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* HFMA staff and volunteers determined that this product has met specific criteria
developed under the HFMA Peer Review Process. HFMA does not endorse or
guarantee the use of this product.
©2014 Executive Health Resources, Inc. All rights reserved.
AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for
its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be
increased by the providers to reflect fees paid to the AHA.
2 Midnight Case Examples and Documentation Tips
Ralph Wuebker, MD
1
• Physician’s Order
• Expectation of 2-midnight Stay
• Medical Necessity
• Documentation and Certification
2
Admission Review – Key Considerations
Inpatient Criteria
Met?
Review elements of certification
Review elements of certification
Recommended Hospital Work Flow
Validate or obtain order
change
Validate or obtain order
change
Re-review as new information is
available
Validate or obtain order
change
Physician Advisor Review
InpatientRecommendation
Observation/ OutpatientRecommendation
Follow this process when:• Physician documentation of expected discharge is greater than 2 midnights; or• There is no documentation of expected discharge
* Patient hospitalized for condition other than Inpatient Only Procedure List
Patient Presents at Hospital*
Expected LOS Greater Than Two Midnights or Unclear
No
Yes
3
No+
Recommended Hospital Work Flow
• * Patient hospitalized for condition other than Inpatient Only Procedure List. • +If the expectation is not correct, follow the workflow for an expected length of stay of greater than two midnights.
Condition Code 44
Obtain order change
Obtain order change
Observation
Resolve conflict between order and
expectation
Re-review as new information is
availableObservation Criteria Met?
Yes
No
Expectation correct?
Yes
IP Order?
No
Yes
Follow this process when: • Physician documentation of expected discharge is in less than two midnights
Expected LOS Less Than Two Midnights
Patient Presents at Hospital*
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Case 1
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Symptoms:• 80 year old female admitted with chest pain, positive biomarkers and
EKG changes in the emergency room, urgently taken to catheterization lab
Order • “Admit as inpatient”
Expectation of LOS• “I expect this patient to remain in the hospital for a time greater than 2
midnights”
Medical Necessity • Documentation present to support inpatient admission
Certification • All elements of certification present per document review
Follow up necessary
• Patient does not remain for 2 MN• Was (presumption not met) due to of the exception: death,
transfer, AMA, inpatient only procedure or “recovery faster than anticipated”?
• Evaluate based on start of service to see if benchmark met
Case 2
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Symptoms:
• 65 year old male, no previous cardiac history, presents with shoulder pain after exertion, physician suspects musculoskeletal, biomarkers below detection threshold, no EKG changes. Monitor overnight if telemetry, enzymes and EKG’s remain negative anticipate discharge in am. No planned stress test or further evaluation during hospitalization.
Order • Admit as inpatient
Expectation of LOS • 23 hour monitoring
Medical Necessity • Documentation does not support inpatient admission – observation
Certification • Order and physician expectation of 2 midnights are in conflict• Order and medical necessity are in conflict
Follow up necessary
• Consider Condition Code 44 if requirements are met• If patient remains in hospital, or new information available re-review
for medical necessity at inpatient level• If patient discharged – cannot do Condition Code 44, if within rebilling
timeframe, consider for Part B Rebilling
Case 3
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Symptoms:
• 78 year old female admitted for atrial flutter, stabilized in Emergency Room. Although expected to be discharged after medication adjustments, patient developed heart block requiring additional adjustments and possible pacemaker
Order • Place in observation
Expectation of LOS • Anticipate short stay, 23 hour monitoring
Medical Necessity • Delayed review suggests that inpatient may be appropriate
Certification • All elements of certification would need to be completed prior to discharge
Follow up necessary
• EHR would recommend inpatient level of service• Call with physician to discuss medical necessity in light of order change
requirement• Call with Case manager to discuss order change, and expectation
documentation with regard to certification requirements• Inpatient order, documentation of expectation and all other elements of
certification would need to be addressed prior to discharge
Case 4
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Symptoms:• 76 year old woman with UTI, treated with intravenous antibiotics.
