Many of the problems the Medicare Administrative Contractors have cited during their Probe and Educate audits revolve around documentation, says Bridget Gulotta, RN, senior consultant for The Camden Group, a national healthcare consulting firm with offices in Chicago.
“In many cases, the documentation doesn’t support that medical care would need to be provided over two midnights. Compliance primarily comes down to educating the physicians not only on what the rules and regulations are but on how to document appropriately,” Gulotta says.
Instead of taking a reactive approach after the order is written, provide physicians with appropriate rules to follow so that when they write the inpatient order, they can use the right verbiage to pass muster if the chart is audited, Gulotta says.
“It’s important for physicians to understand that they need detailed documentation to support patient status so the hospital can be reimbursed appropriately,” adds Jean Maslan, BSN, MHA, CCM, ACM, managing consultant for Berkeley Research Group.
Have solid steps in place to make sure the documentation is comprehensive and supports a two-midnight stay, Maslan suggests. Educate the physicians about what documentation is needed. Even if you have forms with check boxes for the physicians to certify an admission, comprehensive documentation still needs to be in the medical record and progress notes, Maslan says.
The documentation should reflect patient complexities based on the diagnosis and prognosis, intensity of services, and details on treatment and tests, such as what type of blood work, Gulotta says. Make sure that any procedures or testing must be done in the hospital rather than on an outpatient basis and that the documentation supports it. “If there is anything that can be done on an outpatient basis, it generally will disqualify a patient from a longer-term stay,” she says.
Linda Sallee, RN, MS, CMAC, ACM, IQCI, director for Huron Healthcare with headquarters in Chicago, recommends having the physician advisor review all observation patients to determine if inpatient care would be more appropriate. “Physicians are focusing on the care and not on getting the status right. Having the physician advisor work with case managers to educate physicians on patient status works very well,” she says.
Gulotta suggests hiring an outside organization that uses nationally recognized care guidelines to review patient status.
“Sometimes peer relationships between the treating physician and those on the utilization management committee can affect what qualifies as inpatient versus observation,” she says.
Case managers should assess patients for their status as close to admission as possible, Sallee says. “Even with the two-midnight rule, case managers still need to conduct medical necessity reviews and work with physicians to get the status right on the front end and make sure that the documentation supports the patient status,” she adds.
Use medical necessity decision support criteria as a guide as to what you need to discuss with the admitting physician, Sallee says. “Case managers shouldn’t ask physicians to document things that are not right, but if it appears that an observation patient meets inpatient criteria based on their assessment, they should use the information in the medical necessity criteria as a tool to point out that evidence-based criteria indicate that a patient with the medical issues could be an inpatient,” she says.
Case managers are an invaluable resource in the emergency department, Gulotta says. “Coverage 24 hours a day may not be necessary, but there should be significant coverage seven days a week at times that are based on the volume of patients,” she says.
She suggests creating a hybrid role that combines utilization review and case management and stationing these employees in the emergency department to assist physicians in determining patient status and ensure that patients who are admitted meet inpatient criteria.
“The people who fill this position should be well versed in the financial aspects and medical necessity and can be an excellent resource for the emergency department physicians and the admitting physicians. They should be familiar with resources in the community that patients could be referred to, rather than receiving observation services,” Gulotta says.
For instance, the case manager could obtain an appointment for appropriate patients at a heart failure clinic. “Sometimes a lack of information about resources may indicate whether a patient is kept in the hospital with observation services as opposed to being discharged,” she says.
Case managers should tighten up on their observation management protocols and avoid unnecessarily long stays in observation, Maslan suggests.
She recommends reviewing observation cases every six hours, or a minimum of twice per shift, to make sure the hospital isn’t losing any opportunity to convert the patient to inpatient status or to discharge the patient.
“Case managers should implement an effective trigger to review any change in a patient’s condition that could result in a conversion to an inpatient stay. Hospitals shouldn’t miss any opportunity to change patients’ status to inpatient if appropriate,” she says.
Follow observation patients closely to make sure they are in the hospital an appropriate amount of time, Maslan says. For example, if a discharge is dependent on lab results, be proactive and get the results to the physician and get a discharge order, she says.
If a patient receives observation services and a physician determines that the patient needs to be there another day or the patient meets inpatient criteria, the hospital is entitled to inpatient reimbursement, Maslan says. “It still shows up as a one-day inpatient stay when the bill drops but the auditors shouldn’t deny it,” she says.
Sallee recommends that hospitals set up an observation unit so the staff can easily distinguish the short-stay patients from those who have been admitted.
“If patients receiving observation services are on an inpatient unit, the staff treats them like the rest of the patients instead of assessing them at short intervals and getting them ready to be discharged or admitted as soon as possible in their stay. If they are in an observation unit, everybody will be focused on performing ongoing assessments and keeping the stay short,” she says.
