ACPA Update – August 2021

ACPA Update

August 2021

In this Update

Editor's Note

Physician Advisors: Decreasing the Distance between Revenue Cycle and the Bedside

Peer to Peer - Pearls and Pitfalls

COVID 19 Commercial Readmission Denials

Ten Points to Improve Clinical Documentation with the ED as a Model

Observation Committee Case of the Month

Observation Committee Case of the Month Responses

Observation Committee Town Hall Unanswered Questions

President's Corner

Editor's Note

Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI

Member, ACPA Advisory Board

Editor, ACPA Update

How many of you were like me and had your world turned upside down when on July 19th CMS released the 2022 OPPS proposed rule and decided their three year plan to eliminate the inpatient only list was a mistake and they are going to reset everything back to 2020? Are they serious? Well it sure seems so. Why is this happening? Well, that depends on who you ask. CMS will tell you that they determined they may have acted to quickly without really considering the patient safety issues involved moving 298 surgeries off the list. But many believe that the payment differential between the same surgery done as inpatient and outpatient was so large as to threaten the finances of every hospital and the AHA convinced CMS to stop and back up.

But aside from why it happened, what we all really need to do is figure out what to do with the information now. First, note that total hip and total knee replacement will remain off the inpatient only list, as will all the other surgeries that were removed prior to 2021, such as cervical and lumbar fusion. So the status determinations for these cases must continue to follow the 2-midnight rule, however your facility interprets that.

Second, this is only a proposal. CMS may get comments and decide that the move to eliminate the list makes sense but the way they do it was faulty. And until they release the final rule, usually at the start of November, all 298 surgeries remain off the list. Now does that mean that a surgery that can be done as outpatient on December 31st must be performed as inpatient the next day on January 1st? Does that make sense? If CMS says there may be a safety issue performing these surgeries as outpatient, is it safe to continue doing them as outpatient? This is where you as a physician advisor show your value to your institution. You need to assess the situation, provide the background, make an assessment, and then provide your recommendation.

And as you evaluate your options, stop and take a minute to submit a comment to CMS about what to do. Submitting comments is easy; simply go to this link https://www.regulations.gov/document/CMS-2021-0124-0001 and start typing. I’ll tell you what I think; the list can still go away but they have to fix the payment differential between the DRG and APC. Now allowing surgeries to be performed at ASCs, that is where safety plays a role in the determination.

Changing topics, if you haven’t heard of Dr Christopher Duntsch, a neurosurgeon from Texas, I urge you to listen to the podcast about his career or watch the new Peacock television series, both titled “Dr. Death.” It is almost unbelievable that this is a real story. That title may give you a clue about what to expect. As a physician advisor, you may see or hear things that others in the hospital don’t see or hear, albeit not as bad as what Dr. Duntsch did. And you may have a choice to either keep quiet or say something. I hope you will choose to do the latter.

Want to write an article for the next newsletter? Email me at signaturedoc@gmail.com.

Physician Advisors: Decreasing the Distance Between Revenue Cycle and the Bedside

Anthony Muni, MD

Member, American College of Physician Advisors

Few physicians understand a hospital’s revenue cycle. Practicing physicians’ top priority is patient care, as it should be, and most have little concern how their practice impacts hospital finances. In the era of cost containment, cost consciousness, price transparency and accountable care, physicians need greater awareness of the hospital revenue cycle and healthcare finances in general. Patients are becoming increasingly savvy and their physicians need a basic understanding of hospital finances in order to communicate with them intelligently.

When it comes to hospital based revenue cycle and finances, physicians have the greatest control over assigning admission status and diagnosis related group. Though Utilization Management (UM) and Clinical Documentation Integrity (CDI) departments follow criteria and rules regarding these areas, the physician’s orders and documentation still drive these decisions. In the last ten years, physician and other healthcare providers are becoming more accustomed and comfortable with this but there is still a large knowledge gap for most providers and institutions. For this reason, it is imperative for intimate physician leadership in the UM and CDI processes. Assuring this will increase physician knowledge of and skill in revenue cycle and decrease the distance between revenue cycle and the bedside.

