Transcript No Slide Title

To Admit or Observe:
THAT Is the Question
Suzanne K. Powell, RN, MBA, CCM, CPHQ
Health Services Advisory Group
Objectives
 Identify why Observation versus Inpatient is
a national concern.
 Define OBSERVATION (OBV).
 Determine the appropriate use of OBV vs.
INPATIENT hospital admissions.
 Identify a proven method to reduce
unnecessary admissions using a case
management protocol.
CMS Concerns
 CMS paid $19.9 billion in error for Medicare fee-forservice claims.*
 17.2% were due to medically unnecessary services.*
 43.7% were due to insufficient documentation.*
 41% of admission errors were associated with one-day
stays that were billed as inpatient.
– DRG 143 is one of the most common billing errors.
Because the payment error rates are increasing, there
may be more auditing in the future.
* Improper Medicare FFS Payments Report FY 2004, Rev. 2/15/05,
http://www.cms.hhs.gov/cert
Arizona Concerns
 In FY 2005 over 4,500 claims were submitted for
DRG 143 (chest pain) in Arizona:
– One-day stays accounted for 52% of the claims.
– Of those one-day-stay claims, InterQual (IQ) admission
criteria were applied to a random sample and 93.5% failed.
– Of those same claims, a further sample of DRG 143 was
requested of the hospitals with the highest number of claims.
• 97% failed to meet IQ admission criteria.
– Since each inappropriate admission cost $2,376, Medicare
overpaid $5,393,520 for these admissions.
 Arizona is #2 in the nation for one-day-stay claims
(only one state has more than AZ).
Hospitals Concerns
SO . . .
Start improving your processes NOW ―
Avoid the CMS RUSH
to audit, and potentially deny, payment for
unnecessary hospitalizations!
Now What?
 Do we have a problem?
YES. One-day stays for chest pain (DRG 143) in Arizona
are high.
 What can we do?
(1) Case Management Protocol (or a ‘variation on a
theme’)
(2) Use OBV status as a default for DRGs with high
error rates (DRG 143)
 How will we know if what we are doing is effective?
Monthly audits / run charts to track progress
Why all the confusion over OBV?
 Misunderstanding of the roles of physicians and
facilities in determining patient status.
 Confusion over the Medicare rules for appropriate
selection of status.
 Distinction between inpatient and extended
outpatient observation is blurry.
 It is difficult to correct admission errors “after-thefact” (i.e., after discharge).
 Difficult to convince clinicians that the difference is
one of BILLING, not MEDICAL TREATMENT.
Definition: Observation Services
CMS Manual System, Pub. 100-02 Medicare Benefit
Policy says …
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.
(up to 48 hours for Medicare FFS beneficiaries)
***Note that managed Medicare and private insurance companies’ admission
status rules may vary from those of FFS Medicare (often 23 hours or 24 hours).
Purpose of Observation
Observation is
used to evaluate
a patient’s
condition in
order to
determine the
need for acute
inpatient
admission.
Advantages of Observation
 Allows the physician to observe the patient
when unsure of diagnosis or trajectory of
current symptoms
 Avoids potentially unnecessary acute care
admission and costs
 Decreases burden on ED and augments
hospital reimbursement (does not alter
physician reimbursement)
 Does not preclude an eventual admission
Observation Services
KEY Questions to ASK
 In what condition will the patient most likely be
tomorrow?
“Better” =  Observation
 Is it risky to send the patient home today?
“Yes” =  Observation
 Is it likely I will know whether to admit or send
the patient home by tomorrow?
“Yes” =  Observation
Observation Services
KEY Questions to ASK
 Are vital signs stable?
“Yes” =  Observation
 Will a diagnosis likely be made in 24 hours?
“Yes” =  Observation
 Will treatment, such as IV fluids, require standard
monitoring and be complete within 24 hours?
“Yes” =  Observation
Observation Services
KEY Questions to ASK
 Is the patient presenting with a symptom(s) (e.g.,
chest pain, abdominal pain, TIA)
“Yes” =  Observation
 Is the patient having an unusually long recovery period
following outpatient procedure (e.g., pain management
issues, cardiopulmonary concerns, urinary retention)
“Yes” =  Observation
Do NOT use OBV for….




