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staffing the unit must have “buy-in” for the OU to
succeed. The medical staff should be apprised of
the OU and how it fits into the patient care
process. Presentations to the medical staff are
invaluable in answering their questions or concerns and by explaining how the OU will benefit
their practices. Face-to-face meetings will help
attain their support and be instrumental in setting
up referrals for the OU patients.
Meetings not only with internal hospital per-
sonnel/departments and physicians, but also key
external “players” (such as payers), are important
not only when setting up or starting an OU, but
also in sustaining the efficient day-to-day operations of the OU. This organizational framework
and preparation and ongoing maintenance is
essential to the successful initiation and continuation of the OU.
References
1. Centers for Medicare and
Medicaid Services (CMS).
Medicare benefit policy
manual, Chapter 6: Hospital
services covered under Part
B. Baltimore, MD: CMS;
[revised Mar 1, 2013].
www.cms.gov/Regulationsand-Guidance/Guidance/
Transmittals/downloads/
R42BP.pdf and www.cms.gov/
Regulations-and-Guidance/
Guidance/Manuals/downloads/
bp102c06.pdf (Accessed March
2016)
2. Ross MA, Hockenberry JM,
Mutter R, et al. Protocol-driven
emergency department
observation units offer savings,
shorter stays and reduced
admissions. Health Affairs
2013; 32(12): 2149–2156.
3. Baugh CW, Venkatesh AK,
Hilton JA, et al. Making greater
use of dedicated hospital
observation units for many
short-stay patients could save
$3.1 billion a year. Health Affairs
2012; 31(10): 2314–2323.
4. Macy ML, Hall M, Shah SS,
et al. Differences in
designations of observation
care in US freestanding
Children’s Hospitals: are they
virtual or real? J Hosp Medicine
2012; 7(4): 287–293.
5. Mace SE, Graff L, Mikhail M,
et al. A national survey of
observation units in the United
States. Am J Emerg Med 2003
21:529–533.
6. Osborne A, Weston J,
Wheatley M, et al.
Characteristics of hospital
observation services: a society
of cardiovascular patient
care survey. Critical Pathways
in Cardiology 2013; 12(2):
45–48.
7. Mace SE, Shah J. Observation
medicine in emergency
medicine residency programs.
Acad Emerg Med 2002;
9: 169–171.
8. Barsuk J, Casey D, Graff L,
et al. The Observation Unit: an
operational overview for the
hospitalist. Society of Hospital
Medicine White Paper. May 21,
2009.
www.hospitalmedicine.org/
Content/NavigationMenu/
Publications/WhitePapers/
White_Papers.htm (Accessed
March 2015)
9. Mace SE. Pediatric observation
medicine. Emerg Med
Clinics North Am 2001: 19(1):
239–254.
10. Ross MA, Naylor S, Compton
S, et al. Maximizing use of the
emergency department
observation unit: a novel
hybrid design. Ann Emerg Med
2001; 37: 267–
274.
11. Zebrack M, Kadish H, Nelson D.
The pediatric hybrid
observation unit: an analysis of
6477 consecutive patient
encounters. Pediatrics 2005; 115
(5): e535–e542.
12. Mace SE. Resuscitations in an
observation unit. J Quality in
Clinical Practice 1999; 19
(3):155–163.
13. Mace SE. Patient complaints in
an observation unit. J Quality
Clinical Practice 1998; 18(2):
151–158.
14. Graff LG, Wolf S, Dinwoodie
R, et al. Emergency physician
workload: a time study. Ann
Emerg Med 1993: 22(7):
1156–1163.
15. Maguire P. What’s the ideal
number of patients to see?
Today’s Hospitalist, July 2009.
Available on-line at:
www.todayshospitalist.com/
index.php?b=articles_read&cnt
+824 (Accessed March 2016)
16. Sheehy AM, Graf B,
Gangireddy S, et al.
Hospitalized but not admitted.
Characteristics of patients with
“Observation Status” at an
academic medical center.
JAMA Intern Med 2013; 173(2):
1991–1998.
Observation Medicine – Key Concepts: Clinical Issues
004
20:18:42
Part 1
Chapter
2
Administration
Observation Medicine – Key Concepts:
How to Start (and Maintain) an
Observation Unit: What You Need to Know
Administrative Issues
Sharon E. Mace, MD, FACEP, FAAP
OVERVIEW
There has been a steady increase in the frequency
and duration of observation encounters in recent
years.
1, 2
In the United States, observation encounters for Medicare beneficiaries increased from 86.9
to 116.6 observation stay events per 1,000 inpatient
admissions per month over a 2-year period during
2007–2009, while there was a decrease in inpatient
admissions for the same time period. The overall
result was a 34% increase in the ratio of observation stays to inpatient admissions.
2
According to
the government, these trends have continued with
an increase in observation, yet a decrease in inpatient hospital services again in 2010 to 2011.
3
The
Medicare Payment Advisory Commission (MedPAC) report notes a 28.5% increase in outpatient
services with a concurrent 12.6% decrease in inpatient discharges for the 2006–2012 period.
