Improper admissions equals paperwork

Weekend coverage avoids issues on Monday

When patients are admitted to the hospital inappropriately, the paperwork involved to correct the error brings to mind the saying "an ounce of prevention is worth a pound of cure."

Hospitals are required to submit a claim for any Medicare inpatient admission, even if it is determined that the admission is not covered. If the determination that an admission is inappropriate is made before discharge, the hospital can file Condition Code 44, but if the hospital's utilization review committee determines after discharge that an entire admission did not meet inpatient criteria, the hospital must submit a provider-liable claim, admitting, in effect, that it made a mistake.

Condition Code 44 is the billing code that indicates that the utilization review committee or physician advisor has determined that a physician's inpatient order for a particular patient is medically unnecessary, says Brenda Keeling, RN, CPHQ, CPUR, president Patient Response, a Durant, OK, healthcare consulting firm. The order may then be changed to outpatient with observation services if the utilization review decision is made while the patient is still in the hospital, if the hospital has not submitted a claim to Medicare for the inpatient admission, the attending physician concurs with the utilization review committee's decision, and the concurrence is documented in the medical record.

When hospitals make frequent use of Condition Code 44, it sends a red flag to auditors. "Using Code 44, except in rare occasions, is an indication that hospitals don't have a mechanism up front to ensure that admissions are appropriate," Keeling says.

When patients are placed in observation status after being admitted as inpatients, the hospital must give them a written notice of their change in status and that they might be responsible for their Medicare Part B deductible and co-pay for outpatient services. If patients insist on continuing as an inpatient, the hospital must give them a hospital-issued notice of non-coverage (HINN), notifying them that Medicare does not cover their care.

The situation gets more complicated when the patient has already been discharged and the determination is made that the stay did not meet inpatient criteria. "In that case, the hospital can't be reimbursed for the inpatient stay, but since it's required to submit a bill to Medicare whenever a patient is admitted, it must send the bill with a provider liable modifier. In most states, the fiscal intermediary will allow the hospital to bill for the outpatient services provided during the stay," Keeling says.

To complicate matters, the physician's office might have billed Medicare for inpatient services, which potentially places the physician at risk, she says. In addition, the patient isn't aware of the Medicare Part B deductible and co-pay for which he or she is responsible.

"Sometimes patients are admitted on a Friday night and are discharged on Sunday," Keeling says. "When case managers aren't on duty in the emergency department during the weekends to review admissions, it creates a difficult situation for everyone. That's why hospitals need a case manager in the emergency department seven days a week."