Fevers continue with tachycardia and hypotension requiring fluid support. Immunosuppressed due to post kidney transplant status.
Order • Admit for inpatient services
Expectation of LOS • Admission orders include order for “discharge in am”
Medical Necessity • Would meet for inpatient by criteria, but documentation clearly violates 2 midnight expectation
Certification • Depending on follow-up activity, if inpatient supported confirm all elements of certification prior to discharge
Follow up necessary
• Although historically inpatient medical necessity would be met, the documentation does not support 2 MN expectation
• Resolve conflict between order/medical necessity and expectation• Update documentation if patient not discharged as planned
• Consider Condition Code 44 if expectation of discharge remains
Case 5
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Symptoms:• 68 year old male, with a history of stroke, known carotid stenosis, and
previous neck irradiation making carotid end-arterectomy high risk. Patient scheduled for carotid angiography and stent placement.
Order • Observation
Expectation of LOS • <2 midnights
Medical Necessity • Procedure appropriate for inpatient based on inpatient-only status
Certification • All elements of certification except the 2 MN expectation would be
required to be documented prior to discharge to support inpatient claim
Follow up necessary
• Order should be corrected for procedure on CMS inpatient only procedure list
• For procedures on the inpatient only list, order must be present on the medical record prior to the initiation of the procedure
• Inpatient only procedures are exempted from the 2 midnight expectation, but all other certification requirements remain
* HFMA staff and volunteers determined that this product has met specific criteria
developed under the HFMA Peer Review Process. HFMA does not endorse or
guarantee the use of this product.
©2014 Executive Health Resources, Inc. All rights reserved.
AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for
its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be
increased by the providers to reflect fees paid to the AHA.
Documentation Tips for Medical Necessity
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Common Documentation Reasons for UM Staff to call Attending Physicians
• Limited or no physician documented info (consult, ED note or H & P) several hours after “admission”– Only information available is a list of symptoms/ labwork/ Interqual®
evaluation • No plan of care or clear impression in the H & P
– Common with mid level providers • OP note/H & P for procedures that doesn’t address/include any risk from
past medical history– Frequently occurs from using office notes as history and physical
• Lack of discharge summary for a readmission review and no mention of stability on discharge/return to baseline in the discharge note.
• Continued stay review that doesn’t include the current progress note or orders to indicate why the patient requires continued acute care following stabilization
• To ensure the physician order matches the CM determination/billing status prior to discharge for billing concordance
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Common Poor Documentation Practices
• Using a symptom rather than a diagnosis for the impression or assessment–N/D/V vs. bowel obstruction–SOB, chest pain, headache, back pain–Listing the diagnosis as an intractable symptom (vertigo, abdominal pain, vomiting) without noting the potential diagnosis
• Using a lab value or treatment plan with no diagnosis
• Documentation for medical necessity is different than for billing level or coding
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General Documentation Takeaways
5 key pieces of documentation for Medicare cases and determining medical necessity of Inpatient:
•Medical History•Current Medical needs•Severity of signs and symptoms•Facilities available for adequate care•Predictability of an adverse outcome
CMS Medicare Benefit Policy ManualChapter 1, §10
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Key Words
• SUSPECTS – What is your suspicion of what is going on i.e. impression?
• CONCERNS – What are your concerns of the situation?
• PREDICTABLE RISK – Given the patient’s history and current presentation what kind of adverse outcomes are likely and what are the chances
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IP Documentation Review
• Custodial• Delay• Convenience• Any “kill the case” statements?
– Can go home from ER but the family cannot take care of the patient.