3
The volume of observation visits and the duration of observation visits are both increasing.
There was nearly a 68% increase in observation
visits from 28 to approximately 47 visits per 1,000
Part B beneficiaries for the period between
2006 and 2011.
4
Looking at the annual number
of observation hours for Medicare beneficiaries
from 2006 through 2010, there was a 70% increase
from 23 million to 39 million.
1
Moreover, the
number of observation stays exceeding 72 hours
increased by 88% from 2007 through 2009.
2
References: Overview
1. Medicare Payment Advisory Commission. A Data
Book: Health Care Spending and the Medicare
Program. June 2012. Section 7. www.medpac.gov/
documents/Jun12dataBookEntireReport.pdf
(Accessed March 2016)
2. Feng Z, Wright B, Mor V. Sharp rise in Medicare
enrollees being held in hospitals for observation
raises concerns about causes and consequences.
Health Aff (Millwood) 2012; 31(6): 1251–1259.
3. MedPAC report to Congress: hospital inpatient
and outpatient services. www.medpac.gov/
documents/mar14_EntireReport.pdfchapters
(Accessed March 2016)
4. MedPAC report to Congress: hospital inpatient
and outpatient services. www.medpac.gov/
chaptersMar13_Ch03.pdf (Accessed March 2016)
THE TWO-MIDNIGHT RULE
In response to this re cent increase in the number
and duration of observation stays, the Centers
for Medicare and Medicaid Services (CMS)
enacted a rules change on October 1, 2013.
5
This
rules change classifies most hospital encounters
of < 2 midnights as observation, while those
2 m idnights are categorized as inpatients.
There has been much discussion and controversy
regarding what the impact of this new rule
will be.
6–8
The2014Medicarepaymentrulesincludean
amended definition of inpatient status. In order
to qualify as an inpatient the following conditions must be met: patients receive only medically necessary services ordered by a physician
and their hospitalization lasts through two midnights. In the CY 2016 OPPS final rule, CMS
maintains the benchmark established by the original two-midnight rule, but permits greater
flexibility for determining when an admission
that does not meet the benchmark should nonetheless be payable under Part A on a case-by-case
basis. The CY 2016 OPPS final rule also discusses
a shift in the enforcement of the two-midnight
rule from Medicare Administrative Contractors
(MACs) to Quality Improvement Organizations
(QIOs).
9
005
20:20:18
References: Two-Midnight Rule
5. Centers for Medicare and Medicaid Services
inpatient prospective payment system 1599-F.
Fiscal year 2014 Final rule. www.gpo.gov/fdsys/
pkg/FR-2013-08-19/pdf/2013-18956.pdf (Accessed
March 2016)
6. Sheehy AM, Caponi B, Gangireddy S, et al.
Observation and inpatient status: clinical impact
of the 2-midnight rule. Journal of Hospital
Medicine 2014; 9(4): 203–209.
7. www.healthcapital.com/hcc/newsletter/01_14/2Midnight%20Rule.pdf (Accessed March 2016)
8. Society of Hospital Medicine Public Policy
Committee. The Observation Status Problem.
Impact and Recommendations for Change.
Society of Hospital Medicine Whitepaper, July
2014. Available at www.hospital medicine.org/
advocacy (Accessed March 2016)
9. www.cms.gov/Newsroom/MediaReleaseDatabase/
Fact-sheets/2015-Fact-sheets-items/2015-10-30-
4.html (Accessed March 2016)
BACKGROUND
What Is Observation?
Before discussing the two-midnight rule, several
caveats must be noted.
1
First, the term observation
has been applied to many types of patient encounters. There is a distinction between observation
medicine that is protocol driven – that has specific
protocols, guidelines, and order sets; that has explicit clinical guidelines with strong administrative
leadership; and that is generally applied to patients
cohorted in a specific area of the hospital, most
frequently in an emergency department (ED) based
observation unit (OU), known as a type I OU –
versus observation medicine that is non-protocol
driven, without guidelines and order sets, without
strong administrative organization and leadership,
and with observation patients placed throughout
the hospital instead of in a discrete unit or area.
2–4
This optimal construct is clearly different from
observation in “scatter beds” in inpatient areas.
“When observation is used as a billing status in
inpatient areas without changes in care delivery,
it’s largely a cost-shifting exercise – relieving the
hospital of the risk of adverse action by the RAC
(recovery audit contractor) but increasing the
patient’s financial burden.”
3
The success of this format and organization
(e.g., type I OU) is detailed in the evidence-based
chapters in this textbook. This is what is generally
referred to as “ED observation” or “simple observation.” Placing patients in “observation” or
“observation status” without this clinical and
administrative organizational structure is generally doomed to fail and frequently exceeds the
previously stated time-based goals of 24 hours.
The incidence of ED OUs in the United States
has grown from about 19% according to a 2003
study
5
with a higher incidence (about 36%) in
academic centers in a 2002 study
6
to about onethird of all EDs in the United States having a
dedicated OU.
7–9
The administration of the OUs
is usually under the ED.
