All Entries in the "case management" Category
Diagnose first, admit second
Consider CDI collaboration with case management to target documentation concerns in the emergency department.
Among other tidbits in my background, I’m a recovering case manager. It’s a hard, often thankless job, and it never ends. I don’t think I could do it again, and I give lots of credit to those who still work in this field. Nevertheless, I have had many occasions to interact with case managers in my previous role as a CDI specialist, and now, a CDI consultant.
As a recovering case manager, I often shied away from dealing with the CM department, but I’ve come to realize that not developing collaborative processes can be a huge mistake. When we avoid case management, we avoid the opportunity to build an ally. We both want medical records that reflect the optimum patient acuity, and that will survive RAC and other audits. And this process starts at the hospital’s front door.
Case managers review patients in the emergency department for admission criteria. If they know that chest pain and syncope and abdominal pain are RAC targets, and that documentation of diagnoses instead of symptoms may move the DRG out of the RAC crosshairs, they can communicate this to the physicians. I like to think of it this way: when the physician writes nothing of consequence, the CDI specialist looks for clinical findings and asks for the diagnosis, while the case manager asks for clinical findings and the treatment plan that support the medical necessity for the admission and strengthen the diagnosis that we just got.
It’s a symbiotic relationship.
I’ve had occasion to work with the case management team at a client hospital, and we decided to put our collective heads together to see how we could educate ED physicians not to admit patients who didn’t meet criteria. We chose as our slogan: “Diagnose first, admit second!”
We created one page flyers to be posted in the ED and distributed to the ED physicians on popular topics such as chest pain and syncope. In the flyers, we briefly gave suggestions of alternative diagnoses, defined what is needed to meet admission criteria, and encouraged physicians to consult with case management before writing that admit order.
At the same time, I’ve been presenting a weekly series of lectures to the case management department, very similar to what I would use to teach a new CDI specialist, but adding a little twist that ties clinical documentation improvement to case management. It’s been a big hit. They are eager to help teach physicians not to write “CHF” or “urosepsis,” and they want to learn more. I’m going to give them all they can handle, including helping them read their PEPPER and use it to their best advantage.
Never assume that because someone doesn’t understand what you do, that they don’t want to understand what you do. It’s like working with physicians and nurses; when you show them how your job relates to them and how it benefits everyone, you get more cooperation. And as we used to say, cooperate and graduate.
Incorporate awareness of transfer DRGs into CDI record review efforts
CMS never met a dollar it didn't want back.
CMS never met a dollar it didn’t try to recoup. So we have RACs and HACs and stacks of regulatory requirements that take many, many healthcare dollars to manage. The post-acute care transfer DRGs are but one example.
(RACs, of course, are Recovery Audit Contractors which the government recently renamed Recovery Auditors or the Recovery Audit Program. And I’m sure you all know that HACs stands for hospital acquired conditions.)
For the uninitiated, post-acute care transfer DRGs exist because CMS doesn’t want to pay the hospital the full freight if the patient receives follow-up care somewhere else, and it ends up having to pay the another facility or healthcare agency (such as home health) as well. When the program began, 10 DRGs were designated as transfer DRGs; that list has since expanded to 273.
You can download the current list here.
Why do you need to know about transfer DRGs?
The CDI specialist is one of the few people who has at least a general idea of where the DRG is going to land before the patient is discharged. As you know, every DRG is attached to both an arithmetic length of stay (A/LOS) and a geometric length of stay (G/LOS). The A/LOS is the average LOS of patients within that DRG, including transfers and long-stay outliers. The G/LOS is the national mean length of stay for that DRG, except for transfers and long-stay outliers. The A/LOS is used for calculating outlier payments, while the G/LOS determines the transfer DRG payments. If you don’t have a good idea of the DRG before you transfer the patient or discharge the patient with services, your facility’s number crunchers could have an unpleasant jolt at reimbursement time.
When a patient is transferred to another facility or home with services after staying fewer days than the transfer DRG’s G/LOS, the post-acute care transfer DRG rule kicks in. Instead of receiving the full DRG reimbursement (relative weight multiplied by the hospital’s blended rate), a per-diem rate applies. The per-diem rate is the DRG reimbursement divided by the G/LOS. The hospital will receive twice the per-diem rate on day one and the per-diem rate every day thereafter up to the full DRG reimbursement.