• “The patient was about to be discharged, but apparently she did does not have much help at home and she is unable to take care of her herself…”
– Contradiction of IP order and certification• IP order and “I anticipate 1 midnight in the hospital and hence she will
be admitted under observation.”– Here for placement– Home in AM after lab result
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IP Documentation Review
“Case Killer” statement:•“The patient was about to be discharged (from ER), but apparently she did does not have much help at home and she is unable to take care of her herself…”
•Instead consider:•86yo female with hx CABG, valve replacement and two hip replacements, had a ground level trip and fall, resulting in an acute left humerus fx and left sup and inf pubic rami fx. She was treated with IV morphine and had an episode of hypotension. Pt lives by herself and was being worked up as an outpt (for frequent falls). In addition, she is on IV antibiotics for a resistant organism after failing outpt treatment.
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Inpatient or Observation?
• 70 yo female presents after a buffet meal with epigastric burning. She has not significant PMH, has normal vital signs, normal physical exam. EKG and initial cardiac enzymes negative.
• Observation or Inpatient?
• 82 yo female presents with known history of CAD with previous MI & 3vCABG, presents c/o similar chest pain as her previous MI. Her vitals and physical exam are normal. EKG and initial cardiac enzymes negative. Plan for stress test and possible cardiac cath.
• Observation or Inpatient?
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Inpatient or Observation?
Observation level of care warranted because this 70 y/o female with no significant history presents with reflux following a large meal. My concern is for GERD as symptoms improved with minimal interventions (antacids). She is at low-risk for a cardiac ischemia based on her presentation, history, and objective findings.
No LOS is documented.
Inpatient level of care warranted because this 82 y/o female with known CAD, CABG, and PCI with recurrent angina similar to her previous cardiac event. My concern is for unstable angina as it is reoccurring at rest with SL NTG only providing short-term relief. She is at high-risk for progression of cardiac ischemia and myocardial injury.
2 midnight stay is reasonable for evaluation of cardiac related chest pain.
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Inpatient or Outpatient?
• 66 yo female comes in for and elective laparoscopic cholecystectomy as and outpatient no co-morbid conditions. Normal vitals and physical exam. No problems during the surgery, no complications.
• Plan for DC after breakfast.
• Outpatient or Inpatient?
• 76 yo female with severe COPD, Stage 3 CHF, CKD 4, comes in for an elective laparoscopic cholecystectomy. Normal vitals and physical exam prior to surgery. During the surgery patient with prolonged hypotension requiring large amounts of IV fluids. Post surgery patient took longer to be extubated.
• Outpatient or Inpatient?
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Inpatient or Outpatient?
Outpatient Extended Recovery level of care warranted because this 66 y/o female with no significant history underwent a routine and uneventful elective lap chole. My concern is for routine nausea and pain control. She is at low-risk for immediate post- operative complications.
Inpatient level of care warranted because this 706 y/o female with NYHA Class 3, CAD, COPD underwent an elective lap chole during which she became hypotensive requiring fluids and greater time to extubation. My concern is for acute decompensation of her heart failure. She is at high-risk for pulmonary edema.
Medical consult for post op management. Expect 2 midnight stay for recovery and medical management.
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EHR has been awarded the exclusive endorsement of the American Hospital Association for its leading suite of Clinical Denials Management and Medical Necessity Compliance Solutions Services.
AHA Solutions, Inc., a subsidiary of the American Hospital
Association, is compensated for the use of the AHA marks and for
its assistance in marketing endorsed products and services. By
agreement, pricing of endorsed products and services may not be
increased by the providers to reflect fees paid to the AHA.
EHR received the elite Peer Reviewed designation from the Healthcare Financial Management Association (HFMA) for its suite of medical necessity compliance solutions, including: Medicare and Medicaid Medical Necessity Compliance Management; Medicare and Medicaid DRG Coding and Medical Necessity Denials and Appeals Management; Managed Care/Commercial Payor Admission Review and Denials Management; and Expert Advisory Services.
* HFMA staff and volunteers determined that this product has
met specific criteria developed under the HFMA Peer Review
Process. HFMA does not endorse or guarantee the use of this
product.
21
©2014 Executive Health Resources, Inc. All rights reserved.
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