Transforming Clinical Information into Medical Necessity

Introduction

Case Management and Utilization Review departments face an uncertain future with respect to the transformation of information into actionable data that will be used to determine the appropriateness of an admission. New laws, regulations, changes in guidelines, therapeutic interventions, technology and quality outcomes all play an integral part in the decision when determining a patient’s admission. In times past it was strictly the physician and the patient that determined that but with the ever increasing intrusion by governments both state and federal and rules applied by private insurance companies the task can be daunting. The patient complexity, the case mix of medical and surgical diagnosis, the types of admissions inpatient, outpatient, observation and the increased use of consultants has placed an overwhelming burden on the case manager/utilization review nurse to ensure that they reliably interpret the patients admission to the correct medically necessary status so as to not affect the revenue cycle of the hospital. The revenue cycle is the life blood of most institutions with marginal margins that keep the doors open to service the public. So how then does a person translate the wealth of information in a moment’s time to capture the correct information to ensure success?

It is necessary to understand how information is captured to begin the review process and that starts with the physician exam.

The duty of the physician is to examine the patient based on the chief complaint but with the whole body system in mind. They must document the findings in the manner outlined below with special care to note how they plan to treat the patient and to ensure they are in compliance with the fundamentals of mitigating misfeasance and malfeasance. In other words they must do as any other prudent physician would do given the same set of circumstances in his or her locality and options for treatment. Physicians mostly treat patients routinely as they were taught to overcome the illness or injury. With the advent of the electronic EMR has come the emergence of predefined order sets and clinical pathways that suggest an evidenced based treatment plan. More importantly many institutions have begun the process of implementing patient specific care plans for high utilizers based on certain diagnosis incorporating evidenced based guidelines and pathways. Even with all of the above available to the physician there remains gaps in the documentation to ensuring proper evidence in the record to prove medical necessity for admission or even the need to place a patient under observation. Enter the case manager and the skills necessary to decipher what is needed. Case Managers and Physicians must bond together to discuss cases and to provide suggestions and directives for missing information especially in an academic setting when working with residents. That is not to suggest that case managers ask for documentation that will make medically necessity work when it is not part of the care that is needed but rather when it was just not documented.

The duty that case managers and utilization review staff is ensuring that the hospital is paid but they are also duty bound to protect the patient since an incorrect status assignment can mean the difference between no co-pay to large co-pays and out of pocket expenses including the Medicare Beneficiary who when placed into an observation level of care will not qualify for the extended benefit for skilled nursing care without a qualifying three day inpatient acute care stay.

Review Process

The first phase of any review entails the gathering of information, which should include the following

1. History of the Present Illness including when the symptoms/problem started

2. Duration of the issue

3. Intensity of the issue

4. Review of systems that have positive findings

5. Past/Family and /or Social History as it impacts the decision to admit

6. Any positive findings or negative (exclusionary findings) of labs or tests

7. The actual order and level of order (Med-Surg, Tele, ICU, etc)

8. The status of the order

9. The Service that the patient is admitted to (Medicine, Ortho, Cardiac, etc)

10. Treatment given in ED or as a continuation of the treatment by an ambulance crew or outpatient treatment which meets the required criteria or will continue upon admission

11. Treatment Plan

12. Expected Outcomes

13. Predictability of an adverse event. (See attached Table of Risk)

Once that is reviewed then a face to face interview with the patient and family should be completed to ensure that all relative information has been gathered. If the patient is in the ED a discussion with the care team including the ED Physician and Nurses should ensue to determine the level of care which the patient should be placed into. A reminder to the physician that status is not an indication of therapeutic intervention may be needed from time to time along with the admitting physician. Additionally the location of where the patient is admitted to; is not relevant to the status as well as the total time the patient stays in hospital although per Medicare an inpatient status generally indicates a two midnight stay although this may not be needed per the patient’s progress.

Using Evidenced Based Clinical Decision Support tools

When selecting a category from any evidenced based guideline tool for review start at the highest level and work down, if you suspect that an observation status can meet inpatient criteria you would begin your review at the inpatient admission level, the same holds true for intermediate to critical as well as nursery to NICU.

Be as specific as you can be when selecting a diagnosis by the evidence in the medical at the time the patient is seen by the physician due to the medical presentation of the patient who may be awaiting a differential diagnosis based on the outcomes of testing or further invasive testing or consultation with a specialist/s.

Condition or disease specific criteria in in evidenced based guidelines are a game changer, it puts the focus on how well the patient is responding to the therapeutic intervention based on episode days instead of a straight intensity of service. This should be viewed as a positive change since we can now focus on the patient’s safety, well being and quality of the interventions that can make the patient well or try to return him or her to their pre-admission wellness state. Patients that require longer lengths of stay are considered non-responders and conversations about the expected outcomes and treatments should occur at least daily with the medical team which includes the attending physician and any consultant.

Open dialogue with the care team ensures that communication of the care plan can be disseminated by the case management/utilization staff to encompass it into the discharge plan. Encompassing reviews with the discharge plan begins the process of a fully integrated care plan, just as important transitioning the patient to the next level of care at the right time and to the correct location is an important aspect of the review process along with resource and time management.

Being able to accurately predict a patient’s discharge comes from the review of the elements discussed and the communication among the care team. Knowing how the patient is responding to the therapeutic interventions and what episode day the patient is on will lead to a more streamlined discharge with proper planning taking place the days ahead of the predicted discharge.