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Using Clinical Criteria for Evaluating Short Stays and
Beyond
Georgeann Edford, RN, MBA, CCS-P
The Clinical Face of Medical Necessity
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The Documentation Faces of Medical Necessity
SettingtheStage SSA§1862(a)(1)(A)Coverage “…itemsorservicesnecessaryforthediagnosisortreatmentofanillnessorinjuryortoimprovethefunctioning ofamalformedbodymember.”
SSA§1156(a)(3) “…willbesupportedbyevidenceofmedicalnecessityandqualityinsuchformandfashionandatsuchtimeasmayreasonablyberequiredbyareviewingpeerrevieworganizationintheexerciseofitsdutiesandresponsibilities.”
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PhysicianCertificationFederalRegister/Volume68,No216 “…However,wecontinuetobelievethatthebeneficiary’streatingphysician‐notanytreatingpractitioner‐isbestsituatedtodetermine“inneed”status,bothbecauseheorsheistheprimarycaregiverandalsoisresponsibleforthebeneficiary’soverallcare”
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MedicalNecessityCriteriaInpatientStays
UseofscreeningCriteria QIO’suseInterQualorsimilar NotwithstandingCMS’scharacterizingthedecisiontoadmitas:• Complex• Madebythepatient’sphysician• Basedoninformationavailableatthetimethedecisiontoadmitismade
Conversely,notmeetingscreeningcriteriadoesnotmeanadmissionwasunnecessary
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AMAPolicyHealthcareservicesthataprudentphysicianwouldprovidetoapatientforpreventing,diagnosisortreatinganillness,injury,diseaseorsymptomsthatis: Accordingtogenerallyacceptedstandards
ofmedicalpractice Clinicallyappropriateintermsoflocation,
type,frequency,durationand Notfortheconvenienceofthephysician,
patientoranother.
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InpatientHospitalAdmissionMedicareBenefitPolicyManualdefinesinpatientadmissionas:FormallyadmittedasaninpatientExpectationthatpatientwillremainatleastovernightevenifdischargedortransferredbeforethenPhysicianisresponsiblefordecidingPhysicianshouldusea24‐hourperiodasabenchmark
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InpatientAdmissionContinued
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FactorsPhysiciansShouldTakeIntoAccount: “Thedecisiontoadmitapatientisacomplexmedicaljudgment”• Severityofsignsandsymptoms• Medicalpredictabilityofadverseevent• Canneededtestsbedoneonanoutpatientbasis?
• Availabilityofdiagnosticprocedureswhenandwherethepatientpresents
• NoteabsenceofreferencetoInterQual
ObservationCMSdefinesobservationas:
Periodoftimeinwhichapatientishelduntilsuchtimethatadecisioncanbemadethatthepatientcanbesafelydischargedhomeoradmittedasaninpatientforfurthertreatment. Maximumperiodoftime48hours
Observationisnotanadmissionstatus;it’salevelofcareforoutpatients
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Outpatient
MedicareBenefitPolicydefinesoutpatientas:
Anoutpatientisapersonwhohasnotbeenadmittedbythehospitalasaninpatientbutisregisteredonthehospitalrecordsasanoutpatientandreceivesservices(ratherthansuppliesalone)fromthehospital.
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What’sReallytheDifferenceBetweenInpatientandObservation Notwhetherthepatientisinabed Notthetypeofbedused Nottheintensityofservices Differenceisabilling/coveragedistinction;
Thedifferenceisnotinherentlyadifferenceincare
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InpatientVSObservation
Inpatient Observation Admittedfortreatmentandassessment
Formallyadmittedasaninpatient
AttendingPhysicianisresponsiblefordeciding
Physicianshouldusea24‐hourperiodasabenchmark
Servicesforshorttermtreatmentandassessment
Clinically,patientneedstobeobservedandmonitored
Reassessmentbeforeadecisionismaderegardingapatient’sneedforinpatientadmission
Usuallydecisionismadeinlessthan48hours,mostlessthan24hours
Nolengthoftimethatdeterminesapatient’sstatus
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ReviewCriteria
InterQual®hashadcontractwithCMSsince1999
forallinpatienthospitalservices.
