Work with physicians to ensure record is complete
Many physicians in hospitals all over the country still haven’t gotten the idea of what needs to be documented in order for hospitals to be reimbursed appropriately, says Kathleen Miodonski, RN, BSN, CMAC, manager for The Camden Group, a national healthcare consulting firm based in Los Angeles.
"Now that the Centers for Medicare & Medicaid Services (CMS) has issued the two-midnight rule in the Inpatient Prospective Payment System (IPPS) final rule for fiscal 2014, physicians are likely to be more confused than ever. Physicians want to do the right thing, but they need guidance. Case managers should be the partners of the physicians and help them tell the story. It comes down to developing a good relationship with physicians," she says.
The final rule means that accurate and detailed documentation is more important than ever and hospitals could face significant payment implications if they don’t follow the rules, adds Ralph Wuebker, MD, MBA, chief medical officer for Executive Health Resources, a Newton Square, PA, healthcare consulting firm.
"CMS has escalated its expectations and is emphasizing that the documentation must clearly show medical necessity, the physician’s expectation of the length of stay, a signed admission order from the physician who will be treating the patient, and the treatment plan. In the past, these were best practices and strong recommendations. Now they are requirements," he says.
When they document, physicians are going to have to do more than just write down the diagnosis and the lab values, Miodonski says. "Physicians have to connect that information to the clinical condition and risk to the patient to justify an inpatient stay," she adds.
"It’s all about connecting the dots. The patient has to be sick enough, the care has to be intense enough, and the physician needs to document all of his or her concerns if the patient is going to require an inpatient stay," she says.
In addition, the documentation must specify that the patient is an inpatient admission or receiving observation services as an outpatient, says Linda Sallee, MS, RN, CMAC, ACM, IQCI, a director at Huron Healthcare with headquarters in Chicago.
Instead of using the word "inpatient," some physicians have been naming the floor or unit, such as writing "admit to 7-North" or something similar, she says. That practice still may pass muster, but to make sure the auditors will consider it an appropriate admission, Sallee recommends that the words "inpatient" or "observation" appear in the order.
Hospitals should have some type of educational program for physicians, Sallee advises. "Based on my experiences, it’s not enough to have one presentation at a medical staff meeting because physicians may skip the meeting," she says.
Use other means as well to reach as many physicians as possible, she suggests. These could be an article in the physician newsletter, a poster in the doctor’s lounge, a pocket card that lists the requirements, an e-mail, or all of them, she adds.
Also educate the office managers and office staff of community physicians since they often are in charge of what the physician provides to the hospital, she says.
However, she points out that one-on-one education with the physicians is likely to be more effective.
"CMS is asking physicians for what they’ve always asked for—a good history and physical with rationale for admission, a medically appropriate treatment plan, a signed admission order, and a signed discharge order," Wuebker says.
He recommends that case managers educate the physicians on all the components of certification and then review each case and make sure that everything is clearly and appropriately documented.
Case management departments need to develop processes to ensure that all of the requirements set out by CMS are clearly and correctly documented, Wuebker says.
Sallee suggests that case management directors encourage their staff to read the final rule and understand the rationale behind it.
"If the case managers understand why they are being asked to do what they are asked to do, they can explain it better to the physicians," she says.