Case based approach to understanding CMS-required documentation for patients in the hospital

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Created by:
• Rekha D. Halligan, MD-PhD; Physician Advisor, FH
Edited by:
• Leila Hosseini, MD; Director, Physician Advisors; AHN
• Mark Rubino, MD, MMA; Chief Medical Officer, FH
• Ezz-Eldin Moukamal, MD; Chief of Medicine, FH
• Julie Chowan, RN, MSN, CCM; Director Care Management, FH
November 2015
Confidential & Proprietary Compliance Approved_11/15

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• Outline the reasons for this presentation
• List the criteria for medical necessity as defined by the CMS
• List the criteria for determination of Observation vs. Inpatient status for a
hospitalized patient
• Outline the process of compliance with the 2- Midnight Rule
• State the CMS criteria for any provider considered to be of “Major” concern after
an audit

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Why ?

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CC. “Can’t breathe”
HPI. 78 y/o female
• COPD
• Sick x 4 days w/ increasing dyspnea, new LE edema, orthopnea, and wheezing.
• No benefit with increasing home nebs.
• In ED, SBP = 105; pulse ox on 3 L O2 by NC = 88 %; + rales and wheezing.
• Treated with 60 mg Lasix iv x 1, nebs x 2
• Reported some improvement but not at baseline
• Pulse ox on 3 liters by NC = 91 %; less wheezing and less rales. W/ exertion
drops to 88 %
You are called by the ED.

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Question 1:
How do you decide whether to hospitalize the patient?

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Answer:
Medical Necessity

7. Page 7 DOCUMENT

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• After your evaluation, you decide patient needs to be in the hospital based
on the medical necessity criteria.
• You instruct the ED physician to put the patient under your service.
• You round on the patient and need to decide whether to put the patient
under Observation vs. Admit as Inpatient.

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Question 2:
How do you decide between Observation vs. Admit to Inpatient?

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Answer:
Severity of Patient Illness vs. Intensity of Services Needed in Hospital

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• Measurable and trackable signs
and symptoms
o JVD
o Extra heart sounds
o Abnormal lung sounds
o Extra oxygenation need
o Temperature abnormality
• Any supporting objective data
• Any interventions that cannot be
safely provided outside the
hospital?
o Meds needing administration
or monitoring in hospital
o Invasive investigations/
procedures
o Consultants appropriate for
the acute illness

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Moderate severity of illness
• Need of supplemental O2
• Suboptimal pulse oximetry
• Chest X-Ray
High intensity of services
• Frequent pulse ox
• Frequent BP checks
• Stability check while weaning off
oxygen

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• Extent of blood work ordered
• Extent of imaging studies ordered
• Extent of consultants obtained
• Placing patient on telemetry
• Placing patient in the ICU

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Before you select between observation and inpatient, know the…

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• For now, applies to Medicare FFS and
United Health Care only
• ED issues:
– ED waiting & triage time do not count
– Clock starts when treatment starts
• The first midnight in observation counts
towards the two midnight benchmark,
but it is still an outpatient day and does
not count toward the three, medically
necessary, inpatient days needed to
qualify for skilled benefits

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• You decide that the patient’s illness is such that it:
o Meets medical necessity, and is of
o Moderate severity that
o Will need high level of services,
o and because of what seems to be new onset heart failure and a
complex course so far, will probably end up crossing at least 2
midnights in the hospital

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You give verbal orders/are ready to enter the orders in EPIC and sign the certification.

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C TPN RD

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Question 3:
What must be documented in your Admission H&P?

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Answer
Document:
• Medical Necessity
• Severity of Illness
• Intensity of services
• Observation or Inpatient Status

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• Assessment (Journal your thoughts, tell the ‘why’ of the story):
o The patient has dyspnea probably secondary to AECOPD, not controlled by her usual
outpatient regimen. She did not respond significantly to the management in the ED.
Her edema and orthopnea are new and of unclear etiology.
o She is hypotensive and has DOE. ABG shows low O2 on supplemental oxygen.
o CXR consistent with pulmonary edema.
o I am concerned about progression of her underlying COPD and new onset heart
failure of uncertain type, both which can result respiratory failure needing intubation,
potentially worsening to death, needing at least a 2 MN stay.