8, 10
Next, although the stated target for simple
observation is 24 hours, the goal is generally to
discharge the patient well before 24 hours. Indeed,
the mean length of stay (LOS) is 15.3 hours
5
and
the median LOS is 19 hours
10
according to two
different surveys with a desired minimum of
8 hours and a maximum of 24 hours.
9
Simple versus Complex or Extended
Observation
Recently, the application of these same principles
of observation medicine on a more extended time
frame, often ≤ 48 hours instead of ≤ 24 hours as
the set goal, has been advocated for several
reasons including the concern for readmissions,
with the expectation that somewhat more complex patients (e.g., those with more than one chief
complaint or problem and with multiple comorbidities) might be diagnosed and treated in a
shorter time frame than the usual several-day
inpatient hospital admission if the same principles of observation are applied. The term “complex” or “extended” observation has been applied
to this patient population. (See Chapters 16 and
17 on extended or complex observation.)
This book is designed to provide the tools for
achieving success with observation patients,
whether “simple” versus “complex” or “extended”
observation patients, with the acknowledgment
that they are two different patient populations.
Historically, inappropriate labelling of
patients as observation, especially adding observation status in postoperative patients, created problems and liabilities, and was one reason why in
years past payment was denied for anything other
than the three cardinal diagnoses of chest pain,
asthma, and heart failure. These three diagnoses
Observation Medicine – Key Concepts: Administrative Issues
005
20:20:18
were singled out because of the extensive
evidence-based medicine verifying the benefits of
observation in the literature.
9,11
Later, as additional research documenting the advantages of
observation as applied to other diagnoses and
conditions was identified, payment was no longer
limited to these three core diagnoses.
Misclassifying and/or reclassifying patients as
observation or inpatient creates problems; the
ideal is to place patients in the correct status from
the beginning rather than rectifying an erroneous
categorization. (See Chapter 64 on Determining
the Correct Status.)
Impact of the Two-Midnight Rule
The impact of the two-midnight rule is yet to be
determined.
12
As mentioned, CMS enacted the
rules change on October 1, 2013 that categorized
the majority of patient–hospital encounters of
< 2 midnights as observation, while those
2 midnights as hospital inpatient stays.
13
However, on April 1, 2014, a bill was signed into law
that directs CMS to delay enforcement of the twomidnight rule. This means that CMS has postponed postpaym ent audits of the two-midnight
rule until after March 31, 2015. However, the rule
is still in effect and hospitals have to meet its
requirements. CMS has applied prepayment
“probe and educate” reviews to see if hospitals
are in compliance. There is also pending legislation in Congress that directs CMS to create criteria for short inpatient stays.
14, 15
As of October 1, 2015, MACs have completed the
third round of Inpatient Probe and Educate reviews
(although some provider education may continue
beyond this date)... Beginning in January 2016,
Recovery Auditor Contractors (RACs) may conduct
patient status reviews only for those providers that
have been referred by the QIO (Quality
Improvement Organization) as exhibiting persistent
noncompliance with medicare payment policies,
including but not limited to: having high denial
rates and consistently failing to adhere to the Two
Midnight rule (including repeatedly submitting
inappropriate inpatient claims for stays that do not
span one midnight) or failing to improve their
performance after QIO educational intervention.
16
So the jury is still out and the results are yet to
be determined. Howe ver, what can and should we
be doing in the meantime? First and foremost,
make sure documentation is complete and accurate, no matter what status the patient is in.
(Table 2.1) Physician documentation must provide a complete picture of what is happening with
or to the patient. The physician must certify medical necessity, sign, date, and time the patient’ s
inpatient admission. The physician documentation should include an estimate of the patient’s
LOS and the physician’s plan of care for the
patient. (See Chapter 66 on Medical Necessity.)
No matter what happens with the twomidnight rule or when, we can be certain that
auditors will be scrutinizing medical records and
frequently employing a look back period that may
be several years. It is also likely that 1- and 2-day
stays will be targeted for audits regarding medical
necessity and for accurate and complete documentation. Undoubtedly, case management and
utilization review will be extremely busy in the
near future. In addition, the billing department
should be compliant with the new rules.
17–21
Ongoing information and updates may be
obtained from the CMS National Provider Calls.
22
References: Background
1. Centers for Medicaid and Medicare Services. CMS
finalizes FY 2014 policy and payments changes for
inpatient stays in acute-care and long-term care
hospitals. www.cms.gov/Newsroom/
MediaReleaseDatabase/Fact-Sheets/2013-FactSheets-Items/2013-08-02–2.html (Accessed
March 2016)
2. Ross MA, Hockenberry JM, Barrett M, et al.
Protocol driven emergency department
observation units offer savings, shorter stays and
reduced admissions. Health Affairs 2013; 32(12):
2149–2156.
3. Baugh CW, Schur JD. Observation care – high-
value care or a cost-shifting loophole? New Engl
J Med 2013; 369(4): 302–305.
