3/17/2015. Objectives: Why is Getting Patient Status Correct Such an Important Issue?

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1 Getting Your Physicians to Think in Ink Ralph Wuebker, MD, MBA, Chief Medical Officer Objectives: Get Physician Buy In, Why status matters Documentation best practices and common errors Key documentation points for the 2 midnight rule Documentation example Why is Getting Patient Status Correct Such an Important Issue? Overuse of Inpatient Overuse of Observation Focus of Recovery Audit Contractors Potential False Claims issue if no complaint process is in place Potential recoupment of reimbursements during audit and loss of opportunity for appropriate OBS APC and ancillary charge payment Length of stay artificially elevated Mortality data artificially elevated Qualified stay impact on patient s skilled care benefit Unexpected patient financial responsibility (self-administered medication charges, inflated co-payments) It s about getting it right! 1

2 Patient Deductible and Copays Inpatient (Part A) 2015: Day 1-60: $1260 inpatient deductible Day 61-90: $315/day Day : $630/day Outpatient (Part B): $147 per year deductible 20% coinsurance for all covered outpatient services 100% of non covered outpatient services Source: CMS-8056-N, Medicare Program; CY 2015 Inpatient Hospital Deductible and Hospital and Extended Care Services Coinsurance Amounts National Exposure NBC Nightly News/MSNBC March 2014: FierceHealthcare, July 15, ?utm_medium=nl&utm_source=internal JAMA: July 8, Invited Commentary: Observation Status for Hospitalized Patients/Hospitalized but Not Admitted Kaiser News May 3, Medicare.aspx Money August 2012; This could Hurt a lot pg. 70 NYTIMES: In the Hospital, but Not Really a Patient; June 22, 2012 USA Today April 17, Washington Post 2010: Patients held for observation can face steep drug bills CMS Transmittal 541 Effective: The auditors have the discretion to deny other related claims submitted before or after the claim in question Limited to surgical claims For services where the patient s history and physical (H&P), physician progress notes or other hospital record documentation does not support the medical necessity for performing the procedure, post-payment recoupment will occur for the surgeon s Part B service. The MAC, Recovery Auditor, and ZPIC are not required to request additional documentation for the related claims before issuing a denial for the related claims. Contactors shall process appeals of the related claim(s) separately. 2

3 [Section Break Slide Insert Section Title] Documentation Tips for Medical Necessity What the Auditors Expect 3

4 What Typically is Provided Foreign Body Removed #! Name Protected, MD Physician Documentation Uses Before: E&M level validation Communication with physician partners and consultants Reminder notes for self use Possible use by nurses Now: Audit defense Billing justification Malpractice defense Quality of Care Measurement Government investigations 4

5 Common Documentation Problem Areas Limited or no physician documented info (consult, ED note or H & P) o Only information available is a list of symptoms/ lab work o No documentation until several hours after admission No plan of care or clear impression in the H & P o Common with mid-level providers, medical students and residents OP note/h & P for procedures that do not address/include any risk from past medical history o Frequently occurs from using office notes as history and physical Lack of discharge summary for a readmission review and no mention of stability on discharge/return to baseline in the discharge note Prolonged stays frequently do not include the current progress note or orders to indicate why the patient requires continued acute care Common Documentation Problem Areas Using a symptom rather than a diagnosis for the impression or assessment N/D/V vs. bowel obstruction SOB, chest pain, headache, back pain Listing the diagnosis as an intractable symptom (vertigo, abdominal pain, vomiting) without noting the potential diagnosis Using a lab value or treatment plan with no diagnosis Documentation for medical necessity is different than for billing level or coding General Documentation Takeaways 5 key pieces of documentation to support medical necessity for Inpatient admissions under Medicare: Medical history Current medical needs Severity of signs and symptoms Facilities available for adequate care Predictability of an adverse outcome 5

6 Key Words SUSPECTS What is your suspicion of what is going on, i.e. impression? CONCERNS What are your concerns of the situation? PREDICTABLE RISK Given the patient s history and current presentation, what kind of adverse outcomes are likely and what are the chances DOCUMENTATION NOT CONSISTENT WITH IP ORDER Custodial Delay Convenience Examples: Can go home from ER but the family cannot take care of the patient The patient was about to be discharged, but apparently she did/does not have much help at home and she is unable to take care of herself Contradiction of IP order and certification IP order and I anticipate 1 midnight in the hospital and hence she will be admitted under observation. Here for placement Home in AM after lab result [Section Break Slide Insert Section Title] Physician Documentation for 2 Midnight Rule 6

7 3 Key Requirements for 2 Midnight Rule Time the patient is expected to stay in the hospital (2 midnights is guide) Order to admit to inpatient or refer for observation/outpatient Documentation of the patient s medical necessity requiring hospital admission H and P, progress note and DC summary [Section Break Slide Insert Section Title] Time: 2 Midnight Expectation Expectation of 2 Midnights Physician should document if they expect the patient s hospital care to span more or less than 2 midnights Treatment time spent in the ED can be counted towards 2 midnights Guidelines: If you believe the patient will be discharged same day or the day following hospitalization, consider ordering Outpatient or Observation If you believe the patient will NOT be ready for discharge the day after hospitalization, consider ordering Inpatient 7

