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To Admit or Not to Admit. Patient. Presents. The Decision Seems Easy…. Admit as Inpatient. Treat as Outpatient. Admit as Inpatient. But It’s Much More Complicated. Office Follow-up. Specialty Clinic Follow-up. Treat as Outpatient. Outpatient Procedure. SNF Follow-up.

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Presentation Transcript
the decision seems easy

Patient

Presents

The Decision Seems Easy…

Admit as Inpatient

Treat as Outpatient

but it s much more complicated

Admit as Inpatient

But It’s Much More Complicated

Office Follow-up

Specialty Clinic Follow-up

Treat as Outpatient

Outpatient Procedure

SNF Follow-up

Diagnostic Testing

Observation

patient status options

Patient

Presents

Patient Status Options

Admit as Inpatient

Outpatient Observation

Outpatient Procedure and/or Followup

effects of unnecessary admissions
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
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 matters7
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
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
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 Documentation
  • Inpatient admission order with date and time
  • Clinical documentation supporting medical necessity
  • No “back-dating” is allowed
what are observation services
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
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
Points of Entry for Outpatient Observation
  • Admission from emergency department
  • Direct admission
  • Outpatient department(s)
observation documentation
ObservationDocumentation
  • 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
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
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
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
Chest Pain Evaluation
  • New onset symptoms may be consistent with ischemic heart disease butnot 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
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
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
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
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
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
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
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
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
Observation or Inpatient?

Hospitalization

required?

Yes

24 hours adequate to

evaluate, treat or

respond?

No

No

Inpatient

Yes

No acute

hospital care

Observation

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