Using Clinical Criteria for Evaluating Short Stays and Beyond Georgeann Edford I. History A. Social Security Act Medical Necessity and Utilization Review 1. Items or services necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. 1 2. For the prevention of illness. 2 3. It shall be the obligation of any health care practitioner who provides health care services for which payment may be made a. will be provided economically and only when medically necessary b. will be of a quality which meets professionally recognized standards of health care c. will be supported by evidence of medical necessity and quality at such time as may reasonably be required by a reviewing peer review organization in the exercise of its duties and responsibilities. 3 4. Any utilization and quality control peer review organization must perform the following functions review some or all of the professional activities.of physicians and other health care practitioners and institutional and noninstitutional providers of health care services in the provision of health care services and items for which payment may be made. 4 B. Federal Register Treating Physician 1. Review of National Coverage Determinations and Local Coverage Determinations Final Rule 1 Social Security Act Title XVIII 1862 (a)(1)(a)health insurance for the aged and disabled Section 1862 Exclusions from coverage and Medicare as secondary payer 2 Social Security Act Title XVIII 1862 (a)(1)(b)health insurance for the aged and disabled Section 1862 Exclusions from coverage and Medicare as secondary payer 3 Social Security Act Title XI 1156 (a) General Provisions 4 Social Security Act Title XI 1154 (a)(1)functions of peer review organizations 1
a. Summary: This final rule will create a new process to allow certain Medicare beneficiaries to challenge national coverage determinations (NCDs) and local coverage determinations (LCDs). b. Analysis of and response to public comment on the rule. c. Physician certification of Medical Necessity We revised the certification requirements at 426.400(c) and 426.500(c) by clarifying that the certification of need can be in the form of a written order for the service or other documentation in the medical record thus significantly simplifying the certification process. 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 C. AMA Policy Medical Necessity 1. Our AMA defines medical necessity as: Health care services or products that a prudent physician would provide to a patient for preventing, diagnosing or treating an illness, injury, disease or its symptoms in a manner that is: a. In accordance with generally accepted standards of medical practice; b. Clinically appropriate in terms of type, frequency, extent, site and duration; and c. Not primarily for the economic benefit of the health plans and purchasers or for the convenience of the patient, treating physician or other health care provider. 6 D. CMS Program Manuals Medical Necessity Chapter II Coverage of Hospital Services Under the peer review organization (PRO) for each hospital is responsible for deciding, during review of inpatient admissions on a case by case basis, whether the admission was medically necessary. The PRO is authorized by the Medicare law to make these judgments, and the judgments are binding for purposes of Medicare coverage. In making these judgments, however, 5 Federal Register Vol. 68 No 216 Friday November 7, 2003 Part IV Department of Health and Human Services Center for Medicare & Medicaid 42 CFR Parts 400,405 and 426 Medicare Program: Review of National Coverage Determinations and Local Coverage Determinations; Final Rule 6 AMA Policy Compendium H 320.952 Definitions of Screening and Medical Necessity 2
PROs consider only the medical evidence which was available to the physician at the time an admission decision had to be made, and do not take into account other information (e.g., test results) which became available only after admission, except in cases where considering the post admission information would support a finding that an admission was medically necessary. 7 E. Quality Improvement Organizations 1. Chapter 1 1005 Purpose of QIO Review CMS has identified the following requirements of the QIP program: a. Improve quality of care for beneficiaries; b. Protect the integrity of the Medicare Trust Fund by insuring that Medicare pays only for services and goods that are reasonable and medically necessary and that are provided in the appropriate setting; and c. Protect beneficiaries by expeditiously addressing individual complaints 8 2. Chapter 4 Premature Discharge Premature discharge of patient that results in subsequent readmission of patient to same hospital. This occurs when a patient is discharged even though he/she should have remained in the hospital for further testing or treatment or was not medically stable at time of discharge. Evidence such as elevated temperature, postoperative wound draining or bleeding, or abnormal laboratory studies on the day of discharge indicate that a patient may have been prematurely discharged from the hospital. 9 F. Medicare Claims Processing Inpatient Only Procedures 1. Chapter 4 180.7 Inpatient only Services CMS defines services for which payment under Outpatient Prospective Payment System for hospitals is appropriate and has determined that the services designated to be inpatient only services are not appropriate to be furnished in a hospital outpatient department. Inpatient only services are generally, but not always surgical services that require inpatient care because of the nature of the procedure, the typical underlying physical condition of patients who require the service 7 CMS Program Manuals Hospital (PUB 10) Chapter II Coverage of Hospital Services 210 Covered Inpatient Hospital Services 8 Quality Improvement Organizations PUB 100 10 Chapter 1 Background and Responsibilities 9 Quality Improvement Organizations PUB 100 10 Chapter 4 Circumvention of PPS 3