8 [Section Break Slide Insert Section Title] Physician Order Physician Order Clarification Qualifications of the ordering/admitting practitioner: At some hospitals, practitioners who lack the authority to admit inpatients under either State laws or hospital by laws may nonetheless frequently write the sets of admitting orders that define the initial inpatient care of the patient. In these cases, the ordering practitioner need not separately record the order to admit.. the order must identify the qualified ordering practitioner, and must be authenticated by the ordering practitioner (or by another practitioner with the required admitting qualifications) prior to discharge. Verbal orders: A verbal or telephone inpatient admission order must be authenticated (signed, dated and timed) by the ordering practitioner (or by another practitioner with the required admitting qualifications in his or her own right) in the medical record prior to discharge, unless the hospital or the State requires an earlier timeframe Timing: The order must be furnished at or before the time of the inpatient admission. Sept 5 CMS Update Memo Physician Order Qualifications of the ordering/admitting practitioner: The order must be furnished by a physician or other practitioner ( ordering practitioner ) who is: (a) licensed by the state to admit inpatients to hospitals, (b) granted privileges by the hospital to admit inpatients to that specific facility, and (c) knowledgeable about the patient s hospital course, medical plan of care, and current condition at the time of admission. The admission decision (order) may not be delegated to another individual who is not authorized by the state to admit patients, or has not been granted admitting privileges by the hospital's medical staff (42 CFR 412.3(b)). However, a medical resident, a physician assistant, nurse practitioner, or other non-physician practitioner may act as a proxy for the ordering practitioner provided they are authorized under state law to admit patients and the requirements outlined below are met if the ordering practitioner approves and accepts responsibility for the admission decision by countersigning the order prior to discharge. The inpatient admission order cannot be a standing order. Source: CMS document: Hospital Inpatient Admission Order and Certification, Jan 30,

9 Physician Order Guidelines Inpatient Cases: should include the words Admit and Inpatient to be a valid inpatient order Observation/Outpatient Cases: Should include the phrase Refer for Observation Services or Outpatient Status Avoid using admit and Observation or Outpatient in the same order. CMS considers this to be contradictory Admit to Tower 7 or Admit to Dr. Smith are not recommended Source: CMS document: Hospital Inpatient Admission Order and Certification, Jan 30, 2014; see also, 78 Federal Register (2014 IPPS Final Rule). Medical Documentation Keys 7 Key Pieces of Documentation for Medical Necessity Physician Order Past Medical History Comorbidities Severity of Signs and Symptoms Pertinent positives on physical exam Current Medical Needs Plan of Care and Accompanying Orders Facilities available for adequate care Predictability of an adverse outcome Suspected diagnosis and need for hospital services Expectation of Length of Stay Medicare s Surgical IP Only List Medicare's Inpatient Only List should be reviewed at the time the procedure is scheduled For procedures that are on the Medicare IP only list, The order for Inpatient must be on the chart PRIOR to the surgery If the procedure changes during surgery to an Inpatient only case Ensure the IP order is put on the chart ASAP after the procedure Source: Medicare Claims Processing Manual, Chapter 4, Payment Window for Outpatient Services Treated as Inpatient Services; Medicare Claims Processing Manual, Chapter 4, Inpatient-only Services 9

10 Surgical Guidelines: Inpatient vs. Outpatient For Elective/Scheduled Procedures: i.e., procedures scheduled days in advance Does not apply to procedures on CMS IP only list 1. Same day discharge (i.e. no overnight stay) is ALWAYS OUTPATIENT 2. 1 midnight/overnight is OP (rarely observation) 3. 2 midnight stay most often is IP, but depends on Medical Necessity High Risk patient is Inpatient Low Risk patient is Outpatient Admission Review Key Considerations Physicians Order Expectation of 2-Midnight Stay Medical Necessity Clinical Rational Medical Necessity Example 1 Chest Pain 76 y/o male with central intermittent chest pain for 2 days which lasts about 20 minutes, few episodes Awoke in the morning with left arm tingling that quickly resolved Past Hx includes MI, DM2, CABG and prior cardiac stents PE BP 90/65 HR 105 RR 24 Tachycardiac with bilateral crackles EKG besides for Sinus Tach is unchanged and cardiac enzymes nondiagnostic, Cr 1.5, Bld Glc 220 g/dl Pain is relieved by NTG, then recurs and feels just like his prior MI THESE FACTS ALONE DO NOT TELL THE STORY 10

11 Documentation is Key: Telling the Chest Pain Story The common term "chest pain" does not necessarily refer to cardiac disease and is often misunderstood Documentation of your clinical judgment (e.g., cardiac ischemia, recurrent or worsening angina, chest wall pain, non-cardiac, GERD) is important What is the rationale or factors you considered in your judgment? Atypical chest pain does not exclude ischemic disease document suspected cause regardless of typical or atypical pattern Acute Coronary Syndrome encompasses UA, NSTEMI, or STEMI UA - rest angina (usually lasting >20min), new onset (<2months) duration of angina, or crescendo pattern of occurrence Symptoms similar to past events? EKG baseline vs. current if known and Cardiac Enzymes Hypotension, Diaphoresis, CHF, Pulmonary Edema? Summary Excellent patient care is top priority Regardless of the payer: Admission order Expected LOS History and Physical/Procedure note Progress note each hospital day Discharge summary and plan Above signed prior to discharge Make the obvious, obvious THANK YOU. Questions? Ralph Wuebker, MD, MBA Chief Medical Officer rwuebker@ehrdocs.com 11

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