Medical Necessity and One Day Stays Initiative

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Medical Necessity and One Day Stays Initiative

• Alan L. Wang, MD
• Chief Medical Officer, EJCH
• Co-Director, Hospital Medicine, EJCH
• Elaine Cooke, RN
• Director, Case Management / Utilization
  Management, EJCH

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History of the Initiative

• CMS began an intensive process improvement plan
  to reduce payment errors from Medicare One Day
  stays.
• QIOs are conducting projects related to medical
  necessity of inpatient admissions for CMS.
• Several of the HCA hospitals are now under QIO
  review and more will be added in the future.
• Incorrect admission status may incur further
  monetary penalties to patients.

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What is observation?

• Use of a bed and periodic monitoring by hospital
  staff to evaluate an outpatients condition to
  determine the need for possible inpatient
  admission.

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Does observation require a doctors order?

• Yes.
• Dated and timed.
• Order should be written PRIOR to the initiation
  of observation services.

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How should the order be written for obs vs.
inpatient?

• Place in observation.
• Admit as inpatient.

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When is observation appropriate?

• Physician needs additional time to evaluate to
  determine need for inpatient.
• Physician feels patient may respond rapidly to
  treatment.
• Complication from outpatient surgery.

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What services would qualify for observation?

• Medical Necessity
• Documented in the chart

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What does NOT qualify for observation?

• Routine stays after late surgery
• Diagnostic testing
• Outpatient therapy/procedures
• Convenience of patient/family/doctor
• Admitting to observation prior to outpatient
  procedure
• Staying past the 48th hour
• Awaiting placement

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How many hours will Medicare cover for
Observation?

• May NOT exceed 48 hours
• Decision to release or admit should e made within
  24 hours.
• Rarely, 48 hours

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Ca you change from inpatient to obsevation?

• Medicare
• Change/Order made/clarified PRIOR to discharge
• Physicians concurrence documented in chart.

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What post-op complications may warrant
observation?

• Persistent N/V
• Fluid/electrolyte imbalance
• Uncontrolled pain
• Arrhythmias
• Excessive/uncontrolled bleeding
• Psychotic behavior
• Unstable LOC
• Deficit in mobility/coordination

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Can observation patients be placed in ICU?

• NO

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Can an outpatient surgery patient be admitted to
observation?

• No complications
• NOnot used as a substitution for the recovery
  room.

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Does the hospital get reimbursed for observation?

• Yes.
• Medicare for example
• packaging of services

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Why did Medicare package observation services?

• CMS noted abuse of observation
• Used inappropriately
• Remaining in observation for days
• Leads to payment errors

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Observation Examples

• Adominal pain not surgical
• Allergic reaction, generalized
• AMS
• Anemia
• Asthma
• Atypical CP
• Back Pain
• Complications post outpatient surgery
• Epistaxis
• HA

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More Observation Examples

• HTN
• Renal colic
• Near drowning (no AMS)
• Smoke inhalation
• N/V (dehydration)
• R/O any condition
• TIA
• Weakness/dizziness/syncope
• Urinary retention requiring cath
• Vaginal bleeding

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Prevention of Errors

• Multidisciplinary rounds on M, W, F at 1130 am
• Meetings with case management representative T,
  R, Sa and Su
• Case management, Case management, Case management!

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Summary (What can I do to help?)

• Date and time admit order
• Specify level of careplace in observation or
  admit as inpatient
• Make decision within 24 hours to either admit or
  discharge
• For outpatient surgery with complications,
  document need for furthering monitoring for
  observation.
• Physician and hospital should bill the same
  status.