2 Midnight Case Examples and Documentation Tips. Ralph Wuebker, MD Executive Health Resources, Inc. All rights reserved.

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1 2 Midnight Case Examples and Documentation Tips Ralph Wuebker, MD AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product Executive Health Resources, Inc. All rights reserved. 1

2 Admission Review Key Considerations Physician s Order Expectation of 2-midnight Stay Medical Necessity Documentation and Certification 2

3 Recommended Hospital Work Flow Expected LOS Greater Than Two Midnights or Unclear Patient Presents at Hospital* Inpatient Criteria Met? Yes No Validate or obtain order change Physician Advisor Review Review elements of certification Inpatient Recommendation Validate or obtain order change Review elements of certification Observation/ Outpatient Recommendation Validate or obtain order change Re-review as new information is available Follow this process when: Physician documentation of expected discharge is greater than 2 midnights; or There is no documentation of expected discharge * Patient hospitalized for condition other than Inpatient Only Procedure List 3

4 Recommended Hospital Work Flow Expected LOS Less Than Two Midnights No+ Yes Resolve conflict between order and expectation Expectation correct? Yes Condition Code 44 Obtain order change Patient Presents at Hospital* IP Order? No Observation Criteria Met? Yes Observation Re-review as new information is available No Obtain order change Follow this process when: Physician documentation of expected discharge is in less than two midnights * Patient hospitalized for condition other than Inpatient Only Procedure List. +If the expectation is not correct, follow the workflow for an expected length of stay of greater than two midnights. 4

5 Case 1 Symptoms: 80 year old female admitted with chest pain, positive biomarkers and EKG changes in the emergency room, urgently taken to catheterization lab Order Expectation of LOS Medical Necessity Certification Follow up necessary Admit as inpatient I expect this patient to remain in the hospital for a time greater than 2 midnights Documentation present to support inpatient admission All elements of certification present per document review Patient does not remain for 2 MN Was (presumption not met) due to of the exception: death, transfer, AMA, inpatient only procedure or recovery faster than anticipated? Evaluate based on start of service to see if benchmark met 5

6 Case 2 Symptoms: Order Expectation of LOS Medical Necessity Certification Follow up necessary 65 year old male, no previous cardiac history, presents with shoulder pain after exertion, physician suspects musculoskeletal, biomarkers below detection threshold, no EKG changes. Monitor overnight if telemetry, enzymes and EKG s remain negative anticipate discharge in am. No planned stress test or further evaluation during hospitalization. Admit as inpatient 23 hour monitoring Documentation does not support inpatient admission observation Order and physician expectation of 2 midnights are in conflict Order and medical necessity are in conflict Consider Condition Code 44 if requirements are met If patient remains in hospital, or new information available re-review for medical necessity at inpatient level If patient discharged cannot do Condition Code 44, if within rebilling timeframe, consider for Part B Rebilling 6

7 Case 3 Symptoms: Order Expectation of LOS Medical Necessity Certification Follow up necessary 78 year old female admitted for atrial flutter, stabilized in Emergency Room. Although expected to be discharged after medication adjustments, patient developed heart block requiring additional adjustments and possible pacemaker Place in observation Anticipate short stay, 23 hour monitoring Delayed review suggests that inpatient may be appropriate All elements of certification would need to be completed prior to discharge EHR would recommend inpatient level of service Call with physician to discuss medical necessity in light of order change requirement Call with Case manager to discuss order change, and expectation documentation with regard to certification requirements Inpatient order, documentation of expectation and all other elements of certification would need to be addressed prior to discharge 7

8 Case 4 Symptoms: Order Expectation of LOS Medical Necessity Certification Follow up necessary 76 year old woman with UTI, treated with intravenous antibiotics. Fevers continue with tachycardia and hypotension requiring fluid support. Immunosuppressed due to post kidney transplant status. Admit for inpatient services Admission orders include order for discharge in am Would meet for inpatient by criteria, but documentation clearly violates 2 midnight expectation Depending on follow-up activity, if inpatient supported confirm all elements of certification prior to discharge Although historically inpatient medical necessity would be met, the documentation does not support 2 MN expectation Resolve conflict between order/medical necessity and expectation Update documentation if patient not discharged as planned Consider Condition Code 44 if expectation of discharge remains 8

9 Case 5 Symptoms: Order Expectation of LOS Medical Necessity Certification Follow up necessary 68 year old male, with a history of stroke, known carotid stenosis, and previous neck irradiation making carotid end-arterectomy high risk. Patient scheduled for carotid angiography and stent placement. Observation <2 midnights Procedure appropriate for inpatient based on inpatient-only status All elements of certification except the 2 MN expectation would be required to be documented prior to discharge to support inpatient claim Order should be corrected for procedure on CMS inpatient only procedure list For procedures on the inpatient only list, order must be present on the medical record prior to the initiation of the procedure Inpatient only procedures are exempted from the 2 midnight expectation, but all other certification requirements remain 9

10 Documentation Tips for Medical Necessity AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product Executive Health Resources, Inc. All rights reserved. 10

11 Common Documentation Reasons for UM Staff to call Attending Physicians Limited or no physician documented info (consult, ED note or H & P) several hours after admission Only information available is a list of symptoms/ labwork/ Interqual evaluation No plan of care or clear impression in the H & P Common with mid level providers OP note/h & P for procedures that doesn t address/include any risk from past medical history Frequently occurs from using office notes as history and physical Lack of discharge summary for a readmission review and no mention of stability on discharge/return to baseline in the discharge note. Continued stay review that doesn t include the current progress note or orders to indicate why the patient requires continued acute care following stabilization To ensure the physician order matches the CM determination/billing status prior to discharge for billing concordance 11

