As hospitals continue to digest the 2014 Hospital IPPS for Acute Care Hospitals, many questions have arisen. In this newsletter we will present a sampling of the questions we have heard from our clients and other interested parties. CMS has promised further guidance, and we will share it with you as it is issued.
1) Is a certification required for every inpatient stay and if so, what is required?
Yes, a certification is required for every inpatient stay. It must be completed, signed and in the record prior to patient discharge. There is no specific format required. We anticipate that CMS will take the position that discharge occurs when the discharge order is written. The required certification elements include: a valid inpatient order, a certification that the services were provided in accordance with 42 CFR 412.3 (that the physician has an expectation that the patient will be required to stay for a period that encompasses two midnights and clinical documentation supporting that rationale), the reasons for inpatient medical treatment, the estimated time the patient will need to remain in the hospital, and plans for post hospital care. Certification requirements apply to ALL inpatient admissions, not simply short stays, so the regulations require a focus on systemic changes to make certain the certification is signed and in the chart prior to discharge. We anticipate that Recovery Auditors will eventually, if not immediately, try to take back reimbursement when the technical certification requirements are not met.
2) Is there a requirement that the physician estimate the length of stay and what if the estimate is wrong?
Yes, the certification requirements include a statement setting forth the estimated time the patient will need to remain in the hospital. You may want case managers to assist by providing average length of stay information based on diagnosis, and to make certain that information regarding length of stay is in the medical record and signed by the physician prior to patient discharge. Discussions regarding estimated length of stay may help case managers start discharge planning very early in the stay that could facilitate timely discharge. In general, the best practice would be to update projections where the patient stays well beyond the projected period and as required for outlier cases, but the regulations do not address update requirements in the absence of outlier issues.
3) If the physician does not complete the certification process will the hospital be able to submit a claim to Medicare for reimbursement?
Certification is a requirement for billing and the items in the certification MUST be signed prior to discharge for an inpatient claim to be submitted.
If the certification requirements are not met the hospital can only bill for Part B services described in the Federal Register §412.2(c) (5), §412.405,§412.540, or §412.604(f) or §413.40(c)(2) .
4) If a physician does not convert a patient to inpatient status before the second midnight, what are the implications for the hospital?
It appears, from a close reading of the regulations and commentary that as long as there is an inpatient order prior to discharge and the clinical documentation is in place, as well as the elements for the certification, it is appropriate to bill it as inpatient even though the regulations assume that the determination will be made before the second midnight and suggest that the physician/hospital must look at the case before the second midnight. It is imperative that the documentation is clear and complete as to the clinical rationale for the inpatient order as these cases will certainly be subject to scrutiny and review.
5) As long as the patient stays in the hospital two midnights, is there a presumption that inpatient status is appropriate?
If the patient stays two midnights AFTER THE INPATIENT ORDER, the case will not be targeted for review in the absence of gaming or intentional delays of service, and inpatient status will be presumed to be appropriate status as long as hospital services were medically required. Conversely, where the patient stays one midnight or less after the inpatient order, the cases will be targeted for reviews, and the review will include a review of all of the certification requirements as well as whether it was medically necessary for the patient to remain a second midnight.
6) Can you define the term “post-acute plan of care” in relation to certification? If the physician writes discharge orders that include post-acute plans, does this meet the certification requirement when he signs the discharge order?
The information in “normal” discharge orders, in our view is adequate unless we receive further guidance to the contrary; however, if the plan of care for post-acute services is part of the discharge order and not signed “prior” to patient discharge then the timeliness requirement is not met. The post-acute plan of care must be SIGNED prior to discharge. If CMS takes the position that “discharge” occurs when the order is written, and discharge instructions are not signed, dated and timed prior to the discharge order, then there is technical deficiency.
7) If a patient has already been in-house one midnight, must the physician discharge the patient or certify as inpatient prior to the second midnight?
If a patient has been in house one midnight, the physician should make a decision as to whether his expectation is that it is medically required for the patient to remain a second midnight. If so, an inpatient order should be written. If not, either a discharge order should be written or if the patient is kept for social reasons or convenience reasons and not justifiable medical reasons supported by the clinical documentation, the hospital should not bill for inpatient services merely because the patient stayed a second midnight. The hospital cannot bill for any services that are not medically necessary. Where the physician has the expectation that the patient is required to stay a second midnight, an inpatient order should be written along with the physician’s rationale for that expectation, including supporting clinical documentation.
8) Is a direct admit from an admitting physician in a clinic to a hospitalist a valid admission order?
As long as the physician writing the admission order has admitting privileges and the order is clear as to ordering admission as an inpatient, and meets the other requirements for a valid order such as being signed, setting forth the expectation that the patient will require services in the hospital for a period spanning two midnights, and the justification, etc., it is a valid order.
9) Should we change our case management coverage from 9:00 am to 9:00 pm to 12 noon to 12 midnight?
Any patients who arrive and start receiving services prior to 12 midnight should be screened to see if there is an expectation that they will require hospital services for two midnights. If the two expectation is that the midnight benchmark is required an inpatient admission order should be obtained and documented in the medical record.
10) Do we still need Interqual?
The regulations still require hospitals to use a screening tool to determine the need for inpatient services although, as in the past, the screening tool is not the determining factor. Complex medical judgment by a physician is still required for the inpatient decision. One client mentioned that Interqual discharge screens may be helpful as a screening tool to help determine whether the clinical documentation adequately supports the need for the patient to remain a second midnight. This is a screen only.
For a quick link to the final rule click here.
We continue to have conference calls with our client hospitals and of course, to take all questions. Feel free to send us any questions by email or by phone call. If you would like to schedule a conference call for an overview of the regulations, please contact Greg Meadows for scheduling. Greg can be reached at 205-970-8818 or at email@example.com. If there are questions, please do not hesitate to contact Joan Ragsdale at firstname.lastname@example.org
or Dr. Gregory Palega at email@example.com.