In last month's column we discussed the distinction between inpatient admission and observation care, widely used inpatient guidelines, and the authority and responsibility Medicare gives to physicians for making an admission decision. This month's column explains the Medicare regulations and requirements physicians must consider when exercising that authority.
The Centers for Medicare and Medicaid Services' (CMS) regulations do not permit anyone other than a clinician with admitting privileges to order inpatient admission versus observation care. Case managers are intended to be a decision-making resource to support and assist clinicians.
CMS has two requirements that are absolutely necessary and should be clearly documented to verify the medical necessity of inpatient admission:
- A reasonable expectation based on legitimate clinical grounds and standards of medical practice that the patient is likely to require two days or more of inpatient care, and
- A specific explanation of the clinical conditions, circumstances, complications, comorbidities and risks to the patient upon which that expectation is based.
CMS specifically instructs physicians to consider and document the following in making an inpatient admission decision:
- Severity of presenting signs and symptoms
- Severity and number of acute conditions requiring care and management
- Any pertinent pre-existing chronic conditions or other comorbidities complicating the patient's care
- Risks associated with the conditions or findings identified
- Any authoritative professional guidelines or evidence-based medical literature supporting inpatient admission (such as ABCD2 score >3 for transient ischemic attack, Pneumonia Severity Score >90, etc.)
- Extenuating circumstances contributing to the medical necessity of inpatient admission like advanced age, poor compliance, limited understanding, lack of social support (these circumstances are not by themselves sufficient reason for admission, but support the need for inpatient care when an acute condition arises).
CMS’ two requirements can be easily met by a single sentence in the initial impression/assessment. For example: “Ms. Smith is expected to need two days or more of inpatient care for the management of pneumonia associated with an acute exacerbation of COPD having a significant risk of progression to respiratory failure or sepsis and complicated by advanced old age, diabetes and immune suppression due to steroids.”
Physicians and hospitals risk being audited, or even sanctioned, by Medicare if they file claims for inpatient care when Medicare's criteria are not met. Documenting a reasonable and legitimate expected length of stay of at least two days and identifying the clinical basis for it will substantiate the medical necessity of the inpatient care provided. Do not rely on someone else's interpretation of your admitting diagnoses, problem lists and test results.
A patient who is likely to improve and perhaps go home in less than two days, assuming nothing unexpected happens, should be put under observation care. If the condition changes for the worse, it is a simple matter to convert the status from observation to inpatient.
Some situations where the clinical circumstances and typical medical practice would indicate an expected stay of less than two days might include:
- Non-specific chest pain admitted for simple “rule-out myocardial infarction (MI)” protocol (even if substantial risk factors are present), unless acute coronary syndrome or non-ST-elevation MI is diagnosed and the aggressive treatment recommended for these conditions is provided.
- Simple dehydration (without acute kidney injury) and/or non-critical electrolyte imbalance requiring IV fluids, repeated lab testing and assessment of clinical response.
- Uncomplicated gastroenteritis, vomiting, diarrhea, or non-specific abdominal pain (with unremarkable findings) that might resolve with minimal care in less than two days, unless the possibility of C. difficile colitis, or other significant acute conditions, is mentioned and treated aggressively. If the patient's condition does not improve, or worsens, over about 24 hours, inpatient admission may then be needed.
- Scheduled, elective percutaneous coronary intervention or percutaneous vascular procedures without serious complications, which in the absence of acute symptoms, are usually expected to result in a hospital stay of less than 24 hours.
In summary, CMS gives physicians the power to make their own inpatient admission decisions (independent of screening guidelines like InterQual® and Milliman [now MCG]) if they reasonably expect the patient to require two days or more of inpatient care consistent with medical practice standards. However, the physician must clearly document this expectation together with the specific clinical reasoning and clinical conditions, circumstances, complications, comorbidities and risks upon which that expectation is based.