This concept of decreasing the distance between revenue cycle and the bedside is an important one as it seems many areas of healthcare management are increasing the distance from the bedside. That is tolerable for some areas but for UM and CDI, it is not. Physician leadership in revenue cycle can take many forms and one form is not necessarily better or worse than another. This involvement can be a chief medical officer position to a medical director or can take the form of dedicated or even part time physician advisors. This leadership structure will depend on the needs of the institution, its size and resources as well as the talent available to it. Some health systems may have an internal candidate capable of fulfilling this role while others may need to seek an outside candidate. Whatever this model looks like, physicians involved in the revenue cycle process should be intimately involved in the following domains.

Connection between revenue cycle and executive leadership. Revenue cycle usually reports up through the institutions CFO. Several of the people in this hierarchy may have a clinical background but if they do, it likely has not kept up with the current healthcare landscape pertaining to clinical practice. UM and CDI may have excellent ideas and initiatives but often they may not have the organizational influence to modify or change policy or procedure. A physician leader in revenue cycle can help bridge this gap and be an advocate for change.
Connection between revenue cycle and practicing providers. As mentioned above, many providers have little insight into the revenue cycle and how much they actually control. This physician leader can be invaluable not only educating practicing providers but also being a conduit back to UM and CDI when these providers have issues or difficultly with current processes. UM and CDI are complex worlds with many rules and regulations that differ based on payer, whether it be CMS, managed insurance plans or commercial ones. Communication between physicians and UM and CDI staff may be awkward and sometimes even contentious. A physician leaders helps to break down these barriers.
Connection between hospital system and payers. Physician involvement in insurance company calls, denials management and contract negotiations is key. Private payers almost always have their medical directors involved in key financial decisions and hospitals need to do the same. These peer to peer conversations carry significant weight in decision making and help break down clinical barriers that these regionalized companies may not understand at the local level. A physician leader in the revenue cycle should also have knowledge of CMS rules and regulations, specifically in the realm of utilization management and utilization review, as well as a relationship with their assigned Quality Improvement Organization (QIO).

Strong physician leadership within revenue cycle is not a luxury it once was. Their involvement in the current healthcare landscape is a necessity as margins become thinner and regulations become tighter. How this leadership structure is modeled will vary depending on the institution but regardless of how this looks, the distance between revenue cycle and the bedside will be bridged.

Anthony Muni, MD is Chief Medical Officer, Utilization Management & Clinical Documentation Integrity at University Hospitals in Cleveland, Ohio

Peer to Peer - Pearls and Pitfalls

Scott M. Brenner, MD, FAAP

Member, American College of Physician Advisors

Peer to peer discussions represent a significant aspect of Physician Advisor work. These have evolved as payers continually change both their approach to payment and their use of evidence-based criteria. In the past, these discussions were primarily a forum for two physicians to dissect a case and determine if, in fact, the patient was most appropriately cared for in the inpatient setting. As time has elapsed, the decisions of Medical Directors have become largely criteria based, especially during the initial 48 to 72 hours of the patient’s hospitalization. Physician Advisor success can be improved when certain strategies are employed.

First and foremost, if the discussion centers around criteria, it is important to understand the criteria that they are using and to point out cases where the patient in fact does meet criteria for inpatient admission, specifically based on those criteria utilized by the payer. While most payers will tell you that criteria are only a guideline, a majority of medical directors will use these to deny cases. However, if the patient does in fact meet criteria, pointing this out will often quickly end the discussion in favor of the Physician Advisor. For example, Milliman require a bump in creatinine to three times baseline. It is therefore critical to know the baseline of the patient and if their creatinine during the hospitalization meets this criteria point. If so, the Physician Advisor will prevail.

