office to make an assessment of patients coming in from a physician office since diagnostic test results may not yet be available and often the only information they have is vital signs, activity and diet orders, and some symptoms, she says. Often a status is ordered by the physician as well.

"If the QWIK bed nurses don't have enough information to make an assessment, they secure a status order or make a recommendation as outpatient with observation services since our electronic system won't allow a patient to be placed in a bed without an order for admission and a corresponding status indicated," she adds.

The case managers on the unit review the case and recommend changes in the status, using Condition Code 44, if appropriate.

"This happens only with cases that were initially admitted as inpatients, then after further review and clarification with the physicians and discussions with the medical director, it is determined that they really meet observation status," she says.

On weekends, nights, and holidays, the emergency department case manager has a housewide responsibility for medical necessity reviews. In order to set priorities, she runs a report of observation cases, and then reviews the charts of the new admissions, and ensures that the patient is assigned the right status.

"On occasion, things may fall through the cracks on weekends and at night. Due to a high census and complex discharge planning needs of emergency department patients, sometimes the emergency department case manager is not able to realistically review all observation patients. When that occurs, their priority is to start with patients in observation longer than 24 hours," she says.