To Admit or Not to Admit

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To Admit or Not to Admit
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The Decision Seems Easy
Admit as Inpatient
Treat as Outpatient
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But Its Much More Complicated
Office Follow-up
Specialty Clinic Follow-up
Treat as Outpatient
Outpatient Procedure
SNF Follow-up
Diagnostic Testing
Observation
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Patient Status Options
Admit as Inpatient
Outpatient Observation
Outpatient Procedure and/or Followup
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Effects of Unnecessary Admissions

• Costs Medicare the largest proportion of
  erroneous payments
• One-day stay admissions are target area for
  potential payment errors in MO
• OIG has taken notice

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Why It Matters

• Majority of error payment amount (1.6B) may be
  attributed to lack of medical necessity
• Nearly 80 of all admission denials were short
  stays (1-3 days)
• MOs net error payment FY2005 estimated at 47M
  majority of which may be attributable to
  unnecessary IP admissions

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Why It Matters

• Why does it matter to the patient?
• Why does it matter to the hospital?
• Why does it matter to the physician?

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Admit as Inpatient

• Treatment longer than 24 hours expected
• Outpatient treatment has not been effective
• Inpatient-only procedure necessary
• Continuous monitoring necessary

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Inpatient Admission Considerations

• Severity of presenting signs and symptoms
• Predictability of the clinical course
• Existence of comorbid conditions which may
  negatively impact course
• Potential for complications
• Services required upon presentation
• Diagnostic procedures available

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Inpatient Admission Documentation

• Inpatient admission order with date and time
• Clinical documentation supporting medical
  necessity
• No back-dating is allowed

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What are Observation Services?

• Services furnished by a hospital including
• use of bed
• periodic monitoring by staff
• requires physician order
• Reasonable and necessary
• evaluate outpatient condition
• determine inpatient admission need

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Why Observation Services?

• Determines need for inpatient admission
• Rapid response to treatment is expected
• Patient has unusually prolonged recovery period
  following an OP procedure

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Points of Entry for Outpatient Observation

• Admission from emergency department
• Direct admission
• Outpatient department(s)

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Observation Documentation

• Observation admission order with date and time
• Assessment of patient risk to determine benefit
  from observation care
• Timed and signed admission notes, progress notes
  and discharge notes

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Observation Services Not Covered

• Services not reasonable or necessary for
  diagnosis or treatment of patient
• Services provided for convenience of patient,
  family or physician
• Services covered under Part A
• Services that are part of another Part B service
• Standing orders for observation after OP surgery
• Custodial care

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Condition Code 44 Policy

• Medicare payment policy that allows inpatient
  admission change to outpatient when
• Change in status made prior to discharge
• The hospital has not submitted Medicare claim for
  inpatient admission
• Physician concurs with decision to change status
• Physicians concurrence is documented in medical
  record

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Chest Pain

• Process of elimination to determine chest pain is
  not cardiac in origin based on
• Symptoms
• ECG
• Enzymes
• Possible early stress testing

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Chest Pain Evaluation

• New onset symptoms may be consistent with
  ischemic heart disease but not associated with
  ECG changes or convincing evidence of unstable
  ischemic heart disease at rest or with minimal
  exertion
• Known CAD but symptoms do not suggest true
  worsening
• Observation beneficial because etiology of
  symptoms is unclear

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Chest Pain Case Study 1

• 84-year-old female, PMHCABG, presented to ED
  with intermittent chest pain x1 wk which
  increases on deep inspiration Initial enzymes
  ECG unremarkable pain resolved prior to
  admission
• Patient admitted with atypical pain in setting of
  prior CABG Planserial ECGs enzymes
• Admission to observation status appropriate

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Chest Pain Case Study 2

• 63-year-old female, PMHCAD with prior MI 1990s,
  HTN, CVA presented to ED with chest pain, sharp,
  retrosternal, dyspnea diaphoresis pain
  increases with minimal exertion pain relieved
  w/rest NTG pain recurred several times in ED
  SBP gt100
• Initial impressionunstable angina, r/o MI

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Chest Pain Case Study 2 (contd)

• Initial enzymes WNL, ECGnon-specific ST- T
  changes admitted to telemetry unit for r/o MI
  protocol stress perfusion w/dipyridamole, which
  showed anterior wall ischemia
• New onset angina in setting of prior MI IP
  admission appropriate

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Syncope Collapse Case Study 3

• 70-year-old female presented to the ED knees
  gave out I fell to floorhit back of head
  denies LOC, dizziness, lightheadedness, chest
  pain, N/V PMHDM vital signs WNL w/no
  findings on exam BS189 Enzymes nl ECG WNL
  head CT negative

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Syncope Collapse Case Study 3 (contd)

• Questionable pre-syncope of unknown etiology
  admit to monitor for arrhythmias or other neuro
  signs
• Admission to observation status appropriate

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Syncope Collapse Case Study 4

• 65-year-old male came to ED with 3 syncopal
  episodes each lasting several seconds, occurring
  over 18-hr period HP unremarkable
  ECGbradycardia of 54bpm 18 sec pause
  ECHOWNL
• Appropriate IP admission for pacemaker insertion
  and postprocedure monitoring

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Dehydration Case Study 5

• 92-year-old female presented to the ED with
  weakness x2 days difficulty getting in out of
  bed no fever, dizziness, nausea, vomiting,
  diarrhea PMHHTN, dementia, recent tx for UTI
  Sodium132 decreased oral intake HR gt100
  postural SBP drop gt30
• Tx planBP meds held IVFs 100/hr po antibiotics

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Dehydration Case Study 5 (contd)

• Meets severity of illness (InterQual
  endocrine/metabolic) but doesnt meet intensity
  of service
• Per PR review---documentation indicates status of
  dehydration could reasonably be expected to
  improve within 24-hour period overnight
  monitoring in observation status appropriate.

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Observation or Inpatient?
Hospitalization required?
Yes
24 hours adequate to evaluate, treat or respond?
No
No
Inpatient
Yes
No acute hospital care
Observation
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References

• Federal Register, Nov. 10, 2005
• Medicare Claims Processing Manual
• Medicare Benefit Policy Manual
• Mutual of Omaha
• InterQual admission screening criteria
• HPMP Compliance Workbook