Social reasons
Physician or patient convenience
Routine prep for diagnostic testing
Routine recovery from outpatient
procedures
 Procedures designated as “inpatient only”
OBSERVATION: The RULE
It’s Elementary!
R/O Rule Out
=
R/O Remember
Observation
Will my patients get second-class care? NO!
And, by the way,
my hospital does NOT have an OBV Unit…
 Observation services can be provided anywhere in the
hospital
– Example: Continuous monitoring (such as telemetry) can be
provided in observation or inpatient status; consider overall
severity of illness and intensity of services in determining
admission status rather than any single or specific
intervention.
 Level of care, not physical location of the bed, dictates
admission status.
Observation . . . it’s not a “place”
It’s a
state of
Mind.
WHEN does the OBV
“CLOCK” START?
 Observation time begins at the documented time in the
patient’s medical record that coincides with the time
the patient is placed in a bed for the purpose of
initiating observation.
 Must be in accordance with a physician’s order /
nursing note; computer time may be inaccurate
 Round out to the nearest hour.
 FFS Medicare coverage for observation services
requires at least 8 hours of monitoring and is limited to
no more than 48 hours unless the fiscal intermediary
grants an exception.
WHEN does the OBV
“CLOCK” END?
 The ending time for observation occurs when:
– The patient is discharged from the hospital, OR
– The patient is admitted as an inpatient.
 The time when a patient is “discharged” from
observation status is the clock time when all clinical or
medical interventions have been completed, including
any necessary follow-up care.
 Observation care does not include time in the hospital
subsequent to the conclusion of medical interventions
(e.g., time waiting for a ride home).
Can I change from
OBV to Inpatient?
YES!
OBV-to-Inpatient An outpatient observation
patient may be progressed to inpatient status
when it is determined the patient’s condition
requires an inpatient level of care―anytime up
to 48 hours (for FFS Medicare patients).
Can I change from
Inpatient to OBV?
YES!
Inpatient-to-OBV (CODE 44): Hospitals can
convert and bill an inpatient case as an outpatient if
the hospital utilization review committee determines
before the patient is discharged and prior to
submitting a bill/claim that this setting would have
been more appropriate. The patient’s physician must
concur with the decision of the review committee,
and the physician’s concurrence and status change
must be documented in the medical record.
Considerations when making
OBS/Inpatient adjustments

Only use information available to the
physician AT THE TIME of the decision to
admit to OBV or inpatient. Patient Safety is
number #1 criterion:
–
–
–
Medical necessity for admission must be met and
documented at the time of conversion.
Physicians can only change admission status prior
to discharge.
Any change in admission status must be supported
by the medical record (physician notes and orders).
Documentation is Critical
Observation status MUST be specifically stated in the
order

Documentation must support the level of care
provided (inpatient admission versus OBV):
–
–
An order simply documented as “admit” will be
treated as an inpatient admission.
A clearly-worded order will ensure appropriate
patient care and prevent hospital billing errors. Some
use:
 “admit to observation” or
 “place patient in outpatient observation”
Once the patient has been in OBV
status for 24 hours . . .

Document the answers to these questions:
Is there a need to continue observation status for the
next 12–24 hours?
or

Is there a need to convert to inpatient status?
– It is important to document the medical necessity
for admission status.
or

Is the patient medically stable for discharge?
– Document the plan for follow-up as needed.
THE ADMISSION
DECISION TEST
Medicare Observation or Inpatient?
Admission Decision Test
Observation is appropriate.
Yes
Yes
Does condition
require hospital
Treatment?*
Can condition be
evaluated / treated /
improved
within 48 hours?
No
Unsure
Inpatient admission is appropriate.
No
Alternate level of care is appropriate
Additional time is needed to determine if
inpatient admission is medically
necessary. Observation is appropriate.
* The decision to admit a patient as an inpatient requires complex medical judgment, including consideration of the
patient’s medical history and current medical needs, the medical predictability of something adverse happening to the
patient, and the availability of diagnostic services/procedures when and where the patient presents.
THE CASE MANAGEMENT
PROTOCOL
Admission Per Case Management Protocol
Physician Order “Admit patient per Case
Management/Utilization Management Protocol”
Standing Order
for all patients
regardless of payor
source?
No
Yes
PRN Order
at the discretion of
the individual
physician?
Other
No
Yes
Patient admitted to Protocol
Admitting Dept.
and/or Business Office
has “hold status” (2-6 hr
timeframe) for patient until inpatient or
observation status are determined
by CM/UM
personnel
No
Other
Yes
CM/UM
personnel assess patient
admitted per protocol
in 2-6 hrs
No
Default to observation status
CM/UM personnel assess
patient admitted per protocol
Yes
Case Management personnel assign patient to appropriate status
Decision binding and upheld by the physician writing the order
Admitted as “Inpatient” using
hospital admission criteria
CM/UM
Decision
Assigned as
“Observation status”
CM/UM continuous
assessment
Discharged after evaluation and/or
treatment within 24-48 hrs after
placed in observation status
and/or
Decision
Physician notified, and
assesses
Patient subsequently meets
criteria for conversion to
inpatient status within 24-48 hrs
Case Management Protocol
An Answer to the Observation Conundrum
 Physician admits patient to the Observation CM/UM
Protocol
 Case Manager/Utilization Manager assessment
 Determine appropriate status of patient (Inpatient vs.
Outpatient)
 Ordering Physician abides by case management
determination
 Protocol for all patients, regardless of payer (but only
send HSAG Medicare FFS charts)
Admission Per Case Management Protocol – Part 1
Physician Order “Admit patient per Case
Management/Utilization Management Protocol”
Standing
Order
for all patients regardless of
payor source?
NO
PRN
Order
at the discretion of
the individual
physician?
YES
YES
Patient admitted to Protocol
NO
Other
Admission Per Case Management Protocol – Part 2
Admitting
Dept. and/or Business
Office has “hold status” (2-6 hr
timeframe) for patient until inpatient or
observation status are determined by
CM/UM personnel
NO
Other
YES
CM/UM personnel
assess patient admitted
per protocol in 2-6 hrs
NO
Default to observation status
CM/UM personnel assess patient
admitted per protocol
YES
Admission Per Case Management Protocol – Part 3
Case Management personnel assigns patient to
appropriate status. Decision binding and upheld by
the physician writing the order
Admitted as “Inpatient” using
hospital admission criteria
Assigned as “Observation
status”
CM/UM
Decision
CM/UM continuous
assessment
Discharged after
evaluation and/or
treatment within 24-48
hrs after placed in
observation status
&/
or
Decision
Physician notified,
& assesses
Patient subsequently
meets criteria for
conversion to inpatient
status within 24-48 hrs.
THE CHEST PAIN
PROTOCOL
CHEST PAIN Considerations
 Inpatient admission: consider when a patient has:
–
–
–
–
–
Elevated Troponin
ST elevation
MI or dynamic ST-T wave changes on the EKG
Hemodynamic instability
Chest pain not responding to Nitroglycerin
 Observation: consider when the patient has no EKG
or enzyme changes, but the patient’s story suggests
the possibility of acute cardiac ischemia
Algorithm for Chest Pain Patients
Observation Status vs. Inpatient Admission



