Using Clinical Criteria for Evaluating Short Stays and Beyond Georgeann Edford, RN, MBA, CCS-P The Clinical Face of Medical Necessity 1
The Documentation Faces of Medical Necessity ç3 Setting the Stage SSA 1862(a)(1)(A) Coverage items or services necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. SSA 1156 (a)(3) will be supported by evidence of medical necessity and quality in such form and fashion and at such time as may reasonably be required by a reviewing peer review organization in the exercise of its duties and responsibilities. 3 2
Physician Certification Federal Register / Volume 68, No 216 However, we continue to believe that the beneficiary s treating physician not any treating practitioner is best situated to determine in need status, both because he or she is the primary caregiver and also is responsible for the beneficiary s overall care 5 Medical Necessity Criteria Inpatient Stays Use of screening Criteria QIO s use InterQual or similar Notwithstanding CMS s characterizing the decision to admit as: Complex Made by the patient s physician Based on information available at the time the decision to admit is made Conversely, not meeting screening criteria does not mean admission was unnecessary 6 3
AMA Policy Health care services that a prudent physician would provide to a patient for preventing, diagnosis or treating an illness, injury, disease or symptoms that is: According to generally accepted standards of medical practice Clinically appropriate in terms of location, type, frequency, duration and Not for the convenience of the physician, patient or another. 7 Inpatient Hospital Admission Medicare Benefit Policy Manual defines inpatient admission as: Formally admitted as an inpatient Expectation that patient will remain at least overnight even if discharged or transferred before then Physician is responsible for deciding Physician should use a 24 hour period as a benchmark 8 4
Inpatient Admission Continued Factors Physicians Should Take Into Account: The decision to admit a patient is a complex medical judgment Severity of signs and symptoms Medical predictability of adverse event Can needed tests be done on an outpatient basis? Availability of diagnostic procedures when and where the patient presents Note absence of reference to InterQual 9 Observation CMS defines observation as: Period of time in which a patient is held until such time that a decision can be made that the patient can be safely discharged home or admitted as an inpatient for further treatment. Maximum period of time 48 hours Observation is not an admission status; it s a level of care for outpatients 10 5
Outpatient Medicare Benefit Policy defines outpatient as: An outpatient is a person who has not been admitted by the hospital as an inpatient but is registered on the hospital records as an outpatient and receives services ( rather than supplies alone) from the hospital. 11 What s Really the Difference Between Inpatient and Observation Not whether the patient is in a bed Not the type of bed used Not the intensity of services Difference is a billing/coverage distinction; The difference is not inherently a difference in care 12 6
Inpatient Admitted for treatment and assessment Formally admitted as an inpatient Attending Physician is responsible for deciding Physician should use a 24 hour period as a benchmark Observation Services for short term treatment and assessment Clinically, patient needs to be observed and monitored Reassessment before a decision is made regarding a patient s need for inpatient admission Usually decision is made in less than 48 hours, most less than 24 hours No length of time that determines a patient s status Inpatient VS Observation 13 Review Criteria InterQual has had contract with CMS since 1999 for all inpatient hospital services. The contract was renewed in 2003 and continues to be used today. The majority of State Medicaid programs utilize previous versions of InterQual for its reviews. 14 7
InterQual Review InterQual reviews are focused on the intensity of which the patient is being treated The information is broken down in 2 ways Level of Care Body System Further breakdown within the level of care and body system are additional subsets Severity of illness or SI Intensity of service or IS Discharge Screen 15 Severity of Illness How sick are they? Focus on patient s presentation rather than diagnosis Presentation Clinical Indicators that represent an illness: Main clinical issues chief complaint Abnormal vital signs, Pain location, type, cause, relief Neurological status alert, alternate level of consciousness Description of diagnostic tests labs or x rays Consults or evaluations 16 8
Intensity of Service Type of treatment being administered: Medications route and frequency IV Fluids Blood / blood products Oxygen Diet Wound Care 17 InterQual Criteria Components Discharge Screens Criteria that must be met for discharge Utilized when the intensity of service is not met for that day Patient is unsafe for discharge. 18 9
Problematic Chief Complaint Chest pain Could be caused by: GERD indigestion, reflux Angina Heart Attack Musculoskeletal strain, pulled muscle Anxiety unrelated Respiratory pneumonia, pleurisy Renal kidney stones ç19 Observation Episode Day 1 Severity of Illness çchest PAIN Inpatient Episode Day 1 Severity of Illness (1) Acute coronary syndrome suspected Initial cardiac markers negative, continue to monitor EKG non diagnostic Systolic B/P at baseline Pain resolved/resolving Acute Myocardial Infarction Unstable Angina and controlled pain, EKG, one: Post observation level of care and ischemia on stress test Chief complaint chest pain comparison of documentation 20 10