or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged. These services have OPPS status indicator C in OPPS Addendum B and are listed together in Addendum E of each year s OPPS/ASC final rule. 10 G. InterQual Inpatient Procedure List The Guidelines for Surgery and Procedures in the Inpatient Setting was developed to assist clients in determining when a procedure might be appropriate for the inpatient setting and does not align with the CMS guidelines on inpatient setting. 11 H. Medicare Benefit Policy Manual 1. Chapter 1 10 Covered Inpatient Hospital Services Covered Under Part A a. Inpatient Definition: An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight. b. Physician Responsibility: The physician or other practitioner responsible for the patient s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient. 1) Physicians should use a 24 hour period as a benchmark. 2)..the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient s medical history and current medical needs, types of facilities available to inpatients and outpatients, the hospitals by laws and admission policies and the relative appropriateness of treatment in each setting. 3) Factors to be considered when making the decision to admit include such things as: 10 Medicare Claims Processing Manual PUB 100 04 Chapter 4 Part B Hospital (Including Inpatient Hospital Part B and OPPS) 11 InterQual Guidelines for Surgery and Procedures in the Inpatient Setting 4
a) The severity of signs and symptoms exhibited by the patient; b) The medical predictability of something adverse happening to the patient; c) The need for diagnostic studies that appropriately are outpatient (i.e. their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and d) The availability of diagnostic procedures at the time when and at the location where the patient presents. 12 2. Chapter 6 Hospital Services Covered Under Part B a. Outpatient Defined: A hospital outpatient is a person who has not been admitted by the hospital as an inpatient but is registered in the hospital records as an outpatient and receives services (rather than supplies alone) from the hospital or CAH. b. Outpatient Observation Services Defined: 1) Observation care is a well defined set of 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 if they are able to be discharged from the hospital. 2) Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge. 3) Observation services are covered only when provided by order of a physician or another individual authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason 12 Medicare Benefit Policy Manual Basic Coverage Rules (Pub 100 02) Chapter 1 Inpatient Hospital Services Covered Under Part A Section 10 5
for observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours. 13 I. Recovery Audit Contractor Memorandum Inpatient Admissions Without a Physician Inpatient Admission Order If the order to admit is missing or defective (i.e., illegible or incomplete), yet the physician intent, physician decision, and physician recommendation to admit to inpatient can clearly be derived from the medical record, Recovery Auditors shall substitute this information for a written or electronic admission order. In order for the documentation to provide acceptable evidence of an admission to inpatient status, there can be no disagreement regarding the physician intent, decision and recommendation to do so and no reasonable possibility that the care could have been adequately rendered in an outpatient setting. Example A patient comes into the Emergency Department with complaints of chest pain and the physician writes an order for observation. The physician proceeds to perform an EKG (electrocardiogram) and sends the patient to the cardiac catheterization lab. During the cardiac catheterization, severe coronary artery disease is discovered and the patient is sent to the Operating Room for Coronary Artery Bypass Graft. The patient is sent to the cardiac surgical Intensive Care Unit post operatively with an endotracheal tube still in place and orders are written for frequent vital signs, nursing assessments, and intravenous medications. Due to the timing of these events, a written or electronic order to admit the patient to inpatient status was never completed. In this case, there can be no reasonable disagreement that there was the intent, decision and recommendation to admit this patient to inpatient status, therefore providing an adequate substitute for the written admission order. 14 J. Medicare Claims Processing Manual 1. Chapter 3 Inpatient Hospital Billing Section 40.2.2 Charges to Beneficiaries for Part A Services C Inpatient Care No Longer Required 13 Medicare Benefit Policy Manual Basic Coverage Rules (Pub 100 02) Chapter 6 Hospital Services Covered Under Part B Section 20 Outpatient Hospital Services 14 CMS Recovery Audit Contractor (RAC) Memorandum 8/30/2011 Medical Review Policy Clarification Inpatient Admissions without a Physician s Inpatient Admission Order 6