Although criteria have become a mainstay of these discussions, many Medical Directors will approve the case if the patient has been in the hospital “beyond a reasonable observation timeframe and continues to be symptomatic or receive appropriate inpatient care. Therefore, articulating the condition of the patient on hospital day three and being specific about abnormal vital signs, persistence of symptoms, abnormal labs and specific interventions will often result in a favorable outcome for the hospital. In addition, discussing the complexities of an individual patient with regard to a specific diagnosis and/or treatment plan can go a long way in ensuring that the case is viewed favorably by the Medical Director.

Patients with multiple comorbid conditions can present greater difficulties in management. For example, a patient with an acute exacerbation of CHF who has concomitant chronic kidney disease results in greater complexity of diuretic management and fluid balance. In other cases, although any specific problem may not meet criteria, discussing the multiple medical issues being managed and the interplay of these issues in developing a management strategy can again often result in a favorable outcome of the peer to peer discussion.

Medical directors often don’t have all of the information. Providing additional information and articulating the need for ongoing care in the inpatient setting is often enough to prevail in peer to peer conversations. In addition, it is useful to remember that Medical Directors are colleagues and not adversaries. Their job is to represent the insurance company and the job of the Physician Advisor is to represent the interests of the hospital. In both cases, each physician believes that they also represent the interests of the patient. Being cordial, but direct, in these conversations will assist in more favorable outcomes for the Physician Advisor. Of course, the role of the Physician Advisor goes beyond interactions with the payer. Assisting hospitals in ensuring that patients are in the correct status and that progression of care is appropriate will reduce the number of denials and as a result, the number of peer to peer discussions needed.

Always being prepared with the necessary information to conduct a peer to peer, an understanding of the criteria being used and a broader knowledge of the patient’s overall condition and it’s effect on the care being provided will certainly result in an increase number of favorable outcomes for the Physician Advisor.

Scott M. Brenner, MD is Chief Medical Officer at PAOC

COVID-19 Commercial Readmission Denials

Nicholas S. Libertin M.D., CHCQM-PHYADV

Member, American College of Physician Advisors

If your health system has not received commercial COVID 19 related readmission denials...they will soon. At the inception of the pandemic, my health system did not receive ANY of these denials for our COVID 19 patients. Then…they slowly began to trickle in. They may be disguised as COPD or CHF exacerbations who “just happen” to be COVID +, have bibasilar infiltrates on CXR, acute hypoxic respiratory failure, a cough and lymphopenia…but there they were.

Commercial insurance providers will deny a second inpatient stay if they feel it is directly related to the 1st admission and within 30 days. Different insurers have different exceptions to this policy (oncologic care, AMA etc.) but the overarching theme is the same. COVID 19 presented a plethora of challenges for health systems that were dealt with in real-time. Do we treat with Remedesivir and steroids? Who do we treat? Who needs to be admitted to the hospital? Who can safely go home? We quickly discovered elderly patients as well as those with major comorbidities were at higher risk for adverse outcomes. Hospitals and communities banded together and began evolving care at a rapid rate. Patients' hospital length of stay decreased as more aggressive outpatient treatment regimens were developed to save hospital bed space for the critically ill. These same insurers even started to argue that many of our hospitalized patients could have care rendered elsewhere.

COVID has proven itself unpredictable, and unfortunately a subset of patients will decompensate as part of the natural progression of the disease and subsequent complications. Patients can suddenly deteriorate weeks after their positive PCR test and symptom onset due to a cytokine storm. It is not feasible to monitor these patients in a hospital bed simply for the possibility that they will deteriorate and be readmitted (for 30 days no less!). This would unnecessarily occupy bed space (not ideal for insurers nor hospitals) and place other hospital patients at risk. The hospital is thus put in an impossible dilemma. As advocates for both our patients and health systems, we need to be proactive in fighting these readmission denials. These admissions are not preventable nor avoidable (especially given the resources at the time), and the health system should not be penalized for providing excellent care. The first and most important step is documentation education. In our health system we have monthly educational sessions that are provided by physician advisors specific to each facet of our health system (outpatient, inpatient and emergency room). We also have physician documentation specialists to help our providers capture acuity.