Age > 30 with chest pain?
SOB or syncope and > 45
years of age?
Women with typical sxs that
are anginal equivalent?
Is Chest Pain fully
explained by:
 obvious local trauma?
 CXR findings?
OR is the chest pain…
 fully and unambiguously
positional, pleuritic, or
reproducible by
palpation?
NO
YES
YES
EKG
NO
EKG
Inpatient
Admission
YES
Are EKG findings High
Risk for ischemia?
Very Low
NO
MD H&P with Risk Stratification
NO
YES
One or more
YES
Positive Troponin?
HIGH
LOW
Low, but non-chest pain
diagnosis (i.e., HTN,
pneumonia, CHF)
NO
Admit as an inpatient
with a diagnosis related
to area of concern
Systolic BP <100 mmHg
or > 180 mmHg and/or
Persistent or Recurrent
Chest Pain?
All NO
Observation
Status
Observation
Status
TEST ~ Case Study #1
 67-year-old seen in the ED with
gradual onset of CP over past 2 hours
 EKG normal
 First set of cardiac enzymes showed
increased Troponin level
 Observation OR  Inpatient
TEST ~ Case Study #2
 66-year-old seen in the ED with CP
 EKG slight ST elevation
 First set of cardiac enzymes negative
 Observation OR  Inpatient
TEST ~ Case Study #3
 74-year-old man presented to his doctor with chest pain
“off and on” for a week.
– Patient was found to be bradycardic in the 50s
– No syncope
– Medications included toprol
 Sent to ED: VS stable, BP 180/70, HR of 50/min. EKG
sinus bradycardia. Enzymes normal. Chest pain description
in the chart did not support a diagnosis of unstable angina.
Bradycardia is explained by the medications
Correct Call?
DRG 143 Case Study #4
 67-year-old male, history of
palpitations for 2 months, usually
at rest in evening before bed, was
admitted for cardiac monitoring
and enzymes related to complaint
of chest pain and palpitations.
Physical exam was unremarkable.
Cardiac enzymes were negative.
ECG showed sinus rhythm with
occasional PVCs. Discharge
diagnoses were unspecified chest
pain and PVCs.
Correct Call?
DRG 143 Case Study #5
 84-year-old man, history of
CABG, was admitted with
atypical chest pain for a week,
which increased on deep
inspiration. Enzymes and
ECG unremarkable. Also
complaining of weight loss
over 3-year period. MI was
ruled out. Also had work-up
for weight loss while in the
hospital. Discharge diagnoses
were unspecified chest pain
and weight loss.
Correct Call?
DRG 143 Case Study #6
 63-year-old woman, history of CAD,
HTN, CVA, with prior MI in the
1970s, was admitted with chest pain
described as sharp, retrosternal, with
dyspnea and diaphoresis occurring at
rest. Pain lasted for minutes, increasing
with exertion and decreasing with rest.
Pain started day before and has
recurred several times. BP 140/80.
Initial ECG showed minor nondiagnostic ST-T-wave changes. The
hospital admitted to rule out MI. Serial
cardiac workup negative. Stress
perfusion study negative for ischemia.
Discharged with diagnosis of chest
pain. GI work-up planned as outpatient.
Contact Information
Suzanne K. Powell, RN, MBA, CCM, CPHQ
Director, Acute Care/QI Program
602.665.6109
[email protected]
All Medicare beneficiaries
have the right to appeal their discharge from
a hospital, skilled nursing facility, home
health agency, or comprehensive outpatient
rehabilitation facility.
For more information, go to
http://www.hsag.com/azmedicare
or call 1.800.359.9909.
www.hsag.com
This material was prepared by Health Services Advisory Group, the
Medicare Quality Improvement Organization for Arizona, under
contract with the Centers for Medicare & Medicaid Services (CMS),
an agency of the U.S. Department of Health and Human Services.
The contents presented do not necessarily reflect CMS policy.
Publication No. AZ-8SOW-SS-120106-01