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Created by:• Rekha D. Halligan, MD-PhD; Physician Advisor, FH

Edited by:• Leila Hosseini, MD; Director, Physician Advisors; AHN• Mark Rubino, MD, MMA; Chief Medical Officer, FH• Ezz-Eldin Moukamal, MD; Chief of Medicine, FH• Julie Chowan, RN, MSN, CCM; Director Care Management, FH

November 2015

Confidential & Proprietary Compliance Approved_11/15

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• Outline the reasons for this presentation

• List the criteria for medical necessity as defined by the CMS

• List the criteria for determination of Observation vs. Inpatient status for a hospitalized patient

• Outline the process of compliance with the 2- Midnight Rule

• State the CMS criteria for any provider considered to be of “Major” concern after an audit

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Why ?

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CC. “Can’t breathe”

HPI. 78 y/o female• COPD• Sick x 4 days w/ increasing dyspnea, new LE edema, orthopnea, and wheezing. • No benefit with increasing home nebs.• In ED, SBP = 105; pulse ox on 3 L O2 by NC = 88 %; + rales and wheezing. • Treated with 60 mg Lasix iv x 1, nebs x 2 • Reported some improvement but not at baseline • Pulse ox on 3 liters by NC = 91 %; less wheezing and less rales. W/ exertion

drops to 88 %

You are called by the ED.

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Question 1:

How do you decide whether to hospitalize the patient?

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Answer:

Medical Necessity

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• After your evaluation, you decide patient needs to be in the hospital based on the medical necessity criteria.

• You instruct the ED physician to put the patient under your service.

• You round on the patient and need to decide whether to put the patient under Observation vs. Admit as Inpatient.

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Question 2:

How do you decide between Observation vs. Admit to Inpatient?

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Answer:

Severity of Patient Illness vs. Intensity of Services Needed in Hospital

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• Measurable and trackable signs and symptomso JVDo Extra heart soundso Abnormal lung soundso Extra oxygenation needo Temperature abnormality

• Any supporting objective data

• Any interventions that cannot be safely provided outside the hospital?o Meds needing administration

or monitoring in hospitalo Invasive investigations/

procedureso Consultants appropriate for

the acute illness

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Moderate severity of illness

• Need of supplemental O2

• Suboptimal pulse oximetry

• Chest X-Ray

High intensity of services

• Frequent pulse ox

• Frequent BP checks

• Stability check while weaning off oxygen

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• Extent of blood work ordered

• Extent of imaging studies ordered

• Extent of consultants obtained

• Placing patient on telemetry

• Placing patient in the ICU

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Before you select between observation and inpatient, know the…

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• For now, applies to Medicare FFS and United Health Care only

• ED issues:– ED waiting & triage time do not count– Clock starts when treatment starts

• The first midnight in observation counts towards the two midnight benchmark, but it is still an outpatient day and does not count toward the three, medically necessary, inpatient days needed to qualify for skilled benefits

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• You decide that the patient’s illness is such that it:o Meets medical necessity, and is ofo Moderate severity thato Will need high level of services,o and because of what seems to be new onset heart failure and a

complex course so far, will probably end up crossing at least 2 midnights in the hospital

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You give verbal orders/are ready to enter the orders in EPIC and sign the certification.

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C TPN RD

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Question 3:

What must be documented in your Admission H&P?

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Answer

Document:

• Medical Necessity• Severity of Illness• Intensity of services • Observation or Inpatient Status

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• Assessment (Journal your thoughts, tell the ‘why’ of the story):

o The patient has dyspnea probably secondary to AECOPD, not controlled by her usual outpatient regimen. She did not respond significantly to the management in the ED. Her edema and orthopnea are new and of unclear etiology.

o She is hypotensive and has DOE. ABG shows low O2 on supplemental oxygen.o CXR consistent with pulmonary edema. o I am concerned about progression of her underlying COPD and new onset heart failure of uncertain

type, both which can result respiratory failure needing intubation, potentially worsening to death, needing at least a 2 MN stay.

