Proactive approach predicts patient status

Surgical case manager does reviews

Sherman Hospital in Elgin, IL, takes a proactive approach to ensuring that surgical patients are placed in the proper inpatient or observation status by asking physicians to fill out a surgical reservation form before the surgery is scheduled.

The form includes space for the name of the surgical procedure, the CPT code, and the ICD-9 code.

It has space for insurance and pre-authorization information and boxes where physicians can check to indicate if they predict that the patient will be an outpatient, be admitted as an inpatient, or require an extended recovery.

In addition, the hospital has dedicated a case manager to the surgical unit to review all scheduled surgeries and ensure that they are in compliance with Medicare and other payer guidelines.

"There's too much money at stake not to do this. We want to get the patient status correctly established up front to avoid having the Recovery Audit Contractors (RACs) take back the whole payment for surgeries done in the wrong setting," says Ronald Hirsch, MD, FACP, medical director of care management for the 255-bed hospital, and physician advisor in case management for B.E. Smith healthcare consulting firm with headquarters in Lenexa, KS.

The surgical reservation form, which is available on the Sherman Health Documents web site, reminds physicians that observation services must be ordered after surgery and only if there is a medical reason to monitor the patient. It instructs them that Extended Recovery should be chosen for non-medical patient stays that are for the convenience of the physician or patient.

The Sherman Health document library also has a copy of the Medicare Inpatient-Only List and instructs surgeons that if a procedure is on the list, they should order an inpatient admission and that if procedures are not on the list and surgeons want to admit the patient, they must document the reasons on the medical record. The web site also includes a page describing outpatient, inpatient, and extended recovery and when each is appropriate. (See resource at end of story.)

Once the physician fills out the form, he or she faxes it into the scheduling department. The scheduling nurse reviews it to determine if the procedure is on the Medicare inpatient-only list and, if so, to make sure the doctor has ordered an inpatient admission. If not, the nurse contacts the physician and asks for new orders. When the patient gets to the surgical unit, Heather LaCoco, RN, BSN, surgical care case manager, reviews the record to make sure the orders are appropriate and the documentation is complete.

"A big part of my job is educating the surgeons and their office staffs about the difference between observation services, inpatient admissions, and extended recovery to help them understand the appropriate admission status for their patients. Surgeons just want to be doctors and surgically fix their patients and safely send them home. Case managers are the glue that puts it all together to make sure patients receive the care they deserve, that insurance and Medicare regulations are followed, and the hospital is capturing the information it needs to be appropriately paid for the care we deliver," LaCoco says.

The post-operative order sheet gives surgeons three choices: they can leave the status they designated preoperatively, change it to an inpatient admission, or order observation services for the patient. "We've worked hard to educate the physician that observation is indicated only when patients need monitoring beyond the usual recovery," Hirsch adds.

The hospital created the information sheets and forms for physicians after reviewing the RAC rules and records, and determining that in many cases, observation was not appropriate. "We also realized that some surgeries that were on the Medicare inpatient-only list were being performed as outpatient procedures and that there were instances where older patients with comorbidities needed inpatient care after routine procedures that were not on the list. The orders were not appropriate, and we were being poorly compensated for the services we provided," Hirsch says.

The hospital has created an extended recovery status for patients who need to stay overnight but their conditions don't warrant observation services or an inpatient stay. An example is a patient who has a procedure that Medicare has deemed to be outpatient surgery but the physician isn't comfortable sending the patient home after a four-hour recovery. "The hospital gets no additional payment for patients in extended recovery, but it keeps the surgeons happy, and the patients appreciate it," Hirsch says.

LaCoco reports spending a lot of time educating physicians and office staff about the need for accurate documentation and making it simple for them to get the right patient type, so the hospital can capture the services it is providing for patients and get paid appropriately. For example, a laparoscopic colectomy might be a simple outpatient for some patients, but not for an 82-year-old patient with heart failure, chronic obstructive pulmonary disorder, and diabetes.

"In this case, we need to educate the surgeon and the office staff to document that due to his comorbidities and risk factors, the patient needs to be admitted after surgery for close monitoring and medical management," she says. "This way we are capturing patient needs and are able to bill accurately for the care we provided." (For more on surgical admissions, see story below.)

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Dedicated case managers review surgery schedule

Inpatient vs. outpatient is focus

At Port Huron (MI) Hospital, a full-time case manager is dedicated to the surgery department and reviews the cases of all patients scheduled for surgery to make sure they are in the proper status of being an inpatient or observation patient.

Hospitals must walk a fine line when it comes to determining if surgical patients who need more than normal recovery times should be admitted or remain as outpatients with observation services, says Rochelle Schiller, RN, MBA, director of care management at the 186-bed community hospital. Hospitals lose money if they provide observation services for patients who meet admission criteria. On the other hand, if they have a large number of one-day inpatient stays, it attracts the attention of the Medicare Recovery Audit Contractors (RACs), Schiller adds.

"We determined that we needed someone on site to prospectively conduct a clinical review of surgical cases. We knew we needed an RN case manager with expertise in admission criteria to make sure the patients are in the proper status. A case manager dedicated to the surgery department was the solution," she says.

Working with the hospital administration and the business office, Schiller conducted an analysis of surgical cases over 12 months. The analysis showed that in some cases, procedures were ordered as outpatient procedures, but the patients were being transferred from recovery to the inpatient unit for a variety of reasons. "Some had clinical issues. Others were social admissions, and some simply didn't belong there," Schiller says. In all cases, the hospital was getting paid only for the outpatient services and not for the inpatient stay, she says

"We were losing revenue on some patients who met medical necessity criteria but were kept overnight as outpatients. We also determined that there were a lot of outpatients in beds when their care was not reimbursable," she says

The case management department worked with the business office to track all of the write-offs because the patients were treated as outpatients but the procedure was on the Medicare inpatient-only list. "We were missing the boat on some inpatient procedures. The procedures were being booked as outpatient procedures, and the patients were being kept in observation, so we weren't getting paid," she says.

The case management team looked for trends and picked the 15 most common procedures where there were problems, then educated the surgeons about the inpatient-only list, starting with those who performed the most common procedures. In addition, the surgical case manager compares the procedures scheduled for Medicare recipients to the inpatient-only list and makes sure that an inpatient stay is ordered. "We want to admit patients if they are having procedures on the inpatient-only list so we can get paid correctly," Schiller says.

As part of their initiative to place patients in the correct status, Port Huron Hospital created an outpatient extended stay level for patients who need to stay overnight for non-clinical reasons, such as they don't have a ride home or the doctor doesn't discharge them until the next day.

The extended stay level enables the hospital to put patients in a bed overnight without billing Medicare. "It doesn't generate a room charge, so it doesn't count as a one-day stay, and there's no red flag for the RACs. We have compassion for patients who can't get home late in the day, but it's not appropriate for us to bill for those services," she says.

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