Intensity of Service Requirements Chest Pain Observation Aspirin / Antiplatelet administered or contraindicated Cardiac monitoring Inpatient Treatment, ALL Beta blocker/ CA Channel blocker administered/ contraindicated Aspirin administered/ contraindicated Antiplatelet administered/contraindicat ed Anticoagulant administered/contraindicat ed Cardiac monitoring 21 Episode Day 2 Observation; One: Responder, discharge expected today if stable for 12 hours all NSTEMI and STEMI ruled out Pain resolved Objective cardiac risk assessment, one: Completed prior to discharge Low cardiac risk and scheduled outpatient Assessment not indicated as ACS ruled out Inpatient Treatment, ALL Beta blocker/ CA Channel blocker administered/ contraindicated Aspirin administered/ contraindicated Antiplatelet administered/contraindicat ed Anticoagulant administered/contraindicat ed Cardiac monitoring ç22 11
Supporting the Admission Both SI and IS criteria must be met to support the medical necessity for admission, observation, or another service in the system. These criteria are similar, but inpatient admission SI and IS criteria indicate a higher acuity level. The criteria for observation vs. inpatient admission are not always clear cut and falls to physician judgment. Physician documentation is a key component to support high acuity. 23 Documentation Unlike the intent for admission, diagnosis needs to be specific to accurately reflect the severity of illness and the resources used. Provide a detailed system by system assessment including vital signs, test results, symptoms Provide a plan for all treated diagnosis. 24 12
Looking For Intent Key clinical descriptors and assessment of risk for an adverse event can make the difference between inpatient and outpatient admission status. Comorbid conditions Potential risk Physician Orders 25 Example 1 Jane, a 70 year old female, presented to the ED with severe chest pain. One month duration resolved on its own. Today non resolving B/P 188/90, pulse 110 respirations 28, PO2 94% EKG ST changes; age indeterminate One set of cardiac markers drawn; normal Treated with O2, aspirin and Nitro drip. Pain resolved Physician ordered transfer to cardiac care for observation 26 13
WAS INPATIENT ADMISSION CORRECT? 27 WAS THERE MEDICAL NECESSITY? 28 14
Example 2 John a 64 year old male presented to the ED experiencing a dry cough for 3 days associated with wheezing for 1 day. B/P 120/72, pulse 108, respirations 20 with an O2 sat of 84% EKG normal CBC normal Chest x ray COPD (chronic obstructive pulmonary disease) He was treated with steroids and albuterol inhaler X3. He continues to have wheezing. 29 OBSERVATION OR ADMISSION? 30 15
Example 3 Arthur, a 72 year old male presented to the ER with a history of dizziness and fainting five hours prior to arrival. Vital signs were B/P 90/60, pulse 132, PO2 90% CBC mild anemia Nasogastric tube bright red fluid IV started 150 cc/hour Physician orders for further testing Transferred to medical floor 31 INTENT 32 16
Inpatient Only Procedures A procedure is designated as inpatient only for three reasons: The nature of the procedure The need for at least 24 hours of post operative recovery time or monitoring before the patient can be safely be discharged The underlying physical condition of the patient requiring surgery An inpatient only procedure will be paid only when the patient is an inpatient at the time the procedure is performed 33 Inpatient Vs. Outpatient Annually, CMS identifies certain procedures as Inpatient only Procedures get on the list by means of data claims analysis of procedures and the LOS associated with them InterQual also has an inpatient only procedures list The procedures get on the list if someone calls or writes in to ask about a procedure 34 17
Outpatient vs. Observation Outpatient Surgical Procedures Normal post operative recovery period is 4 6 hours Observation following outpatient surgical procedure requires: Adverse/unexpected event Event must be recognized as a risk to the patient Requires additional observation and assessment beyond the standard recovery period Has a diagnosis that is separate and distinct from the operative procedure Outpatient Procedure Requiring Observation Freda was a 74 year old who had a cardiac catheterization as an outpatient. There is no significant past history other than intermittent chest pain and questionable stress test results. Post procedure in recovery the patient developed an intractable headache. She was given IV pain medication and monitored. Seven hours later she is still experiencing severe pain and met criteria for Observation Level with: Severity of Illness Post ambulatory surgery/ procedure, One: Pain /Headache / Vomiting uncontrolled Intensity of Service Medication (s) 2 doses: Analgesics 36 18
Continued Stay The next day the patient continued to have pain. She no longer required the intensity of services provided as she was now receiving oral pain medication. HOWEVER She cannot be discharged as she does not meet the discharge screen of pain controlled and manageable. Another day of Observation is the correct level of care for this patient. 37 Conclusion Documentation found in the medical record can provide the information needed to support medical necessity and beyond. EHR is not the panacea! Utilizing qualitative clinical documentation criteria can be a friend when justifying a level of care. 2012 criteria is far more rigid. 38 19
THANK YOU FOR ALLOWING ME TO SHARE OUR EXPERIENCE WITH YOU! Georgeann Edford 39 20