4. Baugh CW, Venkatesh AK, Hilton JA, et al.
Making greater use of dedicated hospital
Table 2.1 Inpatient Admission Documentation Checklist
– Documentation is complete and accurate
– Documentation details what is happening with
or to the patient
– Documentation includes an estimated length
of stay
– Documentation includes a plan of care
– Documentation includes physician certification
of medical necessity
– Documentation of the patient’s admission must
be dated, timed, and signed
Sharon E. Mace
005
20:20:18
observation units for many short-stay patients
could save $3.1 billion a year. Health Affairs 2012;
31(10): 2314–2322.
5. Mace SE, Graff L, Mikhail M, et al. A national
survey of observation units in the United States.
Am J Emerg Med 2003; 21: 529–533.
6. Mace SE, Shah J. Observation medicine in
emergency medicine residency programs. Acad
Emerg Med 2002; 9:169–171.
7. Graff LG. Observation Medicine: The Healthcare
System’s Tincture of Time. American College of
Emergency Physicians Web site: www.acep.org/
WorkArea?Download/Asset.aspx?id=45885
(Accessed March 2016)
8. Venkatesh AK, Geisler P, Gibson Chambers JJ,
et al. Use of observation care in US emergency
departments, 2001 to 2008. PLos ONE 2011;
6(9):1–10 (e24326).
9. Baugh CW, Venkatesh AK, Bohan JS. Emergency
department observation units: a clinical and
financial benefit for hospitals. Health Care
Manage Rev 2011; 36(1): 28–37.
10. Osborne A, Weston J, Wheatley M, et al.
Characteristics of hospital observation services:
A Society of Cardiovascular Patient Care survey.
Critical Pathways in Cardiology 2013; 12(2): 45–49.
11. Department of Health and Human Services
(DHHS) Centers for Medicare and Medicaid
Services (CMS). CMS Manual System Pub. 100-02
Medicare Benefit Policy. Transmittal 42. Date:
December 16, 2005. Available at www.cms.gov/
Regulations-and-Guidance/Transmittals/
downloads/R42BP.pdf (Accessed March 2016)
12. Sheehy AM, Caponi B, Ganigreddy S, et al.
Observation and inpatient status: clinical impact of
the 2-midnight rule. JHospMed2014; 9(4): 203–209.
13. Centers for Medicare and Medicaid Services
Hospital inpatient prospective payment system
1599-F. Fiscal year 2014 Final rule. Federal
register/Vol. 78, No.160/Monday, August 19,
2013/Rules and Regulations. www.gpo.gov/fdsys/
pkg/FR-2013-18956.pdf (Accessed March 2016)
14. Don’t ignore the two-midnight rule. It’s still in
effect. Hosp Case Manag 2014; 22(5): 57–66.
15. CMS announces delay in two-midnight rule
enforcement. Hosp Peer Rev 2014; 39(4): 37–38.
16. www.cms.gov/Research-Statistics-Data-andSystems/Monitoring-Programs/Medicare-FFSCompliance-Programs/Medical-Review/
InpatientHospitalReviews.html) (Accessed March
2016)
17. Carlson J. Auditing inpatient stays. “Twomidnight” rule may still prove costly. Mod Healthc
2013 September 9; 43(36):9
–10.
18. Is the two-midnight rule much ado about nothing?
Hosp Case Manag 2013 December; 21(12):
161–164.
19. Egusquiza D. 8 critical steps for 2-midnight
compliance. Healthc Financ Manage 2014
February; 68(2): 54–57.
20. Edelberg C. A. closer look at the two-midnight
rule, what it means for ED providers. ED Manag
2013 December; 25(12): 142–143.
21. Cesta T. Case management insider. The
2-midnight rule – a game changer for case
management. Hosp Case Manag 2014 April;
22(4): 47–50.
22. www.cms.gov/Outreach-and-Education/
Outreach/NPC/National-Provider-Calls- andEvents.html (Accessed March 2016)
PEPPER REPORT
What Is the PEPPER Report?
The Programfor Evaluating Payment Patterns Electronic Report, known as the PEPPER report, is an
electronic data report that contains hospital-specific
information for various areas targeted by CMS. An
individual hospital’s PEPPER report contains
hospital-specific Medicare claims data for targeted
areas. Areas targeted by CMS include 1-day stays,
hospitalreadmissions, and diagnosis-related groups
(DRGs) that have historically been associated with
high rates of Medicare payment errors.
1
What Is Contained in the
PEPPER Report?
The PEPPER report gives data on areas targeted
by CMS where there are likely payment errors
secondary to billing, MS-DRG (Medicare Severity
Adjusted – DRG) coding, and/or problems with
medical necessity for admissions. The information contained in the PEPPER report should assist
hospitals in identifying possible overpayments
as well as possible underpayments. It can assist
in identifying potential problems and can be used
to establish what items should be targeted for
internal audits and validation analysis. It can aid
in finding areas where medical necessity may be
questionable, overcoding or undercoding occurs,
and readmissions are too common. It can help
detect areas where the hospital may be susceptible
to denials from the Recovery Audit Contractors
(RACs).
