1. Publication MO-06-40-HPMP June 2006 This 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

2. The Decision Seems Easy… Presents Patient Admit as Inpatient Treat as Outpatient

3. 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

4. Patient Status Options Admit as Inpatient Outpatient Observation Outpatient Procedure and/or Followup Presents Patient

5. 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

6. 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

7. Why It Matters Why does it matter to the patient? Why does it matter to the hospital? Why does it matter to the physician?

8. Admit as Inpatient Treatment longer than 24 hours expected Outpatient treatment has not been effective Inpatient-only procedure necessary Continuous monitoring necessary

9. 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

10. Inpatient Admission Documentation Inpatient admission order with date and time Clinical documentation supporting medical necessity No “back-dating” is allowed

11. 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

12. Why Observation Services? Determines need for inpatient admission Rapid response to treatment is expected Patient has unusually prolonged recovery period following an OP procedure

13. Points of Entry for Outpatient Observation Admission from emergency department Direct admission Outpatient department(s)

14. 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

15. 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

16. 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

17. Chest Pain Process of elimination to determine chest pain is not cardiac in origin based on: – Symptoms – ECG – Enzymes – Possible early stress testing

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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.

27. Observation or Inpatient? Hospitalization required? No acute hospital care No Yes 24 hours adequate to evaluate, treat or respond? Yes Observation No Inpatient

28. References Federal Register, Nov. 10, 2005 Medicare Claims Processing Manual Medicare Benefit Policy Manual Mutual of Omaha InterQual® admission screening criteria HPMP Compliance Workbook