Once the readmission denial has been administered, we make sure to appeal nearly all of these with a letter written by one of our physician advisors. I have had some success in overturning these denials by providing well established data in my appeal letters. I will include the patient’s COVID-GRAM Critical Illness Risk Score and Veterans Health Administration COVID-19 (VACO) Index for COVID-19 Mortality (both easily calculated on the website “MD Calc”). These provide objective assessments of a patient’s risk for critical illness and mortality. Now, if only we could develop a score that predicted the likelihood of insurance companies retroactively denying inpatient admissions during the midst of a pandemic?

Does the patient have a beating heart?

Evaluated in the hospital for a medical condition?

Number of medical problems > 1?

Your hospital billed for an IP admission?

Each affirmative answer scores a 1 and any score of 1 or more is subject to denial

(Shout out to Dr. Carolyn Dutton for this scoring system)

References:

Dr. Libertin became a Cleveland Clinic Enterprise Physician Advisor in 2020 and is ABQAURP Health Care Quality and Management Certified with a physician advisor sub-specialization. He is a Clinical Assistant Professor of Emergency Medicine at Case Western Reserve University.

Ten Points to Improve Clinical Documentation with the ED as a Model

Erica E. Remer, MD, FACEP, CCDS

Member, ACPA Board of Directors

Co-Chair, ACPA Clinical Documentation Integrity Committee

I just finished developing a webinar to present best documentation practices to emergency medicine residents, and thought I would share some thoughts with you. It is generalizable to other segments of medicine.

1. Get ‘em young

Residents are the ones doing the lion’s share of the documenting and teaching them is a big bang for your buck. Since we mostly teach documentation by legend in medicine, training the youngsters reaps rewards for years to come.

2. Know why you are teaching it to them

Optimizing emergency medicine documentation serves multiple purposes:

Supports medical necessity for status determination
Improves medical care because it takes discipline to organize documentation
Establishes conditions as being present on admission
Conditions in the ED may resolve by the time the patient arrives in their room. If it wasn’t documented, did it exist?
Models good documentation for the folks upstairs to imitate and propagate
Improves mortality quality metrics

Why is the administration or their department asking you to give them education?

3. Know why they might be interested in learning it

Their motivation for learning it may have nothing to do with your motivation for teaching it to them. In the ED, I focus on how documenting comorbidities supports complexity of medical decision making for the professional fee (providers do care about money if it goes into their kid’s college fund, not necessarily if it is the hospital’s coffers). It also makes the emergency medicine group more valuable to their employer (the hospital) which encourages retention. Excellent documentation is valuable for medicolegal reasons, and, of course, documentation is first and foremost for clinical communication, so patient care is improved.

4. They need to know the “why” to change their behavior

They need a rudimentary understanding of how the facility gets paid (i.e., Diagnosis Related Groups methodology and metrics), and how documentation, coding, quality, and reimbursement intercalate to be motivated to make changes in their clinical documentation. If they don’t know why, you are just asking them to do one more thing for no good reason.

5. It’s always about the O/E

Just about everything in medicine relates to Observed to Expected metrics (O/E). Improving care delivery affects observed, but documentation and capturing all comorbidities to reflect how sick and complex the patient is impacts expected.

6. No one really expects you to document every single thing that you thought or that happened

If it isn’t documented, it still could have happened. No one will know, though.
If it is important to be recorded and registered, it should be documented in a codable format.
There should be a diagnosis for every complaint, significant physical finding, and procedure performed.

7. How you document things matters

Computer-assisted coding or CDI, utilization review/case management, auditors, and other clinicians read your words and make assessments based on how you documented conditions. If you use verbiage that mirrors or is concordant with the terminology they are looking for, you will get credit for that condition.