A peck of PEPPER, Part 3
Sort through your PEPPER reports to find additional query opportunities.
If you’ve started using your PEPPER to help you identify potential issues at your hospital, good for you! In this final entry, I’m going to suggest you take it a step further—identifying charts that may fail for lack of medical necessity.
I’m pretty sure that a RAC bounty hunter will jump at the chance to overturn your admissions due to not meeting criteria. Nobody’s expecting you to become a case manager, but it behooves all of us to gain an understanding of what documentation may survive a medical necessity audit.
Quite a few of the PEPPER medical necessity target areas involve what might be considered questionable diagnoses—including our old favorites, chest pain, TIA, back pain, and syncope—and some others that you might not have thought of as questionable, such as DRG 314-316 and DRG 393-395, as well as short stays in renal failure, vascular surgery, and heart failure DRGs. If you are a high outlier, review your short stay patients, to see if their documentation supports an inpatient stay.
InterQual(TM) guidelines now include the condition-specific diagnoses of acute coronary syndrome (ACS), asthma, epilepsy, heart failure, pneumonia, and stroke/TIA, with plans to add many more. The new guidelines help you determine who qualifies for inpatient and who should stay in an observation status. If you don’t have access to admission and continued stay criteria, make friends with someone who does, or better yet, ask your manager to give you access and send you to class to learn the basics. (Some hospitals use Milliman (TM) guidelines, so your mileage may vary.)
Your impact will be on documentation that supports inpatient severity of illness. The physician admitting a patient for acute onset chest pain or suspected MI needs to understand the importance of documenting a specific diagnosis such as acute MI supported by positive cardiac markers, or unstable angina, any EKG changes that support the diagnosis, and following specific treatment protocols.
It’s not enough for a physician to diagnose pneumonia in a stable patient—the treatment on day one is the same for both observation and acute inpatient status so the difference is in the presentation, and that means documentation. What is the oxygen saturation? Did the patient fail outpatient antibiotics? Is there evidence of abscess or empyema? Is the pneumonia multilobar? Are there additional clinical risk factors?
For your TIA patients, a TIA lasting longer than 60 minutes raises the likelihood of meeting inpatient criteria. Teach your physicians to assess and document the duration of TIA symptoms. “R/O stroke” won’t allow you to work around TIA, without documentation of specific physical findings consistent with a possible stroke, such as paresis or dysphagia, or confirmation of CVA by CT or MRI. For your stable heart failure patients, among the requirements for an acute inpatient admission is oxygen saturation below 89% or a sustained heart rate of 100-120 bpm within 24 hours of admission. Evidence of greater instability, such as hypotension, mental status changes, or heart rate > 120, with IV medications or increased oxygen requirements, may move the patient into an intermediate or critical care status.
In DRG 314 – 316, other circulatory system diagnoses, you might have patients who come back with a vascular complication such as an occluded central line. Just having a complication is not enough to justify an inpatient stay—is there evidence of a decreased peripheral or femoral pulse? Did they qualify for an inpatient admission in some other way? Syncope, DRG 312, may meet inpatient criteria if it is attributed to a cardiovascular drug, reflects evidence of certain arrhythmias or pacemaker failure, or if the patient has known cardiac disease. Do you see a documentation opportunity there?
Look closely at your short-stay patients, regardless of DRG. Did they meet criteria because they underwent a procedure on the inpatient list? Or did the physician not really think about admission status when they wrote the order? Your PEPPER will list your top medical DRGs for one-day stays. Consider auditing the top DRGs, particularly if they are the non-specific DRGs such as chest pain and syncope, for medical necessity. Can the top DRGs be explained by a specific patient population your hospital services? Did the documentation support the status order? Did the patient leave before the case manager had a chance to review the case? Does your CM department just do a great job of moving patients through the system? What processes does your hospital have in place for reviewing short-stays, either concurrently or retroactively? What documentation improvement processes can you recommend and/or implement?
I was trying to think of some snappy way to join SALT with PEPPER, but all I came up with was the strategic arms limitation talks. So on that note, don’t try to force documentation to fit when it doesn’t. But the more you know, the more you can do.
Saluting leadership that both challenges and supports staff
Happy National Case Management Week to all those leaders in the field.
