Case Management

Mentor moment: ED case management and CDI will lead to better medical necessity documentation

Case Management Weekly, April 21, 2010

The following article is adapted from HCPro’s resource for hospital case managers—www.CaseManagementMentor.com—a free blog dedicated to connecting hospital case managers to industry pacesetters, peers, and best practices.

The March 2010 Case Management Monthly article “Ten Steps to Implementing Case Management in the ED” includes several salient points that should motivate readers to action.

The 10 steps outlined in the article provide an excellent conceptual framework for determining the role of the ED case manager as well as assessing your facility’s need for ED case management. Addressing the quality and detail of documentation in the ED may provide additional roles for an ER case manager.

I work at a small community hospital with fewer than one hundred beds. We have implemented an ED case management model that primarily focuses on weekday admissions during regular business hours. We are training the ED nursing supervisor to perform the basic tenets of case management (i.e., ensuring proper patient admission status and helping patients and families navigate the maze of the healthcare delivery system). This enables the ED nursing supervisor to help with case management responsibilities during case management’s off-duty hours. The ED medical director was instrumental in getting the ED interested in case management and related clinical documentation improvement (CDI) tasks. He realized that establishment of medical necessity and accurate reporting is predicated on sound, effective documentation techniques that best capture patient acuity.

Aside from guiding physicians in level of care decisions, the ED physicians recognized that case managers help educate and train them in CDI needs.

Physician decision to admit to the hospital 

In preparation for the RAC, our facility reviewed short stays associated with symptoms that present a medical necessity challenge (i.e., chest pain, abdominal pain, syncope, malaise and fatigue, “failure to thrive,” and dehydration). The review revealed that physician clinical documentation was in need of serious improvement. The old adage of “more is better” does not apply to clinical documentation; instead, more effective documentation that is specific, accurate, and detailed is the objective.

As case managers, we are familiar with the provisions governing inpatient admission beyond the commonly used screening criteria. The CMS Medicare Benefit Policy Manual, Chapter, 1 section 10 reads as follows:

”The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of complex factors, including the patient’s medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital’s by-laws and admission policies, and the relative appropriateness of treatment in each setting. Factors to be considered when making the decision to admit include such things as:

  • The severity of the signs and symptoms exhibited by the patient;
  • The medical predictability of something adverse happening to the patient
  • The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and
  • The availability of diagnostic procedures at the time when and at the location where the patient presents”
While reviewing the hospital’s records for appropriate short-stay admissions, it became apparent the ED physician’s documentation failed to capture the following information:
  • The patient’s severity of signs and symptoms
  • The physician’s thought processes
  • The patient’s comprehensive history performed
  • The physician’s concern of patient’s risk factors
  • The physician’s clinical impression based on the patient’s history of present illness and nature of presenting problem.

In summary, the physicians’ diagnoses provided in the record consisted of mainly symptoms (i.e., shortness of breath, acute dyspnea, acute respiratory distress, and hypoxemia) that fail to show the physician’s cognitive skill sets and knowledge base.

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