Transcript No Slide Title

To Admit or Not to Admit
Publication MO-06-40-HPMP June 2006
This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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
The Decision Seems Easy…
Patient
Presents
Admit as
Inpatient
Treat as
Outpatient
But It’s Much More Complicated
Office
Follow-up
Admit as
Inpatient
Treat as
Outpatient
Outpatient
Procedure
Observation Diagnostic
Testing
Specialty
Clinic
Follow-up
SNF
Follow-up
Patient Status Options
Admit as
Inpatient
Patient
Outpatient
Observation
Presents
Outpatient
Procedure and/or
Followup
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
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)
MO’s net error payment FY2005 estimated at
$47M; majority of which may be attributable
to unnecessary IP admissions
Why It Matters
Why does it matter to the patient?
Why does it matter to the hospital?
Why does it matter to the physician?
Admit as Inpatient
Treatment longer than 24 hours expected
Outpatient treatment has not been
effective
Inpatient-only procedure necessary
Continuous monitoring necessary
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
Inpatient Admission Documentation
Inpatient admission order with date and time
Clinical documentation supporting medical
necessity
No “back-dating” is allowed
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
Why Observation Services?
Determines need for inpatient admission
Rapid response to treatment is expected
Patient has unusually prolonged recovery
period following an OP procedure
Points of Entry for Outpatient Observation
Admission from emergency department
Direct admission
Outpatient department(s)
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
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
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
–
Physician’s concurrence is documented in medical
record
Chest Pain
Process of elimination to determine chest pain
is not cardiac in origin based on:
–
Symptoms
–
ECG
–
Enzymes
–
Possible early stress testing
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
Chest Pain Case Study #1
84-year-old female, PMH=CABG, 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; Plan=serial ECGs & enzymes
Admission to observation status appropriate
Chest Pain Case Study #2
63-year-old female, PMH=CAD 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 >100;
Initial impression=unstable angina, r/o MI
Chest Pain Case Study #2 (cont’d)
Initial enzymes WNL, ECG=non-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
Syncope & Collapse Case Study #3
70-year-old female presented to the ED “knees
gave out & I fell to floor…hit back of head”;
denies LOC, dizziness, lightheadedness, chest
pain, & N/V; PMH=DM; vital signs WNL w/no
findings on exam; BS=189; Enzymes nl; ECG
WNL; head CT negative
Syncope & Collapse Case Study #3 (cont’d)
Questionable pre-syncope of unknown
etiology; admit to monitor for arrhythmias or
other neuro signs
Admission to observation status appropriate
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; H&P
unremarkable; ECG=bradycardia of 54bpm &
18 sec pause; ECHO=WNL;
Appropriate IP admission for pacemaker
insertion and postprocedure monitoring
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; PMH=HTN, dementia, recent tx for
UTI; Sodium=132; decreased oral intake; HR
>100; postural SBP drop >30
Tx plan=BP meds held; IVFs 100/hr; po
antibiotics
Dehydration Case Study #5 (cont’d)
Meets severity of illness (InterQual
endocrine/metabolic) but doesn’t 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.
Observation or Inpatient?
Hospitalization
required?
No
No acute
hospital care
Yes
24 hours adequate to
evaluate, treat or
respond?
Yes
Observation
No
Inpatient
References
Federal Register, Nov. 10, 2005
Medicare Claims Processing Manual
Medicare Benefit Policy Manual
Mutual of Omaha
InterQual® admission screening criteria
HPMP Compliance Workbook