I almost didn’t become a nurse. I was almost booted out of nursing school. For alleged transgressions too ridiculous to describe, a petty instructor failed me in my pediatrics clinical. While the director basically conceded that the instructor’s complaints were insignificant, she nevertheless put me on probation for one rotation. If I didn’t have a good evaluation for my adult nursing rotation, I would have to leave the program.
I approached the rotation with trepidation. I was afraid that anything I did or said would be held against me. But I need not have worried. My new instructor was a wiser, older woman who was going back to rehab nursing after that rotation. We students felt blessed to be her final group. She told me not to worry, and she loaded me up with extra projects and additional assignments, not as a punishment, but so that she could write pages of glowing reviews of all the extra work I did. She challenged me to be brilliant instead of trying to prove that I wasn’t. It ended up being a wonderful rotation, and of course, I eventually graduated from nursing school.
Lately, I have had occasion to think of that marvelous woman, Evelyn Baird. Without going into details, let’s just say it’s been a difficult summer, a summer in which both my professional and my personal lives have been in crisis.
At Banner Good Samaritan Medical Center, our CDI team reports to case management. Last winter Banner hired a new department head. It didn’t take long for me to decide I just didn’t like her. She seemed too pushy, too know-it-all, too focused on capturing revenue and doing whatever it took to keep her job. I couldn’t stand being in meetings with her and I rolled my eyes when she wasn’t looking. I stayed far, far away. But that’s because I didn’t know her.
So how did I get to know her? When my professional and my personal crises intersected, she was right there to tell me I was valuable, I was special, and that she could see that I needed help. She made sure I knew I had her support. She still had a department to run, but she wanted me there and in one piece. So she moved me right where she could see me and I could see her on a daily basis, and she asked me for my opinions, she picked my brain, and she loaded me up with projects.
On the day when everything fell apart, I told her that the one good thing about the whole mess was that at least I was getting to know her. And I get to know her more every day. The only person who hugs me more often these days is my daughter. What about all the extra work and extra projects she’d assigned to me? I get to add them to the portfolio I’m submitting with my application to our hospital’s Clinical Expert Recognition Program (CERN).
Today, I met with my CERN program mentor for the first time. She reviewed my portfolio and told me I was magnificent. Pretty staggering words for me to hear, barely two months removed from the depths of my summer difficulties. Who dragged me to that moment when I could have just as easily been dragged through the mud? My boss, my supervisor, my leader, and now someone I consider my friend, our Director of Case Management, Kathy Singleton.
When I think of Kathy, I think of Evelyn: wise, smart, and infinitely talented in bringing out the best in their team—leaders. A true leader is not always the person who puts in the most hours or creates the fanciest PowerPoint presentation to the C-suite. In my opinion, it is always the one who teaches others to recognize their full potential and equips them to achieve it.
While such leaders can come from any department, my leader is a case manager; and so in honor of case management week, I’d like to acknowledge those great case managers. Kathy, I thank you, and I salute you.
Case management/CDI relationships offer new ways to collaborate
Editor’s Note: ACDIS wishes its colleagues in case management a productive and happy National Case Management Week. For information, visit The Case Management Society of America or The American Case Management Association. The following excerpt is from the October 2011 edition of the CDI Journal.
While the majority of CDI programs report to the director of HIM, a good number (27%, according to the
Many different departments need to let their talents shine in order to effectively care for patients' needs.
2010 CDI Program Benchmarking Report) fall under the supervision of the director of case management (CM). CDI programs that report to CM face a number of challenges but may also take advantage of the multiple opportunities such structures present, says Joann Agin, RHIT, regional director of data quality for Carondelet Health, St. Joseph Medical Center, in Kansas City, MO, and St. Mary’s Medical Center, in Blue Springs, MO.
Ann Giuli, BSN, MPH, CCDS, CDI specialist at the 305-bed Stamford (CT) Hospital, has worked under CM for the past four years. The director of CM supervises the facility’s CDI, CM, social work, and UR teams. No matter where the CDI program falls in the reporting structure, the roles and responsibilities of the staff must be well defined, Giuli says.
Although most experts agree that CDI, CM, and UR have distinctive roles to play in patient care as well as in meeting medical necessity and coding requirements, there is plenty of room for collaboration.
“CDI is connected to all these other roles,” says Gail B. Marini, MM, RN, CCS, LNC, CDI manager at South Shore Hospital in Weymouth, MA. “It is like a Tiffany window; we are each a different part of this beautiful thing.”