“hemodynamic instability as evidenced by hypotension and tachycardia” will support inpatient status
Metabolic encephalopathy may be manifested by altered mental status, but it takes that verbiage to capture the major comorbid condition or complication (MCC)

8. You should follow the basic tenets of documentation

Don’t describe, ascribe. Don’t just record the derangements; interpret them. “Creatinine elevated” does not equate to Acute Kidney Injury (AKI), and “sepsis-like picture” is not “Sepsis.” Importing the radiology findings into your document isn’t asserting clinical significance.
Making diagnoses can be a hASSLe, but include acuity, severity, specificity, and linkage to get most specific ICD-10-CM code.
Lead with the lede. Is the patient being admitted for the UTI or the sepsis which has resulted from the UTI? Have sepsis be the first diagnosis or sequence it with linkage: Sepsis from UTI with acute sepsis-related organ dysfunction as evidenced by metabolic encephalopathy, AKI, and hyperlactatemia.

9. They don’t need to know every CDI condition in medicine, every CC or MCC

They need to know the ones they are likely to see the most, recognize the least, or have the greatest impact. I sing, “Brain, heart, lungs, organs, circulation, code status,” to the tune of Frère Jacques and pick the top two or three conditions in each category to teach them. In the emergency department, documenting hemorrhagic shock or coma may be key whereas in general surgery, ischemia and peritonitis may be important.

10. They should put MENTATION back into documentation

Patients benefit when the providers think about what is going on. In the ED, putting a name to abnormalities and thinking about how all the patient’s conditions fit together improves the patient care. If a patient is hypokalemic 3 days in a row, perhaps the answer isn’t just potassium supplementation but exploration as to the etiology.
In the Office space, the Evaluation and Management level of service is completely dependent on medical decision making (MDM) now, and it is likely to spread to other places of service. The ED course (on the floor, the assessment and plan) is the location in the record where MDM is expressed.
Clinicians must think in ink (even if it is exclusively electronic!).
In the ED, they should be sure to mindfully edit templates to reflect the patient in front of them. On the floor or in the unit, they should think of it as copy and edit as opposed to copy and paste. The documentation should tell the story accurately and truthfully whatever venue they are in.

And finally, the most important thing you can do to improve the documentation of your flock is to believe that documentation is important yourself.

Dr. Remer is the founder and president of Erica Remer, MD, Inc., icd10md.com

Observation Committee Case of the Month

Provided by the members of the ACPA Observation Committee

An 83yo female with FFS Medicare with atrial fibrillation on anticoagulation presents to the ED after a fall. She is unable to provide consistent history, but denies any complaints; per her son, she lives alone and has been increasingly struggling to perform iADLs, but she seems acutely worse over the last week or so. She fell, and EMS reported that the house was in a state of squalor. She is hemodynamically stable, and a trauma survey (performed because of a fall on anticoagulation) did not reveal any musculoskeletal injuries. Her urinalysis showed 5-10 WBCs per LPF and bacteria, but nitrites were negative. Hospitalization is requested, because family cannot care for her. As it is Friday evening, you expect that she will be in hospital for several days.

What status is appropriate?

Inpatient
Observation
Outpatient in a bed

The following day, the urine culture is no growth and no other abnormalities have presented. The patient is cooperative and pleasant but not oriented to place, time, or situation. Nurses are concerned about her gait stability. No post-hospitalization services have been arranged and thus she will stay in hospital and cross a second midnight. What is the appropriate status?

Change to inpatient
Remain in observation
Change to “Outpatient in a bed”

On Sunday, the patient becomes agitated and not redirectable; she strikes at staff and requires sedation. Does this merit change to inpatient status?