2
Observation Medicine – Key Concepts: Administrative Issues
005
20:20:18
CMS makes the PEPPER report available to
fiscal intermediaries (FIs) and to the MAC s.
RACs have the ability to provide PEPPER data
to the individual hospital. PEPPER has various
target areas that have been identified as high risk
for p ayment errors.
2
The PEPPER report provides a spreadsheet
of information unique to a given hospital,
which can be compared with other hospitals in
your region, state, MAC jurisdiction, and the
country.
3
The worksheets in the PEPPER report
show the hospital’s percentiles i n each target
area and compares the hospital’s numbers or
percentiles with other acute care hospitals, as
well as listing the hospital’stopDRGsfor1day stays and the statewide top DRGs for 1day stays for the fiscal year. A high number of
short stays suggests that the inpatient admission
wasn’t necessary or the patient should have been
managedonanoutpatientbasis,perhapsin
observation status.
2
How Can the PEPPER Report
Be Used?
The PEPPER report for any given hospital should
be compared with other hospitals in the region or
state, and items that stand out from other ins titutions that may be outliers should be evaluated
to see if they indicate a problem. Generally, any
time the hospital falls 80th percentile or < 20th
percentile suggests an issue that should be
addressed. When the hospital is uniformly low
in relation to the medical necessity measures,
then this may be an indicator that there is overutilization of observation services, while hospital
scores in the high range suggest coding errors or
problems with regard to medical necessity.
4
Results 80th percentile or < 20th percentile
imply that the hospital may be inappropriately
using observation services.
3
It is also useful to
determine what DRGs comprise the greatest
number of 1-day stays and then review them
for appropriate level of care.
1
A PEPPER Compare Worksheet on shortterm acute care hospitals shows the individual
hospital findings based on the unusualness of
the findings relative to other hospitals in the state
or region including outlier values and the extent
of the potential problem, which is the outlier
value times the number of discharges. PEPPER
may include a variety of tables and graphs that
compare an individual hospital with others .
“Having admissions in the outlier range does
increase your risk of review by your Quality
Improvement Organization (QIO), which could
mean the hospital has to pay back money it has
received because of noncompliance in reviewing
cases prior to admission.”
2
Similarly, compare the 30-day readmission
rate for the hospital with other acute care institutions in the state and ascertain whether or
not there was incomplete care during the first
admission and the secon d admission occurred in
order to provide services that should have been
rendered during the first or initial hospital stay.
1
In the past, PEPPER reports were distributed
to hospitals by their state Medicare QIO as a way
to support the Hospital Payment Monitoring Program (HPMP). Currently, QIOs are no longer
providing these reports. The PEPPER reports
have been sent to hospitals by mail, but are now
available through a secure portal from a website
maintained by TMF Health Quality Institute.
The TMF Health Quality Institute is under
contract from CMS to furnish comparative data
reports not only to providers but also to MACs in
an attempt to decrease Medicare fee-for-service
improper payments. For example, if a hospital
has a high number of 1-day inpatient stays for
chest pain in its PEPPER report, this is an area
noted to be at high risk for payment errors, which
raises a red flag and may trigger a government
contractor to do an audit on the hospital’s 1-day
inpatient chest pain stays.
5
This illustrates the
importance of placing patients in the proper
status initially and raises the question of how
many of these 1-day inpatient chest pain stays or
inpatient admissions could have been placed in
observation status in an OU (which is outpatient
status) instead, avoiding the high rating and misclassification of patients and the increased risk
of an audit. In some instances, the use of observation status could be an alternative for an inpatient
admission.
How Can One Access the
PEPPER Report?
A hospital’s PEPPER report is accessible at a
secure website via TMF.
6
TMF Health Quality
Institute is the contractor for the CMS PEPPER
program, whose job is to prepare the PEPPER
reports for specific institutions/facilities using
Sharon E. Mace
005
20:20:18
claims data. Note: there are PEPPER reports not
only for short-term acute care facilities, (which is
relevant for observation medicine) but also for
long-term acute care facilities.
7
There is also a
training/resource website maintained by the
TMF Health Quality Institute.
8
What Can Happen if There Are Errors
in Payment?
PEPPER reports concentrate on LOS issues, specifically 1-day stays, and on certain MS-DRGS
that have been problems in the past.
9
There are
significant financial consequences that can
greatly impact an institution’s bottom line so it
is crucial that every patient is coded correctly
and compliant.
10
Regarding observation, there
are two types of coding errors. When patients
are misclassified as outpatients instead of as
inpatients, then the hospital does not receive
appropriate inpatie nt payment. Conversely,
when observation patients are misclassified as
inpatients, when audited and such mistakes
are detected, the hospital not only will be compelled to return inappropriate payments but also
can be fined and have to pay penalties and interest on any misclassifications identified during
an audit.
10
Revision of the PEPPER Report Based
on the Two-Midnight Rule
Because of the two-midnight rule for inpatient
admissions, the PEPPER compliance tool has
been recently revised.
