Innovative thinking helps CMs prepare for RACs

Exercise focuses on learning about inpatient criteria

As part of the ongoing education to prepare for Medicare's Recovery Audit Contractors (RAC) program, Cynthia Lawson, RN-BC, MBA, CPHQ, director of case management at North Hills (TX) Hospital is teaching her case management staff to think innovatively when reviewing charts.

During one exercise, the case management team reviewed information from the charts of patients who had been discharged and looked for as many ways as possible to show that the patient's condition met inpatient criteria.

"When we get busy and there's a lot going on around us, we tend to fall into bad habits. We're continuing to work getting patients in the proper status so we can be appropriately reimbursed, and we want to make sure that we have documented all the information we need to defend medical necessity," Lawson says.

As part of the preparation for the exercise, Lawson went through the patient charts and identified those cases that didn't present exactly by the book.

She gave each case manager a copy of information in the chart that they would have had to work with when they reviewed the charts with 24 hours of admission. It included the admission order, the emergency department records, laboratory and radiology results, and a history and physical.

"I challenged them to look through the criteria book and think outside the box to find as many different ways as they could to make the patients meet criteria," she says.

The case managers were asked to review the information over a two-day period, then meet as a group to review each case. Each case manager had one case that had been reviewed by another case manager. They had to rely solely on the information Lawson gave them.

"They couldn't go into the computer system and get other information. They had to use the papers I gave them to make a determination. The point is for them to become more familiar with the criteria," she says.

Seven case managers attended the meeting.

"Everybody had an opportunity to present their case and open it up for the discussion. The team members asked questions and, with some cases, pointed out other ways the case might fit the inpatient criteria. It was a good learning experience for all of us. They brought up some things I hadn't thought of. We educated each other," Lawson recalls.

The information the case managers received was from the charts of patients who had been discharged after receiving observation services. In each case, the case manager had agreed with the physician's order for observation services, but when she reviewed the charts, Lawson believed all of the patients could have been admitted as inpatients.

"In these cases, the case manager looked at the physician's orders and determined that the patient met observation criteria instead of looking more closely to see if the patient might fit into inpatient criteria. After we discussed the cases, the consensus was that all of the patients would have met inpatient criteria. This means the hospital missed a lot of reimbursement," she adds.

Look for all criteria

Some of the cases were straightforward and fit under only one criteria subset. Other patients had multiple issues and might fit under more than one criteria subset, Lawson says.

For instance, a patient who came in with a spinal fracture might fit under the muscular skeletal criteria subset, the trauma subset, or both.

In another instance, a patient came into the emergency department with a persistent nose bleed.

It was the patient's second emergency department visit for the same reason in less than 24 hours. On the previous visit, her nose had been packed and she had been told to follow up with her primary care physician. When she woke up in the middle of the night, her nose had started bleeding again and the packing was soaked.

The emergency department physician ordered observation services, and the case manager agreed.

However, the group determined that the patient met inpatient criteria because the ear-nose-and-throat section of the criteria book specifies that patients with persistent nose bleeding through packing or a recurrent episode of bleeding within 24 hours qualify for an acute inpatient stay.

"The idea was to get the case managers to look carefully at the information in the chart as they review cases, to really become knowledgeable about the criteria, and to collaborate with the physicians on additional documentation to clearly describe the patient's severity of illness," Lawson says.

The group discussed how the wrong admission status affects direct reimbursement from Medicare and commercial payers as well as having an adverse financial impact on the patients since copays are typically higher for an observation stay than for an inpatient stay.

"It also affects the budget and the staffing of the hospital by reducing the average daily census. Every department that staffs based on census is affected when patients are in the wrong status," she says.

The purpose of the exercise was to help the case managers increase their proficiency with inpatient criteria so they wouldn't have to spend a lot of time looking them up when they review a case.

"I wanted the case managers to realize that the window for meeting inpatient criteria can be very narrow and they have to be on top of it and use all the information they have available to see if the case will fit into an inpatient criteria subset," she says.

Education to continue

The entire nurse case manager team participated in the program, with the exception of three emergency department case managers who work different shifts. Lawson plans to develop a similar exercise for the emergency department case managers.

"I'll probably restrict the information even further. The emergency department case managers really do have to try to make decisions with a minimal amount of information," she says.

The exercise helped create buy-in for the importance of reviewing charts for medical necessity and helped the case management team learn to work together, Lawson says.

"The direct impact was education, but it also increased the comfort level the team has in working with each other. Now they know that when they get blocked on a case or aren't sure what to do, they can go to their team members and talk it through," she says.

Lawson plans to continue the practice on a quarterly basis. In addition, the case managers requested a similar educational session on using discharge screens in the criteria book.

"Some of the case managers said they'd never experienced determining that a patient meets continued stay criteria because he didn't meet discharge criteria. We're going to work on this aspect later this year," she says.