The hospital (acting directly or through its URC) determined that the beneficiary no longer required inpatient hospital care. (For this purpose, a beneficiary is considered to require inpatient hospital care if the beneficiary needed a SNF level of care but an SNF level bed was unavailable.) The hospital cannot issue a notice of noncoverage if a bed is not available. Medicare pays for days awaiting placement until a bed is available and it is documented in the medical record that SNF placement is actively being sought. 15 K. Medicare Program Integrity Manual 1. Chapter 6 Section 6.5.1 Screening Tools The review shall use a screening tool as part of their medical review of acute IPPS and LTCH claims. CMS does not require that you use a specific criteria set. In all cases, in addition to screening instruments, the reviewer applies his/her own judgment to make a medical review determination based on the documentation in the medical record. a. The following shall be utilized as applicable for each case: 1) Admission criteria; 2) Invasive procedure criteria; 3) CMS coverage guidelines; 4) Published CMS criteria; 5) DRG validation guidelines; 6) Coding guidelines; and 7) Other screens, criteria and guidelines (e.g. practice guidelines that are well accepted by the medical community) b. Contractors shall consult with physician or other specialists if necessary to make an informed medical review determination. 16 L. MLN Matters Number SE1037 Guidance on Hospital Inpatient Decisions There are several commercially available screening tools that Medicare contractors in specific jurisdictions may use to assist in the review of medical documentation to determine if a hospital admission is medically necessary. These include Interqual, Milliman and other proprietary systems. 17 M. History of InterQual 15 Medicare Claims Processing Manual (PUB 100 04) Chapter 3 Inpatient Hospital Billing 16 Medicare Program Integrity Manual (Pub 100 08) Chapter 6 Medical Review Guidelines 6.5..1 Screening Instruments 17 MLN Matters Number SE1037 Guidance on Hospital Inpatient Admission 7
1978 InterQual publishes Severity of Illness and Intensity of Service (SI/IS) criteria for acute care, making practical review of the appropriateness of hospitalization possible. 1999 HCFA licenses InterQual Criteria for use in reviewing Medicare hospital inpatient services. 2003 Centers for Medicare and Medicaid relicense InterQual Criteria 18 II. Determining Level of Care: A. Use of Criteria Hospitals 1. InterQual 2. Milliman and Robertson Care Guidelines 3. Managed Care Appropriateness Protocols 4. Appropriateness Evaluation Protocol B. InterQual Components: 1. Severity of Illness (SI): a. System Specific b. The SI criteria consists of objective, clinical indicators of illness which focus on an individual s clinical presentation and/ or diagnosis. 2. Intensity of Service (IS): a. Defines services, tests and therapeutic interventions that would be expected to be performed and that can only be administered at a specific level of care. C. Supporting the Admission: 1. Both Severity of Illness and Intensity of Service criteria must be met to support the medical necessity for the selected level of care. The criteria among the various levels are similar but the the criteria for inpatient admission require SI and IS of an increased intensity and more detailed parameters demonstrating the severity of illness. These criteria are similar, but inpatient admission SI and IS criteria indicate a higher level of care. 2. The criteria for Observation VS Inpatient admission are not always clear cut and falls to physician judgment. 3. Physician documentation is the key component to support a higher level of care. 18 InterQual Level of Care Criteria 8
D. New InterQual Criteria: 1. In 2011 InterQual began the transition away from body system subsets and introduced six Condition Specific Subsets. The Acute Adult Subsets are: a. Acute Coronary Syndrome (ACS) b. Asthma c. Epilepsy d. Heart Failure (HF) e. Pneumonia f. Stroke / TIA 2. In 2012 InterQual will add additional medical subsets, surgical subsets, extended stay. By 2013 the transition to condition specific subsets will be complete. E. Quality of Documentation: 1. Diagnosis should be specific to accurately reflect the Severity of Illness and resources used. 2. Must include an order / intent to admit. 3. Provided a detailed system by system assessment including vital sings, test results and symptoms. 4. Provide a plan for all treated diagnoses. F. Looking for Intent 1. Key clinical descriptors and assessment of risk for an adverse event can make the difference between inpatient and outpatient status. 2. Identify comorbid conditions that may place the patient at risk, necessitating an inpatient stay. 3. If potential risk exists, look for descriptors of clinical significance. 4. Without an admission order the documentation within a patients chart must clearly prove intent by: a. Clinical picture documentation b. Orders noted to provide scheduled treatment such as IV fluids/medications every 8 hours, vital signs every 4 hours, invasive testing or procedures, evaluations or consults needed. G. What if discharge screen is not met? 9
1. If the patient does not meet continuing stay criteria, then a discharge review is performed to determine the next appropriate level of care for the patient. If the patient does not meet the Discharge Screen critieria the following steps would be taken: a. Identify the reason the patient was not transferred. b. Assign a level of care that represents the alternate level of care which would be appropriate if it had been available. c. Document the number of variance days used at a specific level of care when less intensive level of care is appropriate. d. Refer the case for a secondary review. The secondary review determines the medical necessity of the admission or continued stay based on the review of the medical record, discussions with nursing, discharge planning, and attending medical practitioner. 10