11
The two-midnight rule
was adopted by the Inpatient Prospective Payment System (IPPS) regulation in 2014. The
two-midnight rule usually assumes that hospital
stays crossing two midnights are appropriately
billed as an inpatient, and conversely, shorter
stays are generally not reported as an inpatient
stay, with a few exceptions, excluding patients
who are admitted for inpatient-only procedures.
This revised PEPPER report has six new target
areas: 2-day stays for medical DRGs, 2-day stays
for surgical DRGs, 1-day stays for medical DRGs,
1-day stays for surgical DRGs, same-day stays for
medical DRGs, and same-day stay for surgical
DRGs. Observation status metrics should help
recognize overpayments and underpayments.
The CMS website gives information on the IPPS
2014 and other rulings.
12
References: PEPPER Report
1. PEPPER can help you focus on likely RAC targets.
Hospital Case Management; 2010 December;
18(12): 181–182.
2. PEPPER can identify areas where denials may
occur. Hospital Case Management; 2005 June;
13(6): 84–86.
3. http://store.relearning.com/by-topic/pepper-1/
pepper.html (Accessed March 2016)
4. Wiedemann LA. Seasoning your compliance plan
with PEPPER. How to read PEPPER data on
payment errors; 2007 January; 78(1): 44–49.
5. www.hcpro.com/print/HOM-218293–5750/
What-is-PEPPER-data-and-how-can -it-helpprepare-for-a-RAC-audit? (Accessed March
2016)
6. TMF Health Quality Institute http://
pepperresourcs.org/PEPPER/SecurePEPPER
Access.aspx ( Accessed March 2016)
7. Kulus J. PEPPER gives corporate compliance
guidelines. Provider: Long Term & Post-Acute
Care. 2013 March; www.providermagazine.com/
archives/2014_Archives/Pages/0314 (Accessed
March 2016)
8. TMF health Quality Institute http://
hospitals.tmf.org/PEPPERResources/tabid/1115/
Default.aspx (Accessed March 2016)
9. www.hcpro.com/HIM-245049–865/Use-PEPPERreports-to-stay-on-top-of-common-coding-errors
(Accessed March 2016)
10. Corrati RR. Report data identify risk areas for
improper payments. Healthcare Financial
Management 2011 October; 65(10): 88–92.
11. Report on Medicare Compliance: PEPPER
compliance tool is revised for two-midnight rule
in time for June release. Atlantic Information
Services, Inc. 2014 May; 23(16). Available online at
www.AIShealth.com (Accessed March 2016)
12. Centers for Medicare and Medicaid Services.
www.cms.gov/Medicare/medicare-Fee-forService-Payment/AcuteInpatientPPS/FY2014IPPS-FinalRule (Accessed March 2016)
CRITERIA FOR INPATIENT ADMISSION
OR OBSERVATION
Overview
Recently, the National Gove rnment Services, and
MAC, published their views on the process of
clinical and reimbursement or payment decisions
regarding observation.
1
In step one, the treating
Observation Medicine – Key Concepts: Administrative Issues
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physician should ascertain whether the patient
can be discharged home from the ED. If the
answer is no, discharge is not appropriate, then
the practitioner proceeds to step two and “understand[s] that the patient will need ongoing inpatient services with a high degree of certitude or
assess the likelihood that care may be rendered
within a 48-hour timeframe.”
1
Extended or com-
plex observation could be considered for this situation where there is “outpatient obse rvation up to
48 hours of care (with) appropriate diagnostic
and therapeutic care.” However, “ Physicians
should use a 24-hour period as a benchmark, i.e.
they shoul d order admission for patients who are
expected to need hospital care for 24 hours or
more, and treat other patients on an outpatient
basis.”
1
This again reinforces the 24-hour time
frame for observation (or “simple” observation).
Medical Necessity Screening Tools
There are several medical necessity screening tools
that Medicare and its contractors may select to use
in their determination of medical necessity. The
Milliman care guidelines
2
or McKesson’s Interq-
ual
3,4
are two commonly used screening tools,
although there are other proprietary systems.
5
The
criteria used may vary from state to state or jurisdiction. Moreover, Medicare does not mandate the
use of any particular screening criteria.
The key components of any criteria pertain to
intensity of service (IS) and severity of illness (SI);
both criteria must be met in order to substantiate
the medical necessity for inpatient admission
versus observation status or another service in
the hospital system. There are similarities between
the inpatient admission and observation criteria,
however, inpatient SI and IS criteria generally
indicate higher acuity. The criteria are arranged
by body system, for example, general, cardiorespiratory, central nervous system, gastrointestinal,
metabolic, obstetrics, and surgery/trauma. Components of the SI criteria include as sessments,
monitoring, medication administration, intravenous fluids, administration of blood products, and
psychiatric crisis intervention.
5
The usual process involves a hospital case manager (or care coordinator) or member of the utilization management staff reviewing the patient’s
record.
4,6
Ideally, this process would begin pro-
spectively in the ED, but generally within the first
24 hours of a patient’s admission to determine if
the particular screening tool’s criteria are met.
Documentation by the treating physician is critical
to establishing the IS and the SI.