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Plan what you are going to do: observation or admit to inpatient
• Admit as Inpatient
• Continue Lasix, nebs, and O2
• Monitoring BP and serial pulse ox
• Check Cardiac echo to check function to help guide diuretic therapy
• Pulmonary service input for the optimization of COPD regimen

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HPI.
“No improvement with increase in home nebs and ER interventions. Pulse ox suboptimal and
ongoing wheezing, rales and persistent DOE.
PMH.
COPD
ROS.
Wheezing without relief over the last 4 days, early satiety due to abdominal fullness/edema,
difficulty walking because of LE edema
PE.
Vitals: Pulse ox on 3 L by NC: 88%, BP 95/45; RR 20/min; wheezing and rales; +S3, +2 pitting
edema
Labs.
ABG on 3 L by NC: 7.45, 35, 85; Hgb 12; CXR hyperinflated lungs with increased interstitial
markings; ECG consistent with LVH.

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Must document in your progress note
daily
• Ongoing medical necessity of
why the patient needs to remain
in the hospital
• Objective data (in addition to the
subjective data) supporting the
medical necessity
• Before the 2 MNs have passed, must
document in Progress Note or
Discharge Summary the reason for
patient discharge earlier than your
expectation that the patient was
going to need to cross 2 midnights to
get better
• EPIC users; check appropriate box at
discharge

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• Recovered faster than expected
• Left AMA
• Refused treatment
• Transferred to a higher level of care
• Deceased
• Election of hospice care in lieu of continued treatment in the hospital

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29. CMS criteria for any provider considered to be of
“Major” concern after an audit
Based on results of the random audits, any provider with
denials of 7 claims out of a sample of 10 will be
considered to be a Major concern.
If CMS unable to obtain a 10 claim sample, providers
would be in a moderate concern.

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Procedures Defined as ‘Inpatient–Only’
http://bulletin.facs.org/2013/06/the-inpatient-list/
• Click on CMS website in body of the
bulletin
• Click Hospital Outpatient Regulations
and Notices
• Click CMS-1601-FC
• Click CY2014 OPPS addenda
• Click Accept
• Click Open
• Click Addendum E either in txt or xlsx
format

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http://moodle.wpahs.org/course/category.php?id=37
Approved for AMA PRA Category 1 Credit TM
• Log In,
• Click Course List
• Click Compliance
• Click CMS Inpatient Orders and Physician
Certification Requirements
• Read the course, take the quiz
• Earn 1 unit of AMA PRA Category 1 Credit TM

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2
Take Home
Messages

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You wish to or are
asked to bring patient
into the hospital
Meets
Medical Necessity
criteria?
C TPN RD
Assess severity of
patient illness,
Assess the intensity
of needed hospital
services
Determine if patient
will cross 2 MNs in
order to return to
baseline?
Does not need
hospitalization
before crosses
2 MNs
Crosses 2 or more
MNs: Document in
Progress Note the
Medical Necessity of
Staying in house
Document in
Discharge Summary
and/or check in EPIC,
reason for discharge
before crossing 2
MNs
Back to baseline
before crossing
2 MNs
Condition worsens
before crossing
2 MNs:
Document medical
necessity and convert
to Inpatient
Discharge
Yes No
Admit to
Inpatient
Place Under
Observation
Discharge when
returns to baseline
Start Here

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• Best practice for reviewing the medical necessity of [Medicare] inpatient
admissions has not changed with the institution of the 2-midnight rule.
• CMS provides guidance that the decision to admit a patient is a complex
medical judgment made by a physician in consideration of several factors,
including the following:
• The patient’s age
• Disease processes
• Comorbidities impacting on patient’s presentation
• The severity of the signs and symptoms of the patient’s medical condition
• The medical predictability an adverse event
• The best practice for review of admissions includes the consistent and
reproducible application of evidence-based medical criteria, such as
commercial screening tools, to all cases.
• A trained and experienced physician advisor, also utilizing evidence-based
medicine and published medical literature, can assist in cases which fail the
initial screening criteria.

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• Contact a Physician Advisor and/or Case
Management if you have any questions
about the content in this presentation.