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Plan what you are going to do: observation or admit to inpatient• Admit as Inpatient• Continue Lasix, nebs, and O2• Monitoring BP and serial pulse ox • Check Cardiac echo to check function to help guide diuretic therapy• Pulmonary service input for the optimization of COPD regimen

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HPI. “No improvement with increase in home nebs and ER interventions. Pulse ox suboptimal and ongoing wheezing, rales and persistent DOE.

PMH.COPD

ROS. Wheezing without relief over the last 4 days, early satiety due to abdominal fullness/edema, difficulty walking because of LE edema

PE.Vitals: Pulse ox on 3 L by NC: 88%, BP 95/45; RR 20/min; wheezing and rales; +S3, +2 pitting edema

Labs. ABG on 3 L by NC: 7.45, 35, 85; Hgb 12; CXR hyperinflated lungs with increased interstitial markings; ECG consistent with LVH.

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Must document in your progress note daily

• Ongoing medical necessity of why the patient needs to remain in the hospital

• Objective data (in addition to the subjective data) supporting the medical necessity

• Before the 2 MNs have passed, must document in Progress Note or Discharge Summary the reason for patient discharge earlier than your expectation that the patient was going to need to cross 2 midnights to get better

• EPIC users; check appropriate box at discharge

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• Recovered faster than expected

• Left AMA

• Refused treatment

• Transferred to a higher level of care

• Deceased

• Election of hospice care in lieu of continued treatment in the hospital

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CMS criteria for any provider considered to be of “Major” concern after an audit

Based on results of the random audits, any provider with denials of 7 claims out of a sample of 10 will be considered to be a Major concern.

If CMS unable to obtain a 10 claim sample, providers would be in a moderate concern.

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Procedures Defined as ‘Inpatient–Only’

http://bulletin.facs.org/2013/06/the-inpatient-list/

• Click on CMS website in body of the bulletin

• Click Hospital Outpatient Regulations and Notices

• Click CMS-1601-FC• Click CY2014 OPPS addenda• Click Accept• Click Open• Click Addendum E either in txt or xlsx

format

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http://moodle.wpahs.org/course/category.php?id=37

Approved for AMA PRA Category 1 Credit TM

• Log In, • Click Course List• Click Compliance• Click CMS Inpatient Orders and Physician

Certification Requirements• Read the course, take the quiz• Earn 1 unit of AMA PRA Category 1 Credit TM

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2Take Home Messages

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You wish to or are asked to bring patient into the hospital

Meets Medical Necessity criteria? C TPN RD

Assess severity of patient illness,

Assess the intensity of needed hospital services

Determine if patient will cross 2 MNs in order to return to baseline?

Does not need hospitalization before crosses2 MNs

Crosses 2 or more MNs: Document inProgress Note the Medical Necessity of Staying in house

Document in Discharge Summary and/or check in EPIC, reason for discharge before crossing 2 MNs

Back to baselinebefore crossing2 MNs

Condition worsensbefore crossing 2 MNs: Document medical necessity and convert to Inpatient

Discharge

Yes No

Admit toInpatient

Place Under Observation

Discharge whenreturns to baseline

Start Here

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• Best practice for reviewing the medical necessity of [Medicare] inpatient admissions has not changed with the institution of the 2-midnight rule.

• CMS provides guidance that the decision to admit a patient is a complex medical judgment made by a physician in consideration of several factors, including the following:

• The patient’s age• Disease processes • Comorbidities impacting on patient’s presentation• The severity of the signs and symptoms of the patient’s medical condition• The medical predictability an adverse event

• The best practice for review of admissions includes the consistent and reproducible application of evidence-based medical criteria, such as commercial screening tools, to all cases.

• A trained and experienced physician advisor, also utilizing evidence-based medicine and published medical literature, can assist in cases which fail the initial screening criteria.

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• Contact a Physician Advisor and/or Case Management if you have any questions about the content in this presentation.