Publication MO-06-40-HPMP June 2006This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, 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

To Admit or Not to Admit

The Decision Seems Easy…

Presents

Patient

Admit as Inpatient

Treat as Outpatient

But It’s Much More Complicated

Admit as Inpatient

Office Follow-

up

Outpatient Procedure

Observation

Diagnostic Testing

SNF Follow-

up

Specialty Clinic

Follow-up

Treat as Outpatient

Patient Status Options

Admit as Inpatient

Outpatient Observation

Outpatient Procedure

and/or Followup

Presents

Patient

Effects of Unnecessary Admissions

Costs Medicare the largest proportion of erroneous payments

One-day stay admissions are target area for potential payment errors in MO

OIG has taken notice

Why It Matters

Majority of error payment amount (~$1.6B) may be attributed to lack of medical necessity

Nearly 80% of all admission denials were short stays (1-3 days)

MO’s net error payment FY2005 estimated at $47M; majority of which may be attributable to unnecessary IP admissions

Why It Matters

Why does it matter to the patient?

Why does it matter to the hospital?

Why does it matter to the physician?

Admit as Inpatient

Treatment longer than 24 hours expected

Outpatient treatment has not been effective

Inpatient-only procedure necessary

Continuous monitoring necessary

Inpatient Admission Considerations

Severity of presenting signs and symptoms

Predictability of the clinical course

Existence of comorbid conditions which may negatively impact course

Potential for complications

Services required upon presentation

Diagnostic procedures available

Inpatient Admission Documentation

Inpatient admission order with date and time

Clinical documentation supporting medical necessity

No “back-dating” is allowed

What are Observation Services?

Services furnished by a hospital including:

– use of bed

– periodic monitoring by staff

– requires physician order

Reasonable and necessary

– evaluate outpatient condition

– determine inpatient admission need

Why Observation Services?

Determines need for inpatient admission

Rapid response to treatment is expected

Patient has unusually prolonged recovery period following an OP procedure

Points of Entry for Outpatient Observation

Admission from emergency department

Direct admission

Outpatient department(s)

Observation Documentation

Observation admission order with date and time

Assessment of patient risk to determine benefit from observation care

Timed and signed admission notes, progress notes and discharge notes

Observation Services Not Covered

Services not reasonable or necessary for diagnosis or treatment of patient

Services provided for convenience of patient, family or physician

Services covered under Part A

Services that are part of another Part B service

Standing orders for observation after OP surgery

Custodial care

Condition Code 44 Policy

Medicare payment policy that allows inpatient admission change to outpatient when:

– Change in status made prior to discharge

– The hospital has not submitted Medicare claim for inpatient admission

– Physician concurs with decision to change status

– Physician’s concurrence is documented in medical record

Chest Pain

Process of elimination to determine chest pain is not cardiac in origin based on:

– Symptoms

– ECG

– Enzymes

– Possible early stress testing

Chest Pain Evaluation

New onset symptoms may be consistent with ischemic heart disease but not associated with ECG changes or convincing evidence of unstable ischemic heart disease at rest or with minimal exertion

Known CAD but symptoms do not suggest true worsening

Observation beneficial because etiology of symptoms is unclear

Chest Pain Case Study #1

84-year-old female, PMH=CABG, presented to ED with intermittent chest pain x1 wk which increases on deep inspiration; Initial enzymes & ECG unremarkable; pain resolved prior to admission

Patient admitted with atypical pain in setting of prior CABG; Plan=serial ECGs & enzymes

Admission to observation status appropriate

Chest Pain Case Study #2

63-year-old female, PMH=CAD with prior MI 1990s, HTN, CVA; presented to ED with chest pain, sharp, retrosternal, dyspnea & diaphoresis; pain increases with minimal exertion; pain relieved w/rest & NTG; pain recurred several times in ED; SBP >100;

Initial impression=unstable angina, r/o MI

Chest Pain Case Study #2 (cont’d)

Initial enzymes WNL, ECG=non-specific ST- T changes; admitted to telemetry unit for r/o MI protocol & stress perfusion w/dipyridamole, which showed anterior wall ischemia;

New onset angina in setting of prior MI; IP admission appropriate

Syncope & Collapse Case Study #3

70-year-old female presented to the ED “knees gave out & I fell to floor…hit back of head”; denies LOC, dizziness, lightheadedness, chest pain, & N/V; PMH=DM; vital signs WNL w/no findings on exam; BS=189; Enzymes nl; ECG WNL; head CT negative

Syncope & Collapse Case Study #3 (cont’d)

Questionable pre-syncope of unknown etiology; admit to monitor for arrhythmias or other neuro signs

Admission to observation status appropriate

Syncope & Collapse Case Study #4

65-year-old male came to ED with 3 syncopal episodes each lasting several seconds, occurring over 18-hr period; H&P unremarkable; ECG=bradycardia of 54bpm & 18 sec pause; ECHO=WNL;

Appropriate IP admission for pacemaker insertion and postprocedure monitoring

Dehydration Case Study #5

92-year-old female presented to the ED with weakness x2 days & difficulty getting in & out of bed; no fever, dizziness, nausea, vomiting, diarrhea; PMH=HTN, dementia, recent tx for UTI; Sodium=132; decreased oral intake; HR >100; postural SBP drop >30

Tx plan=BP meds held; IVFs 100/hr; po antibiotics

Dehydration Case Study #5 (cont’d)

Meets severity of illness (InterQual endocrine/metabolic) but doesn’t meet intensity of service

Per PR review---documentation indicates status of dehydration could reasonably be expected to improve within 24-hour period; overnight monitoring in observation status appropriate.

Observation or Inpatient?

Hospitalization required?

No acute hospital care

No

Yes

24 hours adequate toevaluate, treat or

respond?

Yes

Observation

No Inpatient

References

Federal Register, Nov. 10, 2005

Medicare Claims Processing Manual

Medicare Benefit Policy Manual

Mutual of Omaha

InterQual® admission screening criteria

HPMP Compliance Workbook