Thecontractwasrenewedin2003andcontinuestobeusedtoday.
ThemajorityofStateMedicaidprogramsutilizepreviousversionsofInterQual
©foritsreviews.
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InterQual® ReviewInterQual® reviewsarefocusedontheintensityofwhichthepatientisbeingtreated
Theinformationisbroken‐downin2ways LevelofCare BodySystem
Furtherbreakdownwithinthelevelofcareandbodysystemareadditionalsubsets
SeverityofillnessorSI IntensityofserviceorIS DischargeScreen
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SeverityofIllnessHowsickarethey? Focusonpatient’spresentationratherthandiagnosis
PresentationClinicalIndicatorsthatrepresentanillness: Mainclinicalissues‐chiefcomplaint Abnormalvitalsigns, Painlocation,type,cause,relief Neurologicalstatusalert,alternatelevelofconsciousness Descriptionofdiagnostictestslabsorx‐rays Consultsorevaluations
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IntensityofService
Typeoftreatmentbeingadministered:
Medicationsrouteandfrequency• IVFluids Blood/bloodproducts Oxygen DietWoundCare
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InterQual® CriteriaComponents
DischargeScreens Criteriathatmustbemetfordischarge
Utilizedwhentheintensityofserviceisnotmetforthatday
Patientisunsafefordischarge.
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ProblematicChiefComplaint
Chestpain‐ Couldbecausedby:• GERD‐ indigestion,reflux• Angina• HeartAttack• Musculoskeletal‐ strain,pulledmuscle• Anxiety‐ unrelated• Respiratory‐ pneumonia,pleurisy• Renal‐ kidneystones
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Chiefcomplaintchestpaincomparisonofdocumentation
Observation InpatientEpisodeDay1
SeverityofIllness
Acutecoronarysyndromesuspected
• Initialcardiacmarkersnegative,continuetomonitor
• EKGnon‐diagnostic
• SystolicB/Patbaseline
• Painresolved/resolving
EpisodeDay1
SeverityofIllness(1)
AcuteMyocardialInfarction
UnstableAnginaandcontrolledpain,
EKG,≥one:
Postobservationlevelofcareandischemiaonstresstest
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çCHESTPAIN
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Intensity of Service Requirements ‐Chest Pain
Observation• Aspirin/Antiplateletadministeredorcontraindicated
• Cardiacmonitoring
InpatientTreatment,ALL• Betablocker/CAChannelblockeradministered/contraindicated
• Aspirinadministered/contraindicated
• Antiplateletadministered/contraindicated
• Anticoagulantadministered/contraindicated
• Cardiacmonitoring
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EpisodeDay2Observation;One:Responder,dischargeexpectedtodayifstablefor12hoursall• NSTEMIandSTEMIruledout
• Painresolved• Objectivecardiacriskassessment,one:Completedpriortodischarge
Lowcardiacriskandscheduledoutpatient
AssessmentnotindicatedasACSruledout
InpatientTreatment,ALL• Betablocker/CAChannelblockeradministered/contraindicated
• Aspirinadministered/contraindicated
• Antiplateletadministered/contraindicated
• Anticoagulantadministered/contraindicated
• Cardiacmonitoring
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SupportingtheAdmission BothSIandIScriteriamustbemettosupportthemedicalnecessityforadmission,observation,oranotherserviceinthesystem.Thesecriteriaaresimilar,butinpatientadmissionSIandIScriteriaindicateahigheracuitylevel.
Thecriteriaforobservationvs.inpatientadmissionarenotalwaysclearcutandfallstophysicianjudgment.
Physiciandocumentationisakeycomponenttosupporthighacuity.
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Documentation Unlikethe“intent”foradmission,
diagnosisneedstobespecifictoaccuratelyreflecttheseverityofillnessandtheresourcesused.
Provideadetailedsystembysystemassessmentincludingvitalsigns,testresults,symptoms
Provideaplanforalltreateddiagnosis.
