Case Management

Ask the expert: How can we ensure the right documentation for a level of care recommendation?

Case Management Insider, December 1, 2015

Many questions have swirled around the issue of medical necessity and how to document it appropriately. Stefani Daniels, RN, MSNA, CMAC, ACM, founder and managing partner of Phoenix Medical Management, Inc., in Pompano Beach, Florida, and co-author of the recently published Hospital Guide to Contemporary Utilization Review, helped us shed some light on what’s involved and how to make sure this task is done properly.

Q: As part of an integrated access management program, what medical documents are needed to perform a medical necessity review so that the access care coordinator (ACC) can offer a level of care recommendation to the physician?

The recent OPPS rule states, "The physician's decision should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event." But another important consideration should be whether the patient requires hospital level care.

This is the crux of the review. For example, a patient may have an exacerbation of a chronic illness, but the ACC or case manager then needs to ask whether hospitalization is required to resolve the problem. If this is a new illness, does it require hospitalization to find out the source? (“Work up” hospitalizations inevitably get denied if the testing could be performed on an outpatient basis.) Finally, the ACC or case manager must see medical documentation that states that the care the patient requires is expected to exceed two midnights.

Reviewers should consider the history of present illness (a viable substitute for a complete history and physical), the severity of the signs and symptoms of the patient’s current medical condition, and the expectation of a two midnight stay, in addition to:

  • The patient’s age
  • Disease processes
  • The severity of the signs and symptoms of the patient’s medical condition
  • The medical predictability an adverse event

Also look at admitting orders. What are the patient’s current needs that require hospital-level care? What is the risk of not admitting the patient? I call this the “because clause”—if the patient is not admitted, given his history of (pre-existing condition), he may be at risk for (complication).

The decision to admit the patient as an inpatient must be supported by the medical record. If the medical record doesn't support hospital level of care, the hospital won't get paid. The majority of hospitals I visit don't perform reviews till after the patient is admitted since the hospital lacks a robust access management processes. Doing it after admissions invariably results in too many cases that are not really qualified for an inpatient level of care. This leaves the hospital to back track and reverse its decision using Condition Code 44 outpatient Part B billing to cover costs of tests that may have been done.

Got something you want to ask our experts? If you’ve got questions about the 2-midnight rule or any other case management topic, please e-mail them to Kelly Bilodeau at and we will have one of our experts answer it and will publish the response in an upcoming issue of Case Management Monthly.

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