Continue focusing on documentation, status

CMs are needed more than ever

The Centers for Medicare & Medicaid Services’ (CMS) proposed rule for the 2014 Inpatient Prospective Payment System (IPPS) is subject to change, but hospital case managers still should familiarize themselves with the rule and determine the impact, says Ralph Wuebker, MD, MBA, chief medical officer for Executive Health Resources, a Newton Square, PA, physician advisor company.

The proposed rule makes clear and concise documentation and patient throughput more important than ever, he adds.

After the proposed rule was issued April 26, CMS took comments from the healthcare industry until June 25 and will issue the final rule by August 1. “This rule isn’t final yet. There are a lot of pieces in the proposed rule every year that don’t get into the final rule when it is issued in August,” Wuebker says. (For details on the proposed rule, see related articles on pages 95 and 96.)

Case managers should do what they always have done and focus on making sure the documentation accurately and completely represents the reason for admission, especially when there are extenuating circumstances, such as failed outpatient management, factors that increase the risk for the patient, and the availability of diagnostic services at the time the patient comes into the hospital, says Deborah Hale, CCS, CCDS, president and chief executive officer of Administrative Consultant Service, a healthcare consulting firm based in Shawnee, OK.

“CMS is harping on the necessity for an admission order that clearly documents the reason for the admission and requires that the order be issued by a physician or other medical professional licensed to admit patients to the hospital. In cases where it’s blatantly obvious that a patient needs to be admitted, the physician documentation might not be that important. When there is any doubt, physicians should explain what they were thinking in the medical record,” she says.

CMS make it clear that only the physician can determine if patients need to be admitted or be in outpatient status receiving observation services, says Joanna Malcolm, RN, CCM, BSN, consulting manager, clinical advisory services for Pershing, Yoakley & Associates in Atlanta. “It appears that if there is not an order from the physician and the physician documentation doesn’t specify inpatient status that CMS is going to deny payment,” she says. Physicians no longer will be able to write “status by case management protocol,” she says.

Despite CMS’ presumption that a stay spanning two midnights is appropriate for an inpatient admission, Medicare auditors will still review records for medical necessity, which means that case managers must make sure the documentation in the medical record justifies an inpatient admission and discuss the criteria with the physician, Malcolm adds.

Case managers should be educating physicians about medical necessity criteria and what the Medicare auditors are looking for.

If the proposed rule goes into effect, hospitals are going to be tempted to keep all patients who are expected to have a stay of less than 48 hours as outpatients with observation services, but some short stays meet the criteria for an inpatient admission, Hale says. “This creates issues because this rule focuses just on inpatients and doesn’t include information as to whether outpatient reimbursement will be increased. The average observation payment is about $400 [excluding emergency department charges]. This doesn’t cover a 48-hour stay,” she says.

If hospitals automatically keep patients who have a 48-hour or shorter stay as outpatients receiving observation services, it can have financial implications for patients who have to pay co-insurance costs for outpatient services, Hale points out. In addition, Medicare rules say that patients receiving care as outpatients are also responsible for payment of self-administered drugs, which can be more than their inpatient deductible, Hale says. “This can be very expensive for some patients, such as those who need anticoagulation. Even if the nurse administers the medication, it’s considered a self-administered drug,” she says.

The proposed rule creates an increased focus on medical necessity and risk assessment by the attending physician, Wuebker says. “Documentation is key. Often we will see a one-symptom-based diagnosis. The medical record needs to include more of the physician’s thoughts during the decision-making process,” he adds.

Case managers should work with the attending physicians to improve medical necessity documentation and continue to perform the utilization management review to make sure the documentation supports the level of care, Wuebker says.

Patient throughput is going to become extremely important if that provision goes into effect, Wuebker says.

“In most hospitals, the majority of patients are admitted between 5 p.m. and 11 p.m. If the admitting order is signed at 10 p.m. but the patient doesn’t get into a bed until 1 a.m., you’ve lost a midnight,” he says.