Yes
No
Maybe

To answer this month’s questions, go to: https://www.surveymonkey.com/r/8CHN2W9

Observation Committee Case of the Month Responses

Provided by the members of the ACPA Observation Committee

Last Newsletter Case Responses

Case 1

80-year-old Medicare FFS female with PMHx of CAD, CABG, Atrial fibrillation s/p ablation on Xarelto, DM, HTN, and Hyperlipidemia presents with progressive exertional dyspnea with recent outpatient positive stress test. Patient was supposed to have elective cardiac catheterization later this week but due to worsening dyspnea presents to the ED. Patient is placed in Observation status to cardiology service with plan for cardiac catheterization given recent positive stress test and symptoms concerning for angina. Cardiac catheterization that day reveals LAD stenosis and a DES stent is placed. Patient is observed overnight post stent placement. Next morning patient is noted to have decline in Hemoglobin from 9.0 to 8.1 and upon further questioning patient now reports recent dark stools. Cardiology service consults GI team given that patient is now on triple therapy with aspirin, Plavix, and Xarelto and high risk for worsening anemia. GI team evaluates the patient and recommends EGD in house due to recent dark stools and reflux symptoms. Patient is hemodynamically stable but noted to be guaiac positive on exam.

Utilization Management RN sends you the case for a second level review since patient has traditional Medicare fee for service and anticipated to cross a second midnight for EGD procedure and hemoglobin monitoring.

Case 1 Response

This is the first time we have seen 100% of the responders pick the same answer choice. All 18 respondents said they agree with Inpatient as the most appropriate status for this case. First midnight clearly meets medical necessity for post-stent monitoring for any complications. After the first midnight, the patient is found to have a down trending hemoglobin with dark stools in the setting of triple therapy. While some may argue patient’s EGD/colonoscopy could be deferred to outpatient setting, being on triple therapy certainly puts the patient at risk. Even if the procedures are deferred to the outpatient setting, patient will meet medical necessity if the cardiologist wishes to trend hemoglobin further, monitor for any further bleeding along with the possible of adjustment in anti-platelet therapy. Therefore, 100% of the responders would recommend this patient to be admitted to Inpatient status for further medical necessary care.

Case 2

67-year-old male with obesity, OSA, and hypertension, covered by Medicare, presented with abdominal pain at 6 am. He is diagnosed with appendicitis by CT scan. Surgery is consulted in the ED at 9 am and after discussion with the patient, conservative treatment with antimicrobial therapy is chosen. You are asked to help the surgeon determine the proper status at this point. The surgeon plans to start iv antibiotics and monitor the patient.

The next day, the patient was transitioned to oral antibiotics, pain medication, and antiemetics. Patient remains afebrile and hemodynamically stable. However, he developed increased nausea and did not feel able to safely go home independently, resulting in a second hospital night.

Case 2 Response

For the presented appendicitis case, the overwhelming response was outpatient with observation services (14 responses) versus one favoring a change to inpatient status. The first question for fee-for-service Medicare is always “does the patient need medically necessary hospital care?” As presented, it seems that the patient remained in hospital for a second midnight due to personal preference, and that is not necessarily medically necessary care justifying inpatient status. The devil is always in the details, however, and in a case like this I think the physician advisor should contact the admitting physician and get more information. You may find that the patient actually has intractable nausea and cannot maintain hydration, or that the surgeon is worried about ileus, or something else that may warrant a change to inpatient status if properly documented.

Observation Committee Town Hall Unanswered Questions

During the June, 2021 Observation Town Hall, several questions were not addressed. The committee provided the following answers.

Traditional Medicare related questions

Q - After 24hrs, if the Medicare patient does not have medical necessity for 2MN we downgrade to Outpatient. Is that wrong?

A - No. The definition of a patient who should be inpatient status is the expectation or fact of 2 midnights PLUS a need for hospital level care during that time. Logistical delays and unnecessary care do not justify the second midnight, only acute care needs properly documented do. And based on our probe and educate experience, I think the “expectation” of 2 midnights at presentation, while the rule, is less helpful than the fact of 2MN or a properly documented exception.

Q - How do you handle patients who come to the hospital for X complaint and the ED has cleared for discharge however the family is unable to care for the patient at home. There is a need for physical therapy and occupational therapy evaluation for weakness and possible rehab placement. Do you place these patients under observation until placement is found? And if not - what status do you place these patients?

