With the Oct. 1 implementation of the 2014 Inpatient Prospective Payment System (IPPS) rule and the “two-midnight” benchmark for inpatient admission, some in the hospital industry have questioned whether physician advisors (PAs) still are needed to assist with billing status determinations.
In turn, some physician advisors are concerned about their jobs. Well, I would maintain that physician advisors still play a critical role in assisting hospitals with compliant admissions.
Let's count the ways:
- The Centers for Medicare & Medicaid Services (CMS) has not explained what a two-midnight stay looks like, and different physicians may have very different ideas about this. The PA can review each case and advise the attending physician by providing an independent secondary review when a case manager finds that the justification for inpatient admission appears to be weak – especially if the patient fails InterQual or MCG screening. The PA will look critically at the documentation and form a judgment on whether it justifies the expectation of a stay crossing two midnights or more.
- There can be a question of whether there is medical necessity for a second midnight in the hospital, as required to reach the two-midnight benchmark for admission. "CBC in a.m." won't cut it if the last CBC was normal and the patient isn’t bleeding. Not every patient needs “lytes in a.m.” or “IV D5W at 50 cc/hr,” do they? This type of ordering could be considered gaming, but some doctors honestly may think that anything they order for the next day will qualify the patient for admission. The decision must be clinically appropriate, and the reason for the stay past the second midnight should be documented at this time. The physician advisor can review the record and discuss medical necessity with the physician when the need for the second midnight’s stay is in question.
- CMS has indicated that a patient’s stay should not cross a second midnight in the hospital without being admitted. But there will be cases with no discharge or admission order before the second midnight, and the patient will have spent two midnights as an outpatient. Now what? CMS has provided no guidance (so far) on what to do in this situation. It just doesn’t seem to have considered this scenario. Is the patient going home, or do you admit on day 3? The physician advisor can help the case manager and treating physician determine the proper course of action based on consideration of the patient’s condition and the treatment plan.
- Weekends present another sticky problem. Often, a test or procedure a patient needs is not available on the weekend. If the physician won’t release the patient and continue care in an outpatient facility, a decision must be made whether to admit or place him or her in an outpatient bed for the weekend. The physician must consider the medical necessity for the procedure and the need to have it done prior to discharge, based on the risk to the patient. This is another area where the physician advisor can help case managers negotiate a tricky discussion with the attending, and he or she can assist by suggesting alternatives.
- Say a patient is admitted with a two-midnight expectation and is ready to go home after one midnight. Do you convert to outpatient with Code 44? If the patient has been discharged, is this case appropriate for Part A billing, or do you submit a provider liable/no-pay claim and re-bill under Part B? The PA reviews the admission documentation to advise on appropriate actions to ensure correct billing status and avoid payment denials.
- Say a patient was discharged after a two-midnight inpatient stay, but upon pre-billing review, it appears that the patient never should have been admitted. These cases also should have PA review prior to billing. A physician member of the utilization review (UR) committee also has to review the case (just as in the Condition Code 44 process) if a Part A claim is to be rebilled as Part B.
- What if a patient had an outpatient procedure, but was admitted either before or after the procedure? These types of claims are often subjected to audit. Was there justification for inpatient status, or should Part B be billed? The physician advisor will look at the documentation that was entered in the record at the time of admission and advise whether there was sufficient cause to anticipate a two-midnight stay – or, for patients admitted after the procedure, whether there was a post-operative complication that justified admission.
- When a Part A claim is denied by a RAC, MAC or CERT, do you appeal? The PA can review the admission documentation, evaluate the strength of that documentation, and advise on whether an appeal should be made and which clinical arguments should be used. On the other hand, the physician advisor may recommend accepting the denial and re-billing Part B if it still is within the timely filing limit of one year from the date of service. The physician advisor also may write or review the appeal letter.
- CMS makes physicians responsible for ordering registration status, but they are not always knowledgeable about the regulations. The PA plays the leading role in physician education (and their re-education as well).
- Hospitals will continue to use InterQual and MCG for first-level screening, but with the new admission criteria, even cases that pass initial screening may not qualify for admission due to lack of a basis for the two-midnight expectation. On the other hand, some that fail criteria will qualify for admission based on the patient’s clinical picture and anticipated needs. The physician advisor reviews the record and may speak to the treating physician(s) to determine whether the IPPS admission criteria are being met. If short inpatient stays routinely become long observation stays, hospitals will lose revenue and beneficiaries may experience considerably increased out-of-pocket expenses.
So if you are a physician advisor, don’t be alarmed. I think there's job security for PAs.
About the Author
Steven J. Meyerson, M.D., is a Senior Vice President of the Regulations and Education Group (the “REGs Specialists”) for AccretivePAS®. He is Board Certified in Internal Medicine and Geriatrics. He has recently been the Medical Director of Care Management and a compliance leader of a large multi-hospital system in Florida. He has distinguished himself by creating innovative service lines and managing education for Accretive PAS®.
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