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To Admit or Observe: THAT Is the Question

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CMS paid $19.9 billion in error for Medicare fee-for-service claims. ... Confusion over the Medicare rules for appropriate selection of status ... – PowerPoint PPT presentation

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Title: To Admit or Observe: THAT Is the Question


1
To Admit or Observe THAT Is the Question
  • Howard C. Pitluk, MD, MPH, FACS
  • Suzanne K. Powell, RN, MBA, CCM, CPHQ
  • Health Services Advisory Group

2
Objectives
  • Identify why observation versus inpatient is a
    national concern.
  • Define OBSERVATION (OBS).
  • Determine the appropriate use of OBS vs.
    INPATIENT hospital admissions.
  • Identify a proven method to reduce unnecessary
    admissions using a case management protocol.

3
CMS Concerns
  • CMS paid 19.9 billion in error for Medicare
    fee-for-service claims.
  • 17.2 were due to medically unnecessary
    services.
  • 43.7 were due to insufficient documentation.
  • 41 of admission errors were associated with
    one-day stays that were billed as inpatient.
  • DRG 143 is one of the most common billing errors.
  • Because the payment error rates are increasing,
    there may be more auditing in the future.
  • Improper Medicare FFS Payments Report FY 2004,
    Rev. 2/15/05, http//www.cms.hhs.gov/cert

4
Arizona Concerns
  • In FY 2005 over 4,500 claims were submitted for
    DRG 143 (chest pain) in Arizona
  • One-day stays accounted for 52 of the claims.
  • Of those one-day-stay claims, InterQual (IQ)
    admission criteria were applied to a random
    sample and 93.5 failed.
  • Of those same claims, a further sample of DRG 143
    was requested of the hospitals with the highest
    number of claims.
  • 97 failed to meet IQ admission criteria.
  • Since each inappropriate admission cost 2,376,
    Medicare overpaid 5,393,520 for these
    admissions.
  • Arizona is 2 in the nation for one-day-stay
    claims (only one state has more than AZ).

5
Hospitals Concerns
  • SO..
  • Start improving your processes NOW ?
  • Avoid the CMS RUSH
  • to audit, and potentially deny, payment for
    unnecessary hospitalizations!

6
Now What?
  • Do we have a problem?
  • YES. One-day stays for chest pain (DRG 143) in
    Arizona are high.
  • What can we do?
  • (1) Case Management Protocol (or a variation on
    a theme)
  • (2) Use OBS status as a default for DRGs with
    high error rates (DRG 143)
  • How will we know if what we are doing is
    effective?
  • Monthly audits / run charts to track progress

7
Why all the confusion over OBS?
  • Misunderstanding of the roles of physicians and
    facilities in determining patient status
  • Confusion over the Medicare rules for appropriate
    selection of status
  • Distinction between inpatient and extended
    outpatient observation is blurry
  • It is difficult to correct admission errors
    after-the-fact (i.e., after discharge)
  • Difficult to convince clinicians that the
    difference is one of BILLING, not MEDICAL
    TREATMENT

8
Definition Observation Services
  • CMS Manual System, Pub. 100-02 Medicare Benefit
    Policy says
  • Observation care is a well-defined set of
    specific, clinically appropriate services, which
    include ongoing short-term treatment, assessment,
    and reassessment before a decision can be made
    regarding whether patients will require further
    treatment as hospital inpatients or if they are
    able to be discharged from the hospital.
  • (up to 48 hours for Medicare FFS beneficiaries)
  • Note that managed Medicare and private
    insurance companies admission status rules may
    vary from those of FFS Medicare (often 23 hours
    or 24 hours).

9
Purpose of Observation
  • Observation is used to evaluate a patients
    condition in order to determine the need for
    acute inpatient admission.

10
Advantages of Observation
  • Allows the physician to observe the patient when
    unsure of diagnosis or trajectory of current
    symptoms
  • Avoids potentially unnecessary acute care
    admission and costs
  • Decreases burden on ED and augments hospital
    reimbursement (does not alter physician
    reimbursement)
  • Does not preclude an eventual admission

11
Observation ServicesKEY Questions to ASK
  • In what condition will the patient most likely be
    tomorrow?
  • Better ? Observation
  • Is it risky to send the patient home today?
  • Yes ? Observation
  • Is it likely I will know whether to admit or send
    the patient home by tomorrow?
  • Yes ? Observation

12
Observation ServicesKEY Questions to ASK
  • Are vital signs stable?
  • Yes ? Observation
  • Will a diagnosis likely be made in 24 hours?
  • Yes ? Observation
  • Will treatment, such as IV fluids, require
    standard monitoring and be complete within 24
    hours?
  • Yes ? Observation

