If you’ve got a system for getting patient status right up front and it works, don’t change anything but make sure that the documentation is detailed and complete, advises Linda Sallee, RN, MS, CMAC, ACM, IQCI, director for Huron Healthcare with headquarters in Chicago.
“Hospitals should have solid steps in place to make sure the documentation is comprehensive and supports an inpatient stay. Even if the record includes check boxes for the physicians to certify an admission, comprehensive documentation still needs to be in the medical record and progress notes,” Sallee adds.
When CMS changed the Two-Midnight rule to allow physician judgment in determining patient status for short-stay patients, it became more important than ever for the medical record to contain explicit documentation as to why patients need an inpatient stay rather than observation services, adds Deborah K. Hale, CCS, CCDS, president of Administrative Consultant Services, a Shawnee, OK, healthcare consulting firm.
Hale cautions case managers to be especially vigilant when to admit or not to admit is a borderline call. Make sure that the clinical rationale for admitting a patient is carefully documented in the medical record and that the documentation includes an explanation of the risk of sending the patient home and providing services later in a different setting, she says.
“There may be cases where patients don’t stay past the second midnight or there is a weak case for medical necessity to begin with and the patient stays less than two midnights. In these cases, there has to be strong clinical support for an inpatient stay in the medical record or the case is likely to be denied,” Hale says.
It’s important for case managers to ensure that physicians clearly document what is going on with patients that makes an inpatient admission medically necessary, says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts.
Work with the physicians to determine if patients meet inpatient criteria and call on your physician advisor for assistance if necessary, she adds.
“An effective physician advisor is a critical asset to case management departments when it comes to determining whether patients should be admitted. Case managers can advise the admitting physician, but CMS says that a non-physician should never be the person to make the final determination of whether a patients meets medical necessity criteria. This is where the physician advisor comes into play,” she says.
Hospitals need to make sure that everyone on the team works together, rather than operating in silos, Cunningham says. Some hospitals are separating the function of utilization review from the RN case manager role. In that case, it’s particularly important for case management and the utilization review staff to work closely together to make sure that patient status is correct, even if they are in different departments, Cunningham says.
Without good communication, this situation is rife for glitches and, ultimately, denials, Cunningham says. For instance, each morning, the utilization review nurses are reviewing what happened overnight while, at the same time, case managers are making rounds with the physicians. “Neither is aware of what the other is doing because it’s happening simultaneously. Ensuring the status is correct becomes a real challenge,” she says.
“In the situation when utilization management is removed from the case management role, case managers on the unit don’t always have the same medical necessity knowledge level that utilization review nurses have. If utilization review is a separate function, case management directors should make sure that there is communication between the utilization review nurse and the case managers on the unit,” she says.
