Archive for December, 2010
A dozen ways to prevent readmissions
The new year is almost here, and many hospitals are resolving to reduce preventable readmissions.
The federal government will begin penalizing hospitals with high readmission rates starting in October 2012, and hospitals may begin to see regulations that will enforce these penalties emerge in 2011. Regardless of regulations, it would behoove hospitals to get an early start.
Testament to the virtual certainty that readmissions will be a major issue in 2011 is “12 Ways to Reduce Hospital Readmissions.” It tops the list of most popular articles on HealthLeaders Media.com.
The article offers tips from readmission experts, Stephen F. Jencks, M.D., Amy Boutwell, MD, Timothy Ferris, MD, and Estee Neuhirth. Here is their list:
- Dictate discharge summaries within 24 hours of discharge
- Improve communication between hospital discharge planners and receiving facilities
- Provide patients a 30-day medication supply upon discharge
- Schedule follow-up appointments before discharge
- Use telehealth technology to monitor patients after discharge
- Identify patients who frequent the ED
- Identify cracks in the system that occur after discharge
- Provide home healthcare on wheels
- Consider physician medication reconciliation
- Use the teach-back method when giving patients discharge instructions
- Shift resources to patients with conditions who readmit more frequently
- Listen to patients
Read about these strategies in greater detail at HealthLeaders Media.com.
Communicate with coders to assign proper discharge codes
Proper assignment of discharge codes can make a big difference in a hospital’s reimbursement. Unfortunately those who know most about discharge plans—case managers—are not always responsible for assigning these codes.
Assigning the correct MS-DRG requires reporting the patient’s age, gender, discharge status, principal diagnosis, secondary diagnosis and procedures performed. The discharge status has equal weight with diagnosis and procedures, and not everyone appreciates that, according to a Curaspan Connections article entitled “Closing the Gap Between Case Managers and Coders” written by Jackie Birmingham, RN, BSN, MS, vice president of regulatory monitoring and clinical leadership at Curaspan Health Group.
Coders are ultimately responsible for assigning discharge codes. They typically rely on what the physician initially ordered for postacute care. However, the case manager who facilitates the transition of care may have additional information that is valuable to the coders—including where the patient ultimately went, what level of care the patient received, and when the services began, Birmingham wrote. Failing to communicate that information can lead to an inaccurate claim, which can result in financial or legal penalties.
Transfer DRGs
Assigning the correct discharge code is particularly important with respect to transfer DRGs, which are subject to transfer rules that can lead to reduced reimbursement. Most notably, if a patient is a assigned a transfer DRG and is discharged to non-IPPS postacute facility following a short stay, the hospital may receive a reduced payment.
For example, if a patient is discharged to a SNF to receive skilled care (code 03) before his or her stay reaches the geometric mean LOS (GMLOS), the hospital will receive a reduced payment. However if that same patient receives basic care at the SNF, the hospital would receive a full DRG payment. The difference could mean thousands of dollars.
For more information about discharge status codes and transfer DRGs, read the “Pay attention to transfer DRGs and discharge status codes” article in the February issue of the Case Management Monthly newsletter.
Revenue Cycle Institute releases 2010 RAC Preparedness Benchmark Report
The results of HCPro’s second annual “RAC Preparedness Benchmarking Report” are in, and case managers continue to be a large part of RAC preparedness efforts.
A total of 459 providers responded to the survey, representing facilities of all sizes from each of the four RAC regions.
According to the results, many facilities have had minimal contact with their RAC. More than 50% of respondents have not had recoupments related to automated audits, and nearly 40% had not received a record request for complex audit.
Despite the lack of contact with RACs, a greater percentage of facilities have a formal RAC program; 90%. That’s up 20% from 2009. More than half of the respondents (63%) have also designated a RAC coordinator. The most common background for RAC coordinators is HIM/coding (29%), followed by case management (18%).
Looking toward the future, 41% of respondents said medical necessity and one-day stays are their main focus for RAC preparations going forward. Case managers play a key role in determining medical necessity and will no doubt continue to be a large part of RAC preparation efforts.
Download the entire “RAC Preparedness Benchmarking Report” at The Revenue Cycle Institute website.
A 24-hour stay does not equal observation
After years of discussion and attention given to observation services and inpatient status, there are still those who believe all 24-hour hospitals stays should be observation. However, examples of legitimate 24-hour inpatient stays exist. Consider the following.
James presents to the emergency department (ED) with persistent nausea and vomiting that is unresolved with antiemetics administered in the ED. He also has tachycardia with occasional premature ventricular contractions, a serum potassium level of 7.8, and a history of end stage renal disease. James also missed his last dialysis appointment. This patient meets inpatient criteria because his potassium level is critically high and his nausea and vomiting are unresolved.
The physician orders IV fluids, telemetry monitoring, vital signs monitored every four hours, and dialysis. The patient undergoes dialysis later that day, and by the next afternoon his potassium level is 5.1 and his nausea and vomiting have subsided. The physician discharges James that afternoon. Just because James was in the hospital for only 24 hours doesn’t mean he did not need inpatient care. Based on the signs and symptoms presented, the severity of James’ illness, and the intensity of services he received, inpatient admission is appropriate.
I believe the confusion comes with the Centers for Medicare and Medicaid Services’ (CMS) definition of observation. CMS defines observation as specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment, before a decision can be made regarding whether patients will require further treatment as hospital inpatients or whether they can be discharged from the hospital. Physicians have taken this definition to mean that they need to try to predict if the patient will get better within 24 hours. Even if a patient meets inpatient criteria, physicians will make order observation services if they think he or she will get better in 24 hours. This is why so many hospitals end up with observation stays greater than 48 hours.
Communication from case management to the physicians is going to be the best method of clarifying this misconception for physicians. If your hospital has a physician liaison have him or her educate the physicians on the real definition of observation. We need to focus the patient’s clinical signs and symptoms and the physician’s documentation. Remember we cannot predict the future. Inpatient admissions are based on if the patient presents to the hospital with signs and symptoms and severity of illness that require the intensive services at that level.
It is time again to revisit this discussion with your physicians, administration, and your case management team. Do not be afraid to have these discussions with your physicians. Most physicians just want to take care of the patients and will admit that they do not really know when a patient should be observation versus inpatient, but is should not be based on hours in the hospital.
Remember it is the appropriate care, in the appropriate setting, in the most cost-effective manner.