13
Observation ServicesKEY Questions to ASK
  • Is the patient presenting with a symptom(s)
    (e.g., chest pain, abdominal pain, TIA)
  • Yes ? Observation
  • Is the patient having an unusually long recovery
    period following outpatient procedure (e.g., pain
    management issues, cardiopulmonary concerns,
    urinary retention)
  • Yes ? Observation

14
Do NOT use OBS for.
  • Social reasons
  • Physician or patient convenience
  • Routine prep for diagnostic testing
  • Routine recovery from outpatient procedures
  • Procedures designated as inpatient only

15
OBSERVATION The RULEIts Elementary!
  • R/O Rule Out
  • R/O Remember Observation

16
Will my patients get second-class care? NO! And,
by the way, my hospital does NOT have an OBS
Unit
  • Observation services can be provided anywhere in
    the hospital
  • Example Continuous monitoring (such as
    telemetry) can be provided in observation or
    inpatient status consider overall severity of
    illness and intensity of services in determining
    admission status rather than any single or
    specific intervention.
  • Level of care, not physical location of the bed,
    dictates admission status.

17
Observation..its not a place
  • Its a
  • state of
  • Mind.

18
WHEN does the OBS CLOCK START?
  • Observation time begins at the documented time in
    the patients medical record that coincides with
    the time the patient is placed in a bed for the
    purpose of initiating observation.
  • Must be in accordance with a physicians order /
    nursing note computer time may be inaccurate
  • Round out to the nearest hour.
  • FFS Medicare coverage for observation services
    requires at least eight hours of monitoring and
    is limited to no more than 48 hours unless the
    fiscal intermediary grants an exception.

19
WHEN does the OBS CLOCK END?
  • The ending time for observation occurs when
  • The patient is discharged from the hospital, OR
  • The patient is admitted as an inpatient.
  • The time when a patient is discharged from
    observation status is the clock time when all
    clinical or medical interventions have been
    completed, including any necessary follow-up
    care.
  • Observation care does not include time in the
    hospital subsequent to the conclusion of medical
    interventions (e.g., time waiting for a ride
    home).

20
Can I change from OBS to Inpatient?
  • YES!
  • OBS-to-Inpatient An outpatient observation
    patient may be progressed to inpatient status
    when it is determined the patients condition
    requires an inpatient level of care?anytime up to
    48 hours (for FFS Medicare patients).

21
Can I change from Inpatient to OBS?
  • YES!
  • Inpatient-to-OBS (CODE 44) Hospitals can convert
    and bill an inpatient case as an outpatient if
    the hospital utilization review committee
    determines before the patient is discharged and
    prior to submitting a bill/claim that this
    setting would have been more appropriate. The
    patients physician must concur with the decision
    of the review committee, and the physicians
    concurrence and status change must be documented
    in the medical record.

22
Considerations when making OBS/Inpatient
adjustments
  • Only use information available to the physician
    AT THE TIME of the decision to admit to OBS or
    inpatient. Patient Safety is number 1 criterion
  • Medical necessity for admission must be met and
    documented at the time of conversion.
  • Physicians can only change admission status prior
    to discharge.
  • Any change in admission status must be supported
    by the medical record (physician notes and
    orders).

23
Documentation is Critical
  • Observation status MUST be specifically stated in
    the order
  • Documentation must support the level of care
    provided (inpatient admission versus OBS)
  • An order simply documented as admit will be
    treated as an inpatient admission.
  • A clearly-worded order will ensure appropriate
    patient care and prevent hospital billing errors.
    Some use
  • admit to observation or
  • place patient in outpatient observation
  • For this project, we suggest
  • Admit Patient to Observation Case Management /
    Utilization Management Protocol

24
Once the patient has been in OBS status for 24
hours
  • Document the answers to these questions
  • Is there a need to continue observation status
    for the next 1224 hours?
  • or
  • Is there a need to convert to inpatient status?
  • It is important to document the medical necessity
    for admission status.
  • or
  • Is the patient medically stable for discharge?
  • Document the plan for follow-up as needed.

25
THE ADMISSION DECISION TEST
26
Medicare Observation or Inpatient? Admission
Decision Test
Observation is appropriate.
Yes
Can condition be evaluated / treated /
improved within 48 hours?
Inpatient admission is appropriate.
Yes
No
Does condition require hospital Treatment?
Alternate level of care is appropriate
No
Additional time is needed to determine if
inpatient admission is medically necessary.
Observation is appropriate.
Unsure
The decision to admit a patient as an inpatient
requires complex medical judgment, including
consideration of the patients medical history
and current medical needs, the medical
predictability of something adverse happening to
the patient, and the availability of diagnostic
services/procedures when and where the patient
presents.
27
THE CASE MANAGEMENT PROTOCOL
28
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29
Case Management ProtocolAn Answer to the
Observation Conundrum
  • Physician admits patient to the Observation CM/UM
    Protocol
  • Case Manager/Utilization Manager assessment
  • Determine appropriate status of patient
    (Inpatient vs. Outpatient)
  • Ordering Physician abides by case management
    determination
  • Protocol for all patients, regardless of payer
    (but only send HSAG Medicare FFS charts)