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LookingForIntentKeyclinicaldescriptorsandassessmentofriskforanadverseeventcanmakethedifferencebetweeninpatientandoutpatientadmissionstatus.
ComorbidconditionsPotentialriskPhysicianOrders
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Example1Jane,a70–yearoldfemale,presentedtotheEDwithseverechestpain. Onemonthduration– resolvedonitsown. Today– non‐resolving B/P188/90,pulse110respirations28,PO294% EKG– STchanges;ageindeterminate Onesetofcardiacmarkersdrawn;normal TreatedwithO2,aspirinandNitrodrip. Painresolved Physicianordered“transfertocardiaccareforobservation”
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Example2Johna64‐yearoldmalepresentedtotheEDexperiencingadrycoughfor3daysassociatedwithwheezingfor1day. B/P120/72,pulse108,respirations20withanO2
satof84% EKG– normal CBC– normal Chestx‐ray– COPD(chronicobstructivepulmonary
disease) Hewastreatedwithsteroidsandalbuterolinhaler
X3.Hecontinuestohavewheezing.
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OBSERVATIONORADMISSION?
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Example3Arthur,a72‐yearoldmalepresentedtotheERwithahistoryofdizzinessandfaintingfivehourspriortoarrival. VitalsignswereB/P90/60,pulse132,PO2
90% CBC– mildanemia Nasogastrictube– brightredfluid IVstarted150cc/hour Physicianordersforfurthertesting Transferredtomedicalfloor
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INTENT
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InpatientOnlyProceduresAprocedureisdesignatedas“inpatientonly”forthreereasons:• Thenatureoftheprocedure• Theneedforatleast24hoursofpostoperativerecoverytimeormonitoringbeforethepatientcanbesafelybedischarged
• Theunderlyingphysicalconditionofthepatientrequiringsurgery
An“inpatientonly”procedurewillbepaidonlywhenthepatientisaninpatientatthetimetheprocedureisperformed
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InpatientVs.OutpatientAnnually,CMSidentifiescertainproceduresas“Inpatientonly”
• ProceduresgetonthelistbymeansofdataclaimsanalysisofproceduresandtheLOSassociatedwiththem
InterQualalsohasan“inpatientonly”procedureslist
• Theproceduresgetonthelistifsomeonecallsorwritesintoaskaboutaprocedure
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Outpatientvs.ObservationOutpatientSurgicalProcedures
• Normalpostoperativerecoveryperiodis4‐6hours
“Observation”followingoutpatientsurgicalprocedurerequires:
• Adverse/unexpectedevent• Eventmustberecognizedasarisktothepatient• Requiresadditionalobservationandassessmentbeyondthestandardrecoveryperiod
• Hasadiagnosisthatis separateanddistinctfromtheoperativeprocedure
OutpatientProcedureRequiringObservation
Fredawasa74yearoldwhohadacardiaccatheterizationasanoutpatient.Thereisnosignificantpasthistoryotherthanintermittentchestpainandquestionablestresstestresults.Postprocedureinrecoverythepatientdevelopedanintractableheadache.ShewasgivenIVpainmedicationandmonitored.SevenhourslatersheisstillexperiencingseverepainandmetcriteriaforObservationLevelwith:
SeverityofIllness
Postambulatorysurgery/procedure,≥One:
• Pain/Headache/Vomitinguncontrolled
IntensityofService
Medication(s)≥2doses:
• Analgesics
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ContinuedStayThenextdaythepatientcontinuedtohavepain.Shenolongerrequiredtheintensityofservicesprovidedasshewasnowreceivingoralpainmedication.
HOWEVERShecannotbedischargedasshedoesnotmeetthedischargescreenofpaincontrolledandmanageable.AnotherdayofObservationisthecorrectlevelofcareforthispatient.
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Conclusion
Documentationfoundinthemedicalrecordcanprovidetheinformationneededtosupportmedicalnecessityandbeyond.
EHRisnotthepanacea! Utilizingqualitativeclinicaldocumentationcriteriacanbeafriendwhenjustifyingalevelofcare.
2012criteriaisfarmorerigid.
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