• The change in patient status from inpatient to outpatient is made prior to discharge or release while the beneficiary is still a patient of the hospital
• The hospital has not submitted a claim to Medicare for the inpatient admission
• A physician concurs with the UR committee’s decision, and his or her approval is documented in the patient’s medical record 

• Improve medication reconciliation through better sharing of real-time information
• Increase continuity of care through access to patient records and historical data
• Assist vendors (e.g., home care agencies and SNFs) with screening patients prior to discharge

In January 2007, the University of North Carolina (UNC) Hospitals in Chapel Hill implemented a standardized, electronic assessment tool to aid its case managers in providing thorough and consistent patient assessments.

Beverly Wagner, RN, BSN, CCM, ACM, clinical care management educator at UNC Hospitals, and colleagues developed the tool with staff members to ensure their buy-in. The result was the brief assessment tool, or BAT. The BAT made documentation easier and more consistent; patient assessment documentation rose immediately. “We had a nice surge from about 8% of discharges having measurable assessment documentation to about 30%,” says Wagner. “But we kind of hit a plateau there.”

• Educate case managers about signs, symptoms, and how patients might progress along the trajectory of care for a certain disease;
• Suggest possible options for negotiating resources to assist meeting patient needs for discharge; and
• Discuss financial concerns that might affect the organization.

PAs also should work with attending physicians to understand the complexity of patient needs and identify barriers that could impede discharge of complex patients.

Editor’s note: This tip was adapted from HCPro’s book, Optimizing the Physician Advisor in Case Management: A Guide to Creating and Sustaining Measurable Program Results, available on HCMarketplace.com.

• One in 5 patients seen in emergency department settings was uninsured,
• Low-income patients accounted for almost one-third of patient visits,
• Residents of rural areas comprised one-fifth of emergency room care

Sebelius observed that uninsured patients often cannot afford primary care and must seek care in the ED. ED physicians, including Nick Jouriles, MD, president of the American College of Emergency Physicians, say this statement helps direct resources to managed care instead of emergency departments where they are most needed.

Source: HealthLeaders Media

• Elderly fall
• Elderly extremity fracture
• Repeat visits for pain (back, abdominal, dental, migraines)
• Failure to thrive, frail elder
• Patients with multiple ED visits within the hospital-defined allotted time frame (e.g., more than two visits/month)
• Patients with readmissions within the time frames set by your facility (e.g., 48-72 hours from ED visit or inpatient admission, 30 days from inpatient admission, etc.)
• Patients with short- or long-term placement needs
• Patients with insurance red flags (e.g., managed care insurance plans, pay-for-performance insurance initiatives, uninsured/self pay)

To target specific populations, set up identifiers in the registration process to alert the case manager to targeted populations that may benefit from CM activities. Alerts can be set up and printed out as case manager worksheets.

Have a tip or tool you’d like to share? Or maybe a question for our experts? E-mail it to editor Julie McGinley at jmcginley@hcpro.com.Your thoughts could be featured in the next issue of Case Management Weekly!

• A team
• Training
• Content
• A QA process

A: There is no regulation that requires specialty-specific H&Ps. Medical staff members should identify—at a minimum—what the H&P should include. For example, our policy states that at a minimum, the H&P for both inpatient and outpatient visits must include:

• A history related to the admission/surgery
• Examination of the heart, lungs, and mental status
• A specific examination related to the condition for which the patient is being treated

It also includes a plan for anesthesia, when appropriate, and a plan of care.

Editor’s note: Jean S. Clark, RHIA, CSHA, service line director for health information management services at Roper Saint Francis Healthcare in Charleston, SC, answered this question.

A: InterQual is merely a screening criteria—CMS doesn’t actually require hospitals to use it. Therefore, use of an older version or a different set of criteria such as Milliman is not inherently a problem. However, because outside entities such as RACs, MACs or QIOs will be reviewing cases, most hospitals choose to use the same version used by their contractors (presumably the version for the year applicable to the case). Additionally, outdated versions may not reflect advances in care and may cause inappropriate screening decisions.

Note that a patient may not meet InterQual inpatient criteria, but still be considered an inpatient upon physician review. InterQual is a screening criteria—it screens for the most likely inpatient and outpatient admissions, but can not take into account every medical circumstance. There are a percentage of patients, who will fail inpatient criteria due to factors not considered in the InterQual criteria that upon physician’s review will nevertheless be appropriate for inpatient admission.

For this reason, each permanent RAC will now have at least one physician medical director who will be involved in developing evidence for individual claims determinations and act as a resource for all reviewers making such individual claim determinations. Additionally, the provider has the opportunity to request that the medical director participate in discussions regarding individual claims denials.

In addition, RACs do not audit for fraud. Their only task is to look for overpayments and underpayments, either due to errors by the hospital or by CMS’ processing systems. RACs are simply looking for incorrect payments, no matter whose fault, and getting that money back to the Medicare Trust Fund after taking their cut. Of course, if a RAC believes it uncovers a fraudulent scheme or set of practices, it may make an appropriate referral to one of the contractors monitoring for fraud, but it is not a part of their scope of work.

Editor’s note: This question was answered by Kimberly Anderwood Hoy, JD, CPC, director of Medicare and compliance for HCPro, Inc.