30
Admission Per Case Management Protocol Part 1
Physician Order Admit patient per Case
Management/Utilization Management Protocol
PRN Order at the discretion of the individual
physician?
NO
YES
YES
Patient admitted to Protocol
31
Admission Per Case Management Protocol Part 2
32
Admission Per Case Management Protocol Part 3


33
THE CHEST PAIN PROTOCOL
34
CHEST PAIN Considerations
  • Inpatient admission consider when a patient has
  • Elevated Troponin
  • ST elevation
  • MI or dynamic ST-T wave changes on the EKG
  • Hemodynamic instability
  • Chest pain not responding to Nitroglycerin
  • Observation consider when the patient has no EKG
    or enzyme changes, but the patients story
    suggests the possibility of acute cardiac ischemia

35
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36
NEXT STEPS?Hospital
  • By 15th of each month, send Monthly Log of 100
    of previous months DRG 143 stays (less than 48
    hours) with diagnosis of Chest Pain for Medicare
    FFS patients
  • Monitor a sample of those records and include on
    the Monthly Log (right side of log)
  • Timely submission of records requested by HSAG
    for HSAG monitoring
  • Read the Case Management Protocol (CMP), convene
    your team, and compare CMP with your process.
  • E-mail Suzanne Powell at spowell_at_azqio.sdps.org
    with questions/concerns re Case Management
    Protocol for Teleconference 3.

37
NEXT STEPS?HSAG
  • Request records based on hospitals Monthly Log
  • Monitor records when received from hospital
  • Prepare a customized RUN CHART and send to
    hospital on a monthly basis, adding data points
    each month
  • Facilitate calls with individual hospitals to
    discuss any barriers and ideas to pilot new
    processes to reduce the number of inappropriate
    one-day stays for DRG 143

38
Questions?
39
TEST Case Study 1
  • 67-year-old seen in the ED with gradual onset of
    CP over past 2 hours
  • EKG normal
  • First set of cardiac enzymes showed increased
    Troponin level
  • ? Observation OR ? Inpatient

40
TEST Case Study 2
  • 66-year-old seen in the ED with CP
  • EKG slight ST elevation
  • First set of cardiac enzymes negative
  • ? Observation OR ? Inpatient

41
TEST Case Study 3
  • 74-year-old man presented to his doctor with
    chest pain off and on for a week.
  • Patient was found to be bradycardic in the 50s
  • No syncope
  • Medications included toprol
  • Sent to ED VS stable, BP 180/70, HR of 50/min.
    EKG sinus bradycardia. Enzymes normal. Chest pain
    description in the chart did not support a
    diagnosis of unstable angina. Bradycardia is
    explained by the medications

42
Correct Call? DRG 143 Case Study 4
  • 67-year-old male, history of palpitations for 2
    months, usually at rest in evening before bed,
    was admitted for cardiac monitoring and enzymes
    related to complaint of chest pain and
    palpitations. Physical exam was unremarkable.
    Cardiac enzymes were negative. ECG showed sinus
    rhythm with occasional PVCs. Discharge diagnoses
    were unspecified chest pain and PVCs.

43
Correct Call? DRG 143 Case Study 5
  • 84-year-old man, history of CABG, was admitted
    with atypical chest pain for a week, which
    increased on deep inspiration. Enzymes and ECG
    unremarkable. Also complaining of weight loss
    over 3-year period. MI was ruled out. Also had
    work-up for weight loss while in the
    hospital. Discharge diagnoses were unspecified
    chest pain and weight loss.

44
Correct Call? DRG 143 Case Study 6
  • 63-year-old woman, history of CAD, HTN, CVA, with
    prior MI in the 1970s, was admitted with chest
    pain described as sharp, retrosternal, with
    dyspnea and diaphoresis occurring at rest. Pain
    lasted for minutes, increasing with exertion and
    decreasing with rest. Pain started day before and
    has recurred several times. BP 140/80. Initial
    ECG showed minor non-diagnostic ST-T-wave
    changes. The hospital admitted to rule out MI.
    Serial cardiac workup negative. Stress perfusion
    study negative for ischemia. Discharged with
    diagnosis of chest pain. GI work-up planned as
    outpatient.

45
www.hsag.com This material was prepared by
Health Services Advisory Group, the Medicare
Quality Improvement Organization for Arizona,
under contract with the Centers for Medicare
Medicaid Services (CMS), an agency of the U.S.
Department of Health and Human Services. The
contents presented do not necessarily reflect CMS
policy. Publication No. AZ-8SOW-SS-120106-01
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