Archive for June, 2009

Medical necessity beyond screening criteria

An underlying foundation for case management is the practical and consistent use of commercially available screening criteria as guidance for initial admission patient status designation as well as continued stay determinations. I call your attention to the term “guidance” from the perspective of Medicare and the Recovery Audit Contractors (RAC).

In a RAC Special Open Door Forum held by Medicare on April 9th, several comments by Medicare representatives and RAC representatives, including the medical director for Health Data Insights, make it very clear that the screening criteria will not be used in and of itself to determine medical necessity or lack thereof for inpatient hospitalization. Consider the HDI medical director comment regarding his organization’s application of screening criteria in the medical necessity determination process:

“We follow CMS guidelines which are that these different products are guidelines. They’re not conclusive for a decision to or for a finding or not a finding.  We have contracts with both Milliman and Interqual and intend to use those along with clinical review judgment and of course, first and foremost the CMS guidelines.”

The implications for the case manager

Unequivocally, screening criteria should be applied and followed as part of the patient status
designation determination process. Just the same, the physician’s clinical judgment, medical-
decision making and clinical impression can and must be incorporated in this decision-making
guidance process.

The real challenge faced by case managers is the physician’s medical record documentation of the same. Commonly, the documentation available to the case manager upon initial and continued stay chart review fails to accurately and completely capture and represent the patient’s true clinical acuity, risk of morbidity and mortality, and other physician clinical concerns that ultimately led the physician decision to admit the patient to the hospital. This lack of focus in clinical documentation further challenges the case manger in providing objective guidance in the complex, arbitrary patient designation status process. [more]

Case study: Avoidable days

The following case study uses InterQual® commercial screening criteria as an example.

InterQual is a set of clinical, criteria-based guidelines that give hospitals suggestions for the most appropriate level of care based on the patient’s medical needs and stability. It is a common language for practitioners that, if used correctly, will help a hospital reduce medically unnecessary acute days, improve the quality of discharges, promote patient safety, and reduce denials from third-party payers.

InterQual’s medical necessity criteria are:

• Severity of Illness (SI): Criteria that consist of objective, clinical indicators of illness, which focus on an individual patient’s clinical presentation rather than diagnosis
• Intensity of Service (IS): Criteria that consist of monitoring and therapeutic services, singularly or in combination, which can only be administered at a specific level of care
  • Stand-alone IS criteria: Criteria that consist of services that should only be provided in an acute care hospital, given that the SI supported an inpatient admission
  • *(Asterisked) IS criteria: Criteria that consist of services that could be provided at a lower level of care based on the type of service or the patient’s stability
• Discharge Screens (DS): Criteria for determining clinical stability and level of care appropriateness

The three criteria patterns are:

1. Does not meet IS and meets DS. This pattern represents patients ready for the next level of care with unnecessary and avoidable days. This is the most common pattern and may represent unnecessary utilization.

2. Meets IS and meets DS. This pattern represents patients who may be ready for a lower level of care, but who are still receiving acute care services. This pattern may represent overutilization.

3. Does not meet IS and does not meet DS. This pattern represents patients who are acutely ill and may not be receiving acute care services necessary for definitive treatment. This pattern may represent underutilization.

For example:

8/07/09 IS cardiac monitor, Lasix 20 mg PO BID, 2LO2/NC*
_____________________________________________________________________
DS NSR (82), RR 20, O2 sat 97% RA, eating 80% of meals, 1.3 kg Ø

On this day (8/07/09), the patient does not meet IS and meets DS. Fortunately, since the case manager was monitoring the patient yesterday, the discharge has been preplanned and everything is ready to go. There will be no potential avoidable day (PAD) assigned to this case.

But what if the attending physician refused to discharge the patient on this day (8/07/09)?

In general, if the DS is met and the discharge is not scheduled or is not included in the immediate plan of care, the case manager must contact the attending physician regarding the discharge plans or justification for continued stay. If the attending physician does not agree with the case manager’s assessment of discharge readiness and cannot justify a continued stay, the case should be referred to the physician advisor (PA). If the PA concurs with the case manager’s findings, the attending physician must be contacted to discuss the case. The PA may approve a continued stay based on medical judgment and not the criteria. The PA should document the outcome of his or her review and rationale for the decision on a PA referral form. If the PA concurs with the case manager, then:

a. A PAD is assigned to the attending physician
b. The case manager and PA follow the hospital and QIO procedure for issuing a Medicare continued stay denial letter, if necessary

This patient (let’s call her Mrs. B) had an LOS of two days. This is a very short LOS, but as you can see from the previous scenario, Mrs. B did not need to stay another day in the hospital. She was stable and safe to go home—and home is a much safer place than a hospital.

