Reducing Admission Denials Through the Promotion of Hospital Observation Status

1. Reducing Admission Denials Through the Promotion of Hospital Observation Status Hospital Payment Monitoring Program Wednesday, December 6, 2006

3. Objectives “WHY” Does Connecticut need to do a project? “WHAT” Do the data and chart review show? “WHERE” Do we go from here? “HOW” Do we reduce admission denials? “WHO” Should be using observation?

4. “Why”Does CT Need A Project? 8th Scope of Work (SOW) Connecticut’s Payment Error Rate Provider Questions and Feedback

5. “WHAT” Does Our Case Review Show? Incomplete documentation to support an inpatient admission. Lack of physician/provider understanding of observation. Unclear documentation in the medical record of a patient’s status - Inpatient versus Observation.

6. “WHERE” Do We Go From Here? Statewide Education Six Outlier hospitals will be identified. Additional Education will be offered. On-site visits will be planned. Chart abstraction will take place.

7. Outpatient Observation Reimbursement Outpatient PPS began 2002. Observation payment package as part of Ambulatory Payment Classification (APC). Separate APCs for chest pain, CHF and asthma. Can be reimbursed for up to 48 hours only, unless exception granted by Fiscal Intermediary.

8. Outpatient Observation Services Not Covered Services that are not reasonable or necessary for the diagnosis or treatment of the patient. Services that are provided for the convenience of the patient, the patient’s family or a physician.

9. Outpatient Observation Services Not Covered Standard orders for observation following outpatient surgery. Services that are covered under Part A, such as a medically appropriate inpatient admission, or services that are part of another Part B service. e.g., normal postoperative monitoring during a standard recovery period.

10. DRG 143 Chest PainFY 2005 #1 DRG for one-day stays. Average statewide length of stay (LOS) is 1.9. Total # of discharges 1,779. Sum of DRG 143 Payment $5,271,244.

11. DRG 143 Chest PainNational Data

12. DRG 143 Chest PainConnecticut Data

13. DRG 143 Chest PainConnecticut Data

14. Chest Pain Only 1/12 of chest pain cases have Infarction. 1/12 of chest pain cases have other Acute Coronary Syndromes. Physician has to make difficult decisions in diagnosis and treatment. Physician usually not concerned with billing issues.

15. Chest Pain A minor portion of physician’s concern is whether the patient’s status should be observation or admission. Physician is trying to determine the safest and most effective manner of treating patient. Physician makes the decision about where is the best setting to place the patient.

16. Where to Put the Patient with Chest Pain? Keep them in the ED. Put them in Observation. Put them in a Telemetry Ward. Put them in Intensive Care Unit (ICU). Take them to the Cardiac Catheterization Laboratory.

17. Medicare Observation or InpatientAdmission Decision Tree

18. Outpatient Observation ServicesCritical Questions In what condition will the patient most likely be tomorrow? “Better” = Observation Is it risky to send the patient home today? “Yes” = Observation Is it likely I will know whether to admit or send the patient home tomorrow? “Yes” = Observation

19. Outpatient Observation ServicesCritical Questions Are vital signs stable? “Yes” = Observation Will a diagnosis likely be made in 24 hours? “Yes” = Observation Will treatment, such as IV fluids, require standard monitoring and be completed within 24 hours? “Yes” = Observation

20. To Admit or To Observe Physicians have been traditionally taught that if they place a patient on a ward or in the ICU, they must admit the patient. In fact, all of the orders are the same except for one word-Admission. Physicians have been given contradictory information and practices in different settings. The physician is supposed to make the decision when s/he writes the order.

21. To Admit or To Observe Hospitals must realize how confusing this is for the physician. Hospitals need to develop care plans that match the logistics at that particular hospital. Standard order sheets that match the patient’s situation might be helpful.

22. To Admit or To Observe Patient has diagnostic evidence of Infarction = Admit. Patient has troponin leak or dynamic ST or T wave changes = Admit. The rest of the chest pain patients are the problem.

23. Rules of Thumb All patients with chest pain have a brief focused history and physical and an electrocardiogram. Electrocardiogram meets criteria for ST elevation myocardial infarction – patient taken to Catheterization lab for PCI (stenting/PTCA) then admitted.

24. Rules of Thumb Electrocardiogram does not show ST elevation MI, but patient has dynamic ST or T changes or has elevated enzymes.

25. Rules of Thumb No ECG changes or enzyme changes, but story suggests moderate to high probability.

26. Rules of Thumb No ECG changes or enzyme changes and story suggests low probability.

27. Other DRGs Appropriate for Observation DRG 127 Congestive Heart Failure. DRG 182/183 Esophagitis, Gastroenteritis, and Misc. Digestive Disorders Age > 17 with CC. DRG 296 Nutritional & Misc. Metabolic Disorders Age > 17 with CC.

28. Advantages of Hospital Observation Status Allows physician to observe patient when unsure. Avoids potentially unnecessary admission and costs. Improves flow in ED. Reduces physician liability.

29. “WHO” Should Be Using Observation? All of Connecticut’s PPS Acute Care Hospitals