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Checks and balances keep denials low
Care managers 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 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.
The case management department worked with the surgery schedulers, the director of surgery, and the nurse manager of the post-anesthesia care unit (PACU) to develop a system for making sure patient status is correct before and after surgical procedures. The pre-admission form that physician offices must fill out before scheduling patients for surgery 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," says Gonzalvo.
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 PACU 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 might 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 thinks 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.