Clinical Care Management at UNC Hospitals

1. Clinical Care Management at UNC Hospitals Medicine House Staff July 9, 2009

2. Case Managers (CM) • Nurses, Social Workers, other professional specialists • Assigned by service • Facilitators for patient throughput • Coordinate discharge planning • Expert consultants on disposition settings & regulations

3. Tell Your Case Manager • Clinical goals/endpoints • LOS (if you know it) • Post discharge care needs • Barriers you know about

4. Your Case Manager Can Tell You • Discharge options available, considering • Payor coverage • Family/support • Transportation • Documentation needs • The status of the discharge plan

5. Don’t Promise What Can’t be Delivered • Home vs SNF for infusion • Home Health vs Outpatient care • Medicare covered placement • Hospital funding

6. Clinical Social Workers • Assigned to specific areas • Psychiatry • Transplant • Some pediatric areas • Psychosocial assessments and therapeutic interventions • Available as consultants to case managers

7. TPN and Infusion Specialists • Consultants to Case Managers • Coordinate arrangements for post-discharge • IV antibiotics • IV hydration • TPN

8. CCM and the UNC Discharge Summary • Multidisciplinary • Physician • Case Manager • Other team designees • Contains • Traditional discharge summary information • Post discharge orders and instructions • Reconciled medications

9. Utilization Managers (UM) • Assigned to every patient in a bed • Perform payor reviews • Depend on clear and precise documentation • Experts in CMS regulations for • Bed billing status • Qualifying stays for placement

10. Executive Health Resources (EHR) • Contracted physician advisor consultants • Experts on CMS regulations and reimbursement • Contact physicians to discuss care plans and documentation

11. So, Who Decides The Status? • Federal Government • Centers for Medicare and Medicaid Services (CMS) Policy • Office of the Inspector General (OIG) Audits & Retractions • Evidence based criteria sets • InterQual • Expert Physician Advisors • Executive Health Resources (EHR)

12. Other CCM Functions • Payor Authorization • Medical Necessity Denials • Bed Management • Transfer Center • Psychiatry Admissions • Avoidable Delay Tracking

13. Why CCTs Care AboutBed Billing Status Short stays are a government audit focus Overuse of Observation Lost revenue for hospital (& soon physician) Inappropriate co-pays to patient Inappropriate use of Inpatient Subject to fraud charges Pay-backs, penalties, & press

14. Billing Status Outpatient • Extended Recovery (EXR) • Observation (OBS) Inpatient (INP) Patients in any of these statuses can be “admitted” to a bed in the hospital.

15. Extended Recovery (EXR) Routine or pre-planned post-operative or procedure recovery Short stay services following uncomplicated treatment or procedure such as chemo or infusion therapy

16. EXR Characteristics Always (almost*) planned/elective Uncomplicated procedure No licensed bed required No physician’s order for billing status required Billed as outpatient unit price based on procedure code No room/board/ancillary billing May advance to Observation or Inpatient *Also used for “social admits” , allows billing of some lab/procedure charges without billing bed charges

17. Observation (OBS) Services & monitoring to evaluate and determine the need for inpatient admission Services are covered only by the order of a physician or other individual… authorized to admit patients.

18. OBS Characteristics Always unplanned No licensed bed required Must have physician’s order for Observation Billed on a per-hour basis to patient’s outpatient benefits Some services billed directly to the patient Case may advance to inpatient if medical necessity is established Not a qualifying stay for SNF placement

19. OBS Billing Ends When EITHER: Observation status is no longer justified* Observation intensity of service criteria no longer met Documentation does not substantiate medical necessity for continued observation services *If the patient remains in-house, hourly room & board charges cannot be billed.

20. OR: Inpatient status is justified Criteria for inpatient status are met Documentation substantiates a defensible need for an inpatient admission. Clinical condition change Confirmed diagnosis Initiation of inpatient treatment Intent

21. The OBS/Inpatient Mix Patient begins stay appropriate for Observation Information or circumstances arise that justify an Inpatient admission Inpatient begins at the time of order entry

22. Now, for Inpatient May be planned or unplanned Requires a licensed bed Requires medical necessity justification Begins with a physician’s order for Inpatient billing status Can be corrected to outpatient under certain circumstances (Condition Code 44)

23. Medical Necessity for Inpatient Status Criteria + Intent/Risk

24. Medical Necessity Criteria • Specialist written • Evidence based • Very specific • Revised annually • InterQual used by Medicare Quality Improvement Organization (QIO) • Milliman used by RAC (Connelly Consulting)

25. Medical Necessity: Intent/Risk Severity of signs and symptoms Differential diagnosis Clinical predictability of something adverse happening Plan for management that requires an inpatient setting *Documentation of intent and risk must come from the admitting team.

26. Why the Urgency for Documentation? Inpatient billing begins with an inpatient order Inpatient order requires medical necessity Medical necessity requires documentation from the admitting team Documentation delay = inpatient order delay = loss of billable inpatient days

27. Provider Liable Medicare case with inpatient order and no documented medical necessity D/C order written Billing status order cannot be manipulated Billing for inpatient without documented medical necessity is fraud The hospital (and soon the physician) cannot bill Medicare for the stay Currently averaging $500,000/month

28. *Qualifying Hospital Stay for SNF Placement • Medically necessary admission • Severity of Illness and Intensity of Service justify inpatient level of care (InterQual) • 3 day inpatient stay within the 30 days preceding SNF admission • Inpatient criteria met for each of 3 consecutive days 3 day stays resulting in SNF are an OIG focus

29. Summing Up Bed Status

30. Observation Advisory • Medicare primary patients only • Billing status changed from INP to OBS • Advises patients of billing status and implications • Delivered by CCM Utilization Managers

31. Documentation Pointers

32. No more “A” word • Abolish the “Admit” word • CMS = Inpatient • UNC = Place Patient in Bed • Does not define a billing status • Has caused payment retractions

33. Know what Observation means • Observation and Monitoring are different • “Observation” is a billing status • “Monitoring” is a better term for clinical activity

34. Avoid Contradictions • Admit to OBS • Admit for observation • Inpatient Observation

35. Which Patients are on What Status?

38. Summing Up • Your Case Manager can be your best friend • Your Case Manager can’t do good work without good information • Your Utilization Manager helps hospital & MD get paid for the care we provide • Precise documentation is better than “more” documentation

39. Contacts • Director: Marie Bossert (3-2766) • Managers: • CM Med/Surg • Sherri Branski (3-0599) • UM Med/Surg • Chris Wehner (6-8290) • Transfer center, Bed Mmgt • Andrea Soltau-Talbot (6-6544)