There may be times where a specific patient
does not meet inpatient criteria, but requires an
inpatient admission. In these instances, the physician in conjunction with the case manag er or
utilization review staff member should consider
the overall scenario to decide on the need for
hospitalization. Excellent documentation of medical necessity is crucial in these cases.
There are times when the initial review of a
record fails to meet screening criteria for medical
necessity. Generally, a medical review, which is a
second-level review, occurs in which a physician or
nurse reviews the record for clinical documentation
to support the hospital admission and payment.
This emphasizes the critical importance of excellent
documentation in order to provide proof of medical
necessity. (See Chapter 66 Medical Necessity)
There are also instances where screening criteria have been met, yet the payer denies payment
because documentation does not support the
medical necessity of admission. Hospitals can
appeal payment denials, but this involves additional time and expense so it is best to assign
the correct status at the beginning. (See Chapter 67
Denials and Appeals)
Unfortunately, the criteria for determining
inpatient hospital admission versus observation
are not always well defined so the decision usually
defers to physician judgment. Indeed, the accuracy of the various criteria in predicting the need
for hospitalization for both medical and surgical
patients has been questioned by some.
7–10
Again, incorre ct patient status, for example,
inpatient admission versus observation, has many
negative repercussions. Categorizing a patient as
inpatient when he or she should have been observation leads to payment errors with the potential
for denial of payment, and perhaps, more importantly, compliance issues related to overpayments.
On the other hand, there is the potential for
revenue loss when a patient is in observation
and should have been an inpatient.
Changes in Observation Status:
From Inpatient to Observation
There are very strict criteria for changing inpatient status to observation and the change must
occur “before” the patient is discharged from the
Sharon E. Mace
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hospital.11Some key prerequisites for changing
from inpatient to observation status are as
follows: the hospital has not already submitted
the inpatient claim to Medicare; the Utilization
Committee makes the decision, the physician
agrees with the Utilization Committee’s decision,
and the physician documents this concurrence in
the patient’s medical record; and the UB04 outpatient bill is submitted with the condition code 44,
“inpatient admission changed to outpatient” in
one of the Form locators 18–28.
12
Code 44 can
still be used even with the two-midnight rule.
13
However, there is one caveat: Medicare anticipates that the use of this code 44 modifier is used
infrequently and frequent usage may be a red flag
that triggers an audit.
Changes in Observation Status:
From Observation to Inpatient
Admission
A patient in observation status may be admitted
to inpatient status at any time for medically necessary continued care, provided inpatient medical
necessity screening criteria are met at the time of
the hospital inpatient admission, which should be
documented. However, two important points
must be mentioned. First, the inpatient medical
necessity screening criteria must be determined at
or from the time of the inpatient admission and
not from the time the patient was first placed in
observation. Second, the patient can never be
retroactively switched from observation to inpatient, since a retroactive change would imply that
the observation never happened.
References: Criteria for Inpatient
Admission or Observation
1. www.ngsmedicare.com/ngs/portal/ngsmedicare
(Accessed March 2016)
2. www.careguidelines.com (Accessed 2016)
3. www.mckesson.com/about-mckesson/ourcompany/businesses/mckesson-health-solutions/
interqual-evidence-based-clinical-content
(Accessed 2016)
4. Mitus AJ. The birth of interqual. Professional Case
Management 2008; 13(4): 228–233.
5. www.acep.org/Clinical–Practice-Management/
Utilization-Review-FAQ (Accessed March 2016)
6. McKendry MJ, Van Horn J. Tips, tools and
techniques. Case Management 2004; 9(2): 61–71.
7. Wang H, Robinson RD, Coppola M, et al. The
accuracy of interqual criteria in determining the need
for observation versus hospitalization in emergency
department patients with chronic heart failure.
Critical Pathways in Cardiology 2013; 12(4): 192–196.
8. Irwin CB, Nigl J, Lowe RA. Accuracy of interqual
criteria in determining the hospitalization need in
medicare patients with gastrointestinal bleeding.
Acad Emerg Med 2000; 7:552–553 (abstract).
9. Irvin CB, Monfette K, Lowe R. Retrospective
evaluation of potential Medicare admission denials
using interqual and Milliman Roberts admission
criteria. Acad Emerg Med 2000; 7:543 (abstract).
10. Rutledge R. An analysis of 25 Milliman &
Robertson guidelines for surgery: data driven
versus consensus-derived clinical practice
guidelines. Ann Surg 1998; 228(4): 579–585.
11. www.cms.gov/Regulations-and-Guidance/
Guidance/Transmittals/downloads/R299CP.pdf
(Accessed March 2016)
12. www.cms.gov/Outreach-and-Education/
Medicare-Learning-Network-MLN/
MLNMattersArticles/downloads/SE0622.pdf
(Accessed 2016)
13. Confusion ahead as CMS changes inpatient
criteria. Hospital Case Management 2013 October;
21(10): 133–136.
INPATIENT PROSPECTIVE PAYMENT
SYSTEM (IPPS)
What Is IPPS?
