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Case Management

Case managers and directors will find the practical tools, information, and expert analysis they need to maintain regulatory compliance and achieve the highest-quality patient care.

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  • CMS finalizes two-midnight inpatient presumption as part of 2014 IPPS final rule

    CMS finalized a major change to its inpatient admission guidelines as part of the 2014 IPPS final rule, released August 1.

    As part of the rule, CMS finalized the two-midnight presumption for inpatient admissions. If a patient the physician expects a patient’s treatment, testing, or surgery to require an inpatient stay covering two midnights, and admits the patient based on that belief, CMS will presume that the stay is be medically necessary.

    CMS emphasized that the physician must formally order an inpatient admission, but added that the physician can consider the time the patient has already spent in the ED or observation when deciding whether to admit the patient.

    CMS made the change in part to reduce long outpatient or observation stays.

    CMS also finalized the timely filing requirement for Part A to Part B rebilling. In March, CMS released a ruling and a proposed rule allowing hospitals to rebill Part A inpatient services as Part B outpatient services if the inpatient stay was not medically necessary and the services would have been covered in the outpatient setting. The ruling, which went into effect in March, did not including a filing timeframe. Under the final rule, hospitals will have one year from the date of service to rebill claims.

    CMS finalized the criteria to rank hospitals with a high rate of hospital-acquired conditions (HAC). Hospitals in the lowest quartile for HACs will see a payment reduction of 1%.

    Look for more analysis of the rule from HCPro next week.

  • Mandatory flu shots aren't a deal-breaker for most medical staff

    Mandatory influenza vaccination as a condition of employment did not cause healthcare workers to flee from Loyola University Medical Center in Maywood, Ill., according to a four-year analysis of vaccination rates. With the backing of hospital leadership, infection control and prevention specialists at Loyola worked with a multidisciplinary task force to develop a facilitywide policy that made flu vaccination a condition of employment.

  • JAMA Viewpoint: Proactive medical staff monitoring could bolster peer review

    Peer review is the accepted modality to identify physicians with impaired performance, but a robust physician health program could further protect patients, wrote Julius C. Pham, MD, PhD, of the Johns Hopkins University School of Medicine, in an April 29 Journal of the American Medical Association online Viewpoint.

  • News: Study shows increase in observation services

    Observation services increased 34% from 2007 to 2009, “from an average of 86.9 observation stay events per 1,000 inpatient admissions per month in 2007 to 116.6 in 2009,” according to a June article in the Journal HealthAffairs.

    Further, the study shows that individuals held in observation were held there longer, some more than 72 hours.
    Although helping physicians determine the best route of service for patients and appropriately designating that service typical falls to the utilization review and/or case management professionals, CDI specialists can play a role by ensuring that the appropriate documentation for the appropriate service is captured in the medical record.
    “This is where CDI specialists can add real value, improving clinical documentation to the extent the record speaks for itself,” says Glenn Krauss, RHIA, CCS, CCS-P, CPUR, FCS, PCS, CCDS, C-CDI, Independent Revenue Cycle Consultant in Madison, WI.
    Editor’s Note: To learn more about the rules governing observation status assignment and payment for services listen to “Observation Services 2012: Build an audit defense, obtain appropriate reimbursement,” on-demand.

  • Q&A: Determine medical necessity for inpatient admissions for COPD

    Q: Our hospital serves a higher than usual population with COPD. Most of these cases are chronic and the patient is typically on home oxygen. Blood gases are almost never obtained on admission unless the patient is placed on a ventilator. Is acceptable to query the physician for chronic respiratory failure, 518.83 a comorbid condition/complication (CC) based on documentation of the presence of home oxygen use by these patients? Or do we also need a pulse oxygen reading of 88% or lower while they are here in the hospital?

  • Tip: Start with emergency room documentation to help reduce claims denials

    By Glenn Krauss, BBA, RHIA, CCS, CCS-P, CPUR, FCS, PCS, C-CDI, CCDS

    Broaden the scope of your CDI efforts by looking for medical necessity indicators and increasing proactive efforts to reduce audit risks.
    CDI specialists can increase their value to their hospital and ensure a far greater degree of physician buy-in by serving as a pro-active denials management specialist. In some respects CDI specialists already serve as denials avoidance agents, playing an active role in changing patterns of physician documentation to reduce the likelihood of medical necessity denials.
    A major role of the CDI specialist is to ensure proof of medical necessity. This does not necessarily mean that CDI specialists should become quasi-case managers. However you cannot perform CDI in a vacuum, either. Getting a physician to document a diagnosis through a query without obtaining supporting documentation (including an accurate picture of patient’s history of present illness, physical findings, abnormal lab and radiology tests, and the physician’s clinical judgment and medical decision-making used to determine the diagnosis or differential diagnoses) will likely result in a denial, and a takeback of the diagnosis by an auditor.

    Therefore, what CDI specialists should focus upon is obtaining documentation in the history and physical (H&P) to support the severity of the patient’s signs and symptoms.

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