12 Common Poor Documentation Practices Using a symptom rather than a diagnosis for the impression or assessment N/D/V vs. bowel obstruction SOB, chest pain, headache, back pain Listing the diagnosis as an intractable symptom (vertigo, abdominal pain, vomiting) without noting the potential diagnosis Using a lab value or treatment plan with no diagnosis Documentation for medical necessity is different than for billing level or coding 12

13 General Documentation Takeaways 5 key pieces of documentation for Medicare cases and determining medical necessity of Inpatient: Medical History Current Medical needs Severity of signs and symptoms Facilities available for adequate care Predictability of an adverse outcome CMS Medicare Benefit Policy Manual Chapter 1, 10 13

14 Key Words SUSPECTS What is your suspicion of what is going on i.e. impression? CONCERNS What are your concerns of the situation? PREDICTABLE RISK Given the patient s history and current presentation what kind of adverse outcomes are likely and what are the chances 14

15 IP Documentation Review Custodial Delay Convenience Any kill the case statements? Can go home from ER but the family cannot take care of the patient. The patient was about to be discharged, but apparently she did does not have much help at home and she is unable to take care of her herself Contradiction of IP order and certification IP order and I anticipate 1 midnight in the hospital and hence she will be admitted under observation. Here for placement Home in AM after lab result 15

16 IP Documentation Review Case Killer statement: The patient was about to be discharged (from ER), but apparently she did does not have much help at home and she is unable to take care of her herself Instead consider: 86yo female with hx CABG, valve replacement and two hip replacements, had a ground level trip and fall, resulting in an acute left humerus fx and left sup and inf pubic rami fx. She was treated with IV morphine and had an episode of hypotension. Pt lives by herself and was being worked up as an outpt (for frequent falls). In addition, she is on IV antibiotics for a resistant organism after failing outpt treatment. 16

17 Inpatient or Observation? 70 yo female presents after a buffet meal with epigastric burning. She has not significant PMH, has normal vital signs, normal physical exam. EKG and initial cardiac enzymes negative. Observation or Inpatient? 82 yo female presents with known history of CAD with previous MI & 3vCABG, presents c/o similar chest pain as her previous MI. Her vitals and physical exam are normal. EKG and initial cardiac enzymes negative. Plan for stress test and possible cardiac cath. Observation or Inpatient? 17

18 Inpatient or Observation? Observation level of care warranted because this 70 y/o female with no significant history presents with reflux following a large meal. My concern is for GERD as symptoms improved with minimal interventions (antacids). She is at low-risk for a cardiac ischemia based on her presentation, history, and objective findings. No LOS is documented. Inpatient level of care warranted because this 82 y/o female with known CAD, CABG, and PCI with recurrent angina similar to her previous cardiac event. My concern is for unstable angina as it is reoccurring at rest with SL NTG only providing short-term relief. She is at high-risk for progression of cardiac ischemia and myocardial injury. 2 midnight stay is reasonable for evaluation of cardiac related chest pain. 18

19 Inpatient or Outpatient? 66 yo female comes in for and elective laparoscopic cholecystectomy as and outpatient no co-morbid conditions. Normal vitals and physical exam. No problems during the surgery, no complications. Plan for DC after breakfast. 76 yo female with severe COPD, Stage 3 CHF, CKD 4, comes in for an elective laparoscopic cholecystectomy. Normal vitals and physical exam prior to surgery. During the surgery patient with prolonged hypotension requiring large amounts of IV fluids. Post surgery patient took longer to be extubated. Outpatient or Inpatient? Outpatient or Inpatient? 19

20 Inpatient or Outpatient? Outpatient Extended Recovery level of care warranted because this 66 y/o female with no significant history underwent a routine and uneventful elective lap chole. My concern is for routine nausea and pain control. She is at low-risk for immediate postoperative complications. Inpatient level of care warranted because this 706 y/o female with NYHA Class 3, CAD, COPD underwent an elective lap chole during which she became hypotensive requiring fluids and greater time to extubation. My concern is for acute decompensation of her heart failure. She is at high-risk for pulmonary edema. Medical consult for post op management. Expect 2 midnight stay for recovery and medical management. 20

21 About Executive Health Resources EHR has been awarded the exclusive endorsement of the American Hospital Association for its leading suite of Clinical Denials Management and Medical Necessity Compliance Solutions Services. AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA. * HFMA staff and volunteers determined that this product has met specific criteria developed under the HFMA Peer Review Process. HFMA does not endorse or guarantee the use of this product. EHR received the elite Peer Reviewed designation from the Healthcare Financial Management Association (HFMA) for its suite of medical necessity compliance solutions, including: Medicare and Medicaid Medical Necessity Compliance Management; Medicare and Medicaid DRG Coding and Medical Necessity Denials and Appeals Management; Managed Care/Commercial Payor Admission Review and Denials Management; and Expert Advisory Services. EHR was recognized as one of the Best Places to Work in the Philadelphia region by Philadelphia Business Journal for the past six consecutive years. The award recognizes EHR s achievements in creating a positive work environment that attracts and retains employees through a combination of benefits, working conditions, and company culture. 21

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