Don’t think the auditors will go away
Chart review remains of utmost importance
The Centers for Medicare & Medicaid Services has declared that a stay spanning two midnights is presumed to be appropriate for an inpatient admission, but Medicare auditors will still be reviewing records for medical necessity.
Medicare auditors are likely to continue to look at one-day stays and will take a close look at two-day and three-day stays and the issue of qualifying stays for a skilled nursing transfer, says Brian Flood, CHC, CIG, AHFI, CFS, an attorney specializing in healthcare issues and partner with Brown McCarroll, LLP, in Austin, TX.
This means that case managers still must review physician documentation to make sure all of the elements required for an admission are included. Otherwise, they are begging for an audit, he says. "Hospitals that don’t have a robust screening process to scrutinize admissions will be subject to losing more money in the future," he says.
Physicians have to do far more documentation than just write "admit" on the chart, Flood points out. If a physician writes "admit" on the chart and doesn’t document a reason for the admission, it will be a red flag for auditors, Flood says.
If physicians don’t include a prediction of the patient’s length of stay in the documentation, it is likely to catch the attention of auditors, but if the patient ended up staying for two midnights and the documentation reflects severity of illness and resources consumed, the hospital can make a good argument in an appeal if the case is denied, he says.
Auditors are likely to continue to focus on DRG validation and coding, particularly as hospitals begin to struggle with meeting the documentation and coding requirements for ICD-10, says Ralph Wuebker, MD, MBA, chief medical officer for Executive Health Resources, a Newtown Square, PA, healthcare consulting firm. He also expects auditors to continue the focus on medical necessity, especially instances where patients who are admitted as inpatients stay less than two midnights and to review two and three midnight stays where there is evidence that the hospital may be keeping patients longer than appropriate to receive inpatient reimbursement.
The final rule clearly states that auditors will make sure that hospitals are not gaming the system for inpatient stays, he adds.
In fact, CMS says in the final rule that it will be on the lookout for hospitals that game the system by keeping patients over two midnights when it’s not medically necessary in order to get inpatient reimbursement, adds Adele Merenstein, JD, an attorney at Hall Render, a law firm specializing in health law with headquarters in Indianapolis. "If hospitals are found to be abusing the two-midnight presumption, CMS auditors will disregard the two-midnight rule when they conduct reviews," she says.
Hospitals are going to be audited if they have a huge increase in three-day stays as the Recovery Auditors and other auditors are likely to focus on whether patients who stayed over three midnights and went to a skilled nursing facility met medical necessity for all three days, says Linda Sallee, MS, RN, CMAC, ACM, IQCI, director for Huron Healthcare with headquarters in Chicago.
"Case managers need to make sure that patients continue to meet medical necessity throughout their stay, particularly if they are candidates for a skilled nursing stay," she says.