Editor’s note: This case study was adapted from The Avoidable Day Analyzer: Data Identification Tools for Effective Case Management, Second edition.Order your copy today online at HCMarketplace.

Can Twitter improve healthcare communication?

Twitter, the social network based around the phrase “What are you doing right now?”, continues to gain popularity in world of healthcare.  But can it help improve communication with patients’ families?

Children’s Medical Center in Dallas thinks so.

The latest facility to “tweet” during surgery (a concept created in February by Henry Ford Health System), Children’s sees the technology as a way to help communication between physicians and families.

Read more about the idea here.

Do you use Twitter? Know anyone that does? Feel free to share your thoughts.

Manual changes related to condition code 44

I’d like to turn my attention to the manual changes related to condition code 44, as promised. Overall, the changes were designed to incorporate discussion and FAQs that were previously published in MLN Matters Article SE0622. In this respect, the changes to the manual have very few surprises. Almost everything added came directly from SE0622 and nothing added was really anything new. With that said, however, I do think that hospital case managers and anyone involved in condition code 44 cases or billing for cases with changed status should review the changes carefully to be sure they are following all the guidance provided.

One of the disappointing things about the changes is that they did not address the issue of whether the period of time from the inpatient order up to the time the patient is changed to outpatient and the observation order is written can be billed as observation time. The language stating that the entire episode of care should be billed as outpatient remains unchanged and nothing was added to clarify it. However, if we carefully consider the other changes made to the observation sections, I think we can discern that CMS does not mean for these hours of care to be billed as observation.

The statement that the entire episode be billed as outpatient would seem to be saying that any service that was rendered during the episode of care should be billed under the outpatient billing, coding and coverage rules. For instance, if the patient had an x-ray during the time prior to being changed to an outpatient, this x-ray would be billed on a revenue code line with a HCPCS code, in accordance with any outpatient edits and policies that might exist. An order for the x-ray would be required and it would be subject to the outpatient medical necessity coverage rules like any other outpatient x-ray.

Applying this same analysis to the observation services, they would be billed as outpatient services on a revenue code line for observation with the appropriate observation HCPCS code. To be billed to Medicare they would have to meet all the coverage and billing requirements, just like the x-ray. This is where the new changes to the observation section of the manual perhaps add a bit of clarity, though the issue is still not crystal clear. The revisions to Claims Processing Manual, Chapter 4 § 290.4.1, indicate that G0378 is used when observation services are “ordered and provided”, with the word “ordered” added. Additionally, revisions to Claims Processing Manual, Chapter 4 § 290.2.2 indicates that time is calculated from when the services are initiated in accordance with the physician’s order. Both of these changes emphasize that an order is required for the observation services to be billed, and seem to indicate that order must be received before time for the services can be counted. [more]

Safe discharge plans for the uninsured

What about those hospital discharges?

Who should be doing the discharge planning and who should be working with the patients and families to make sure the goals set for the patient are being achieved? Who is developing the discharge plan? These are all great and very important questions. Discharge planning should begin as soon as the patient sets a foot inside the hospital, whether that is just to the emergency room or is placed as an observation patient or inpatient.

This is another great reason for the admission case management model. The admission case manager begins the discharge assessment right at the time the patient is either placed in an observation or inpatient status. If the patient is discharged from the emergency room, our social worker works with the emergency room staff, patient, and/or families for appropriate discharge planning.

The seven day a week admission case management model at my hospital is guided by Imogene King’s Theory of Goal Attainment. This theory of goal attainment implies that nursing is to help people achieve, maintain or restore health through the mutual setting of goals (Hood & Leddy, 2006). The nurse and/or social worker and the patient come to agreement on a mutual goal to achieve; this brings the patient to the forefront and the most important being. There is interaction of the nurse/social worker and the patient in the appropriate environment that is most conducive of achieving the goal. Once the goal is agreed upon and set, the next step is defining what steps will be taken to reach the desired goal. Case management as it evolved became a process of assessment of patient needs (goal setting with the patient and or family), planning of care, arranging resources of services and ongoing coordination and evaluation of the care being provided.

Our model is successful because of teamwork. Our case managers and social workers work together with the patient and families as well as the other hospital disciplines, through interdisciplinary rounds to ensure that everyone is working toward the same goal for discharge.

Discharge is more than getting the patient out of the hospital door. It is making sure that the patient is going to a safe, agreed upon place with the appropriate resources available and in place. Successful discharges reduce those unwanted readmissions.

Reference:

Hood, L. J. & Leddy, S. K., (2006). Conceptual bases of professional nursing, (6th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.