The IPPS is “a system of payment for the operating
costs of acute care hospital inpatient stays under
Medicare Part A (Hospital Insurance) based on
prospectively set rates.”
1
Under the IPPS, each case
is classified into a DRG. Each DRG has a payment
weight assigned to it, based on the average
resources used to treat Medicare patients in that
DRG. The base payment rate is split into a laborrelated and nonlabor share. The labor-related
share is adjusted by the wage index according to
where the hospital is located. (Note: If in Alaska or
Hawaii, there is also a nonlabor cost of living
adjustment factor.) The base payment is multiplied
by the DRG relative weight. There is an add-on,
termed the disproportionate share hospital (DSH)
adjustment, for hospitals that treat a highpercentage of low-income patients. There is also
an add-on adjustment, the indirect medical education (IME) adjustment, for approved teaching
Observation Medicine – Key Concepts: Administrative Issues
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hospitals. For specific cases that are unusually
costly, termed outlier cases, the IPPS is increased.
1
The specific DRGs are referenced in the International Classification of Diseases (ICD). The ICD
is maintained by the National Center for Health
Statistics (NCHS) and the CMS. The current version is the ICD-10-CM (International Classification
of Diseases 10th revision clinical modification).
2
The U.S. Department of Health and Human Services issued a final rule finalizing October 1, 2015 as
the new compliance date to transition to the ICD-10
code sets.
3
There is also the Current Procedural
Terminology (CPT), which is “the medical nomen-
clature used to report medical procedures and services under public and private health insurance
programs.”
4
Various manuals are available that list
the ICD-9 and ICD-10 codes and the CPT codes.
5–7
In general, Medicare Part A covers hospital
care, skilled-nursing facility care, nursing home
care (as long as custodial care isn’t the only care
needed), hospice, and home health services.
8
Medicare Part B “covers services (like lab tests,
surgeries, and doctor visits) and supplies (like
wheelchairs and walkers) considered medically
necessary to treat a disease or condition.”
9
Inpatient Hospital Stays, IPPS,
Targeting Short Inpatient Stays,
Reimbursement and Observation
As noted, Medicare’s payment for inpatient admissions is determined by using the ICD-10 diagnosis
codes), submitted by the hospital to determine the
DRG, which ultimately decides the payment for the
inpatient admission. According to Medicare’s
inpatient prospective reimbursement system, every
DRG has a known mean LOS and this mean LOS is
used to determine the DRG’s relative weight and,
therefore, payment. Short inpatient hospital stays,
for example, meaningfully less than the average
LOS, raise concerns that there is potential overpayment and that the admission was “inappropriate”
so Medicare and the QIOs monitor hospital discharge data and specifically target short hospital
stays. Any hospital that has a high incidence of
short inpatient hospital stays is very likely to be
audited; if any inappropriate admissions are discovered, repayment and fines or sanctions can be
onerous with tremendous financial consequences.
Excellent documentation, especially focused on IS
and SI, are useful in justifying an admission.
10
However, in a number of cases, observation
status (placement in observation status but not
“admitted” to observation since observation is
considered an outpatient service) is a viable
option to an inpatient admission and, as detailed
in later chapters, may even be better in terms of
patient/family satisfaction, lower costs, and better
patient outcomes with fewer returns to the ED
and readmissions to the hospital.
References: Inpatient Prospective
Payment System (IPPS)
1. www.cms.gov/Medicare/Medicare-Fee-forService-Payment/AcuteInpatientPPS/index.html
(Accessed March 2016)
2. www.cdc.gov/nchs/icd/icd9.htm (Accessed March
2016)
3. http://cms.gov/Medicare/Coding/ICD10/
index.html (Accessed March 2016)
4. www.cdc.gov/nchs/icd/icd10cm.htm (Accessed
March 2016)
5. ICD-9-CM (International Classification of Diseases
9th Revision Clinical Modification). Hart AC,
Stegman MS, Ford B (eds.) Optum Insight, Inc.,
2012, sixth ed.
6. ICD-10-CM. Official Guidelines for Coding and
Reporting –Fy 2015. Department of Health and
Human Services, 2015. ,
7. Gabber W, Kachur KH, Canter KV. Current
Procedural Coding Expert: CPT Codes with
Medicare Essentials Enhanced for Accuracy.
American Medical Association, 2011.
8. www.medicare.gov/what-medicare-covers/part-a/
what-part-a-covers.html (Accessed March 2016)
9. www.medicare.gov/what-medicare-covers/part-b/
what-medicare-part-b-covers.html (Accessed
march 2016)
10. www.acep.org/Clinical–Practice-Management/
Utilization-Review-FAQ (Accessed March 2016)
MEDICARE’S HOSPITAL PAYMENT
MONITORING PROGRAM (HPMP)
The Medicare HPMP was established by CMS to
measure, monitor, and decrease payment errors
for hospitals (both short- and long-term acute
care hospitals) that receive reimbursement via
the IPPS using DRGs. The goal is to pay only
for services that are “reasonable and necessary”
in order to protect the Medicare trust fund. By
Sharon E. Mace
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