To Admit or Observe: THAT Is the Question

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To Admit or Observe THAT Is the Question

• Howard C. Pitluk, MD, MPH, FACS
• Suzanne K. Powell, RN, MBA, CCM, CPHQ
• Health Services Advisory Group

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Objectives

• Identify why observation versus inpatient is a
  national concern.
• Define OBSERVATION (OBS).
• Determine the appropriate use of OBS vs.
  INPATIENT hospital admissions.
• Identify a proven method to reduce unnecessary
  admissions using a case management protocol.

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CMS Concerns

• CMS paid 19.9 billion in error for Medicare
  fee-for-service 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

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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).

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Hospitals Concerns

• SO..
• Start improving your processes NOW ?
• Avoid the CMS RUSH
• to audit, and potentially deny, payment for
  unnecessary hospitalizations!

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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 OBS 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

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Why all the confusion over OBS?

• 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-the-fact (i.e., after discharge)
• Difficult to convince clinicians that the
  difference is one of BILLING, not MEDICAL
  TREATMENT

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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).

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Purpose of Observation

• Observation is used to evaluate a patients
  condition in order to determine the need for
  acute inpatient admission.

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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

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Observation ServicesKEY 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

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Observation ServicesKEY 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

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Observation ServicesKEY 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

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Do NOT use OBS for.

• Social reasons
• Physician or patient convenience
• Routine prep for diagnostic testing
• Routine recovery from outpatient procedures
• Procedures designated as inpatient only

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OBSERVATION The RULEIts Elementary!

• R/O Rule Out
• R/O Remember Observation

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Will my patients get second-class care? NO! And,
by the way, my hospital does NOT have an OBS
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.

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Observation..its not a place

• Its a
• state of
• Mind.

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WHEN does the OBS CLOCK START?

• Observation time begins at the documented time in
  the patients 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 physicians order /
  nursing note computer time may be inaccurate
• Round out to the nearest hour.
• FFS Medicare coverage for observation services
  requires at least eight hours of monitoring and
  is limited to no more than 48 hours unless the
  fiscal intermediary grants an exception.

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WHEN does the OBS 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).

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Can I change from OBS to Inpatient?

• YES!
• OBS-to-Inpatient An outpatient observation
  patient may be progressed to inpatient status
  when it is determined the patients condition
  requires an inpatient level of care?anytime up to
  48 hours (for FFS Medicare patients).

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Can I change from Inpatient to OBS?

• YES!
• Inpatient-to-OBS (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
  patients physician must concur with the decision
  of the review committee, and the physicians
  concurrence and status change must be documented
  in the medical record.

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Considerations when making OBS/Inpatient
adjustments

• Only use information available to the physician
  AT THE TIME of the decision to admit to OBS 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).

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Documentation is Critical

• Observation status MUST be specifically stated in
  the order
• Documentation must support the level of care
  provided (inpatient admission versus OBS)
• 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
• For this project, we suggest
• Admit Patient to Observation Case Management /
  Utilization Management Protocol

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Once the patient has been in OBS status for 24
hours

• Document the answers to these questions
• Is there a need to continue observation status
  for the next 1224 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.

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THE ADMISSION DECISION TEST
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Medicare Observation or Inpatient? Admission
Decision Test
Observation is appropriate.
Yes
Can condition be evaluated / treated /
improved within 48 hours?
Inpatient admission is appropriate.
Yes
No
Does condition require hospital Treatment?
Alternate level of care is appropriate
No
Additional time is needed to determine if
inpatient admission is medically necessary.
Observation is appropriate.
Unsure
The decision to admit a patient as an inpatient
requires complex medical judgment, including
consideration of the patients 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.
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THE CASE MANAGEMENT PROTOCOL
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Case Management ProtocolAn 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)

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Admission Per Case Management Protocol Part 1
Physician Order Admit patient per Case
Management/Utilization Management Protocol
PRN Order at the discretion of the individual
physician?
NO
YES
YES
Patient admitted to Protocol
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Admission Per Case Management Protocol Part 2
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Admission Per Case Management Protocol Part 3


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THE CHEST PAIN PROTOCOL
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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 patients story
  suggests the possibility of acute cardiac ischemia

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NEXT STEPS?Hospital

• By 15th of each month, send Monthly Log of 100
  of previous months DRG 143 stays (less than 48
  hours) with diagnosis of Chest Pain for Medicare
  FFS patients
• Monitor a sample of those records and include on
  the Monthly Log (right side of log)
• Timely submission of records requested by HSAG
  for HSAG monitoring
• Read the Case Management Protocol (CMP), convene
  your team, and compare CMP with your process.
• E-mail Suzanne Powell at spowell_at_azqio.sdps.org
  with questions/concerns re Case Management
  Protocol for Teleconference 3.

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NEXT STEPS?HSAG

• Request records based on hospitals Monthly Log
• Monitor records when received from hospital
• Prepare a customized RUN CHART and send to
  hospital on a monthly basis, adding data points
  each month
• Facilitate calls with individual hospitals to
  discuss any barriers and ideas to pilot new
  processes to reduce the number of inappropriate
  one-day stays for DRG 143

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Questions?
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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

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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

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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

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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.

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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.

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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 non-diagnostic 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.

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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