A - Not observation as presented. Observation is for medical decision-making. If the weakness is chronic and the inability to care for self is not due to an acute medical issue, I would call that a custodial hospitalization, place the patent in bedded outpatient status, and not submit an insurance claim. If there is a medical question, we may observe for 24 hours to let cultures mature, etc, but again not inpatient as presented. But… they might stay in hospital anyway. We are often the safety net, and maybe the patient has nowhere else to turn, but that’s not acute medical necessity

Q - What if the patient lives alone? Does it warrant inpatient admission or obs for ambulatory dysfunction?

A - No, if there is no concomitant acute medical condition to explain the issue or merit hospital workup. If the admitting service makes the patient inpatient, I have tried to leverage a HINN-1 process to get the QIO to support IP, but the QIO has not understood. Another option is to perform a condition code 44 with UM committee input as referred in the question above.

Q - How do you handle delays in diagnostic tests. Such as the TIA work up. Extending over 2 midnights?

A - Medicare has explicitly stated that avoidable logistical delays do not equal medically necessary midnights. If that new onset atrial fibrillation patient came in on a Friday, was ready to go Saturday, and sat in the hospital until Monday for a TTE and discharge, that does not equal inpatient medical necessity. On the other hand, if the patient needs a surgical procedure, and is on a DOAC, and cannot undergo the procedure expeditiously due to needing to wash out the DOAC, I will call those midnights medically necessary. And if the patient needed to be in house anyway—for example, that AFib patient remained in intermittent RVR with low pressures and had two medically necessary midnights, and the TTE was delayed to Monday, then that is inpatient-appropriate with a potential extra day.

Q - Our ED providers appear to want to place patients who come to the ED with a history of falls into OBS for a 'safety and risk assessment' even though they have no concerns there is a medical / neuro issue causing the falls. The other type of patient they want to place in OBS for this same reason is the elderly person who lives alone and has cognitive deficits but can independently perform ADLs and ambulate, but cannot make good decisions due to cognitive impairments that are baseline. In this case, family members indicate they can no longer live alone and they want the patient placed 'somewhere'. What are your thoughts on these situations?

A - As presented, this is what I call a custodial admission. We have these patients in a bedded outpatient status and do not submit an insurance claim. They may need to stay because there are no other options and this is the societal expectation and local standard of care but does not support an IP claim.

From a care management perspective, we know that there are times that this happens. Consider discussions with local adult family homes, assisted livings, and SNFs that would consider taking these patients under single case agreements for charity care while the care management works through the dynamics. Having a plan of where these patients could go in advance, prevents them from being trapped in the hospital using expensive resources.

Q - If patient presents to the ED and the plan is to transfer to another facility due to lack of services at transferring facility but there is no bed availability at receiving facility, should they be placed as Observation even though they will most likely need a 2 midnight hospitalization at the accepting facility?

A - If the patient needs ongoing medical care and there is a two-midnight expectation, then I would admit them to inpatient and transfer when possible. It would not be appropriate to say you were providing observation services to such a patient, and transfer is an allowable exception to the 2MN policy. Capacity issues are huge everywhere, and this is a scenario that happens all the time…

Commercial/Medicare Advantage payor related questions

Q - What is the intent or explanation of the CMS Policy Manual Chapter 6, section 20.6 "observation services", can it apply in any way to inpatient services definition?

A - While MA/commercial payers do not follow CMS policies when it comes to observation, however, I have used this section when debating payers medical directors who claim that observation can be unlimited number of days. At that time, I will state this is not how CMS perceive observation services.

20.6 - Outpatient Observation Services (Rev. 215, Issued, 12-18-15, Effective, 01-01-16, Implementation: 01-04-16) A. Outpatient Observation Services Defined Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge.

Observation services are covered only when provided by the order of a physician or another individual authorized by state licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours, usually in less than 24 hours. In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours.

Hospitals may bill for patients who are directly referred to the hospital for outpatient observation services. A direct referral occurs when a physician in the community refers a patient to the hospital for outpatient observation, bypassing the clinic or emergency department (ED) visit. Effective for services furnished on or after January 1, 2003, hospitals may bill for patients directly referred for observation services.

See, Pub. 100-04, Medicare Claims Processing Manual, chapter 4, section 290, at http://www.cms.hhs.gov/manuals/downloads/clm104c04.pdf for billing and payment instructions for outpatient observation services. Future updates will be issued in a Recurring Update Notification”

Q - At front line if we do all this hard work switching obs to in or vice versa but at the end if it is denied by the insurance. How can we monitor the end results? Which departments should we contact?

A - This is part of your central business office; analytics can be collected if your CBO – Director of Rev Cycle did a rebill or adjustment. This comes through on the 835 remittances. You will want to make sure this data is shared in your Denials committee and UR Committee.

Q - Is there a COVID guideline that we should follow for commercial payors?

A - Last year, Change Healthcare did release InterQual criteria for acute COVID-19 infection and some of your payors who use InterQual like United Health Care maybe using those guidelines. MCG also released criteria in 2020 related to COVID-19 acute infections. Commercial payors may follow those guidelines based on the criteria set they use for status determinations. There are no universal guidelines for Inpatient vs observation status for COVID related hospitalizations.

Q - Is MCR Advantage within the scope of this town hall? We are encountering issues with Advantage plan requiring an observation stay before allowing inpatient unless patients meets intermediate or critical acuity.

A - Medicare Advantage status is all about your contract with them. On a practical level, I have seen what you describe in some cases, and it’s a case-by-case situation. Part of me does not disagree with that approach—in many cases, initial OBS is not unreasonable. I’ve gotten to know my local medical directors over the years so have some background on what they are looking for. Ultimately, if they give me clear rules that are fair, I can play ball.

Please note, we will have an upcoming session in the future dedicated to questions related to Medicare Advantage plan.

American College of Physician Advisors

President's Corner

August 2021

It’s August and for many around the country, that means back to school. As physician advisors, every day presents an opportunity for education. But, perhaps no opportunity is more anticipated than our annual National Physician Advisor Conference (NPAC).

After the incredibly disappointing decision was made last March to cancel NPAC 2020, I am thrilled to announce NPAC will be back this Fall! NPAC 2021 Co-Chairs Drs. Carolyn Dutton and Julie Kolinski have an amazing, truly one-of-a-kind event planned for you which will be the “go to” conference for physician advisors at all stages of their careers.

“Multifaceted: Advising in An Unconventional World” will take place October 18 – 20. This virtual conference will equip new and existing physician advisors, leaders in case management and clinical documentation integrity, revenue cycle professionals, c-suite leaders, and others with novel approaches to navigate their unique healthcare systems during unprecedented times. Scheduled speakers include outstanding thought leaders and nationally-recognized authorities involved in regulatory affairs and medical necessity screening procedures.

Participants can earn up to 26 AMA PRA Category 1 Credit™ hours while networking with other leaders in the field through one-on-one meet-ups or interactive sessions such as Regional Networking Lunches via our state-of-the-art interactive platform. The event will include topic-based tracks including Clinical Documentation Integrity, Revenue Cycle, COVID-19, Pediatrics, and Professional Leadership; a mixture of 30-minute “Quick Hit” sessions and 60-minute plenaries with live chat Q&A with the speakers; and specialized live presentations including an Observation Case Discussion Panel, a Jeopardy-style session, and an expert panel moderated by the incomparable Dr. Ronald Hirsch. Missing Dine with Docs? This time around you can enjoy Happy Hour with the Pros – small, virtual get-togethers where participants will have the opportunity to solicit advice and guidance from expert physician advisors and learn from each other.

Registration for NPAC 2021 – “Multifaceted: Advising in An Unconventional World” – opens this month! Join us, and make sure you stay up-to-date with the latest news and novel approaches in our field.

Sincerely,

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV

(Pronouns: She/Her)

President, ACPA

Dr. Juliet B. Ugarte Hopkins is Physician Advisor for Case Management, Utilization, and Clinical Documentation for ProHealth Care, Inc. in Waukesha, WI.

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