Carrie Valiant, Esq.
Member, Epstein Becker & Green Founder and President
Health Care Industry Access Initiative
Patrice Sminkey Chief Executive Officer
Commission for Case Manager Certification
1
Proprietary to CCMC®
Observation status and
Agenda
2
•
Welcome and Introductions
•
Learning Objectives
•
Patrice Sminkey, CEO, the Commission
•
Carrie Valiant, Esq., member, Health Care and Life Sciences
practice of the Epstein Becker & Green law firm; and founder and
president, Health Care Industry Access Initiative
Audience Notes
3
•
There is no call-in number for today’s events. Audio is by streaming only. Please use your computer speakers, or you may prefer to use headphones.•
Please use the “chat” feature on the lower left-hand part of your screen to ask questions throughout the presentations. Questions will be addressed as time permits after both speakers have presented.•
A recording of today’s session will be posted within one week to the Commission’s website, http://www.ccmcertification.org•
One continuing education credit is available for today’s webinar only to those who registered in advance and are participating today.L
earning Objectives Overview
4
After the webinar, participants will be able to:
•Demonstrate familiarity with the eight principles of the Code of Professional Conduct for Case Managers;
•Describe how the Commission’s Code of Professional Conduct supports and clarifies the case manager’s priorities and role as patient advocate while
balancing the need for efficiency and resource management;
•Summarize the appropriate designation of patients under “observation status” versus inpatient admission in the hospital, as well as other current practices and challenges to patient access.
Introduction
Patrice Sminkey Chief Executive Officer
6
• Webinars
• Certification Workshops
• Issue Briefs
• Speaker’s Bureau
www.ccmcertification.org
Why a code of professional
conduct for case managers?
Protect the public interest
http://ccmcertification.org/content/ccm-exam-portal/code-professional-conduct-case-managers
Principles
Rules of Conduct
Standards for Professional Conduct
Procedures for Processing Complaints
Principle 1: Certificants will place the public interest above
their own at all times.
Principle 2: Certificants will respect the rights and inherent
dignity of all of their clients.
Principle 3: Certificants will always maintain objectivity in
their relationships with clients.
Principle 4: Certificants will act with integrity in dealing with
other professionals to facilitate their clients’ achieving
maximum benefits.
Principle 5: Certificants will keep their competency at a level
that ensures each of their clients will receive the benefit of
services that are appropriate and consistent for the client’s
conditions and circumstances.
Principle 6: Certificants will honor the integrity and respect
the limitations placed on the use of the CCM designation.
Principle 7: Certificants will obey all laws and regulations.
Principle 8: Certificants will help maintain the integrity of the
Code.
12
Observation status and
ethical considerations for case managers
Carrie Valiant, Esq.
Member, Epstein Becker & Green Founder and President
Code of Professional Conduct
for Case Managers
Observation Status and Ethical
Considerations for Case Managers
• Observation includes ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether
patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.
– Medicare Benefit Policy Manual, CMS Pub. No. 100-02, Ch. 6, §20.6.
Same language in Medicare Claims Processing Manual, CMS Pub. No.100-04, Ch. 4, §290.1.
• Observation services are commonly ordered for patients who present to the emergency department and who then require a significant
period of treatment or monitoring in order to make a decision concerning their admission or discharge.
• The purpose of observation is to determine the need for further
treatment or for inpatient admission. A patient receiving observation services may improve and be released, or be admitted as an inpatient
• Not a status – a type of outpatient service
– When a physician orders that a patient receive observation
care, the patient’s status is that of an outpatient.
• Outpatient: a person who has not been admitted by
the hospital as an inpatient but is registered on the
hospital records as an outpatient and receives services .
. . from the hospital.
• Inpatient: a person who has been admitted to a
hospital for bed occupancy for purposes of receiving
inpatient hospital services.
• “Status” usage for observation is still very common
• Medicare hospital inpatient vs. outpatient
status vs. observation
• Case manager expertise being called on to
– Apply Interqual/Milliman standards
– Educate physicians
– Make status determination
• Ramifications for patients
– coverage of post- hospital services
– coinsurance obligations
• Ramifications for hospital
– amount of reimbursement (usually)
– potential False Claims Act liability
• Manuals say observation should not exceed
24-48 hours
• Also, patients who begin as inpatients may
later be changed to outpatient/observation
(Condition Code 44)
• Condition Code 44, Transmittal 299 (Sep.
2004), now at Medicare Claims Processing
Manual, CMS Pub. No. 100-04, Ch. 1, §50.3,
http://www.cms.hhs.gov/manuals/downloads
/clm104c0
1.pdf (p. 138)
• Increasingly, longer stays in an acute care hospital
may be called “observation services”
• Why?
– Focus on readmissions – there can’t be a readmission if
there wasn’t an admission in the first place!
– Government scrutiny of medical necessity of inpatient
admissions, particularly short stays
• Hospital complaints that auditors were denying large numbers of claims for inpatient care because the patient
could have been considered an outpatient under observation.
• Hospitals’ Use of Observation Stays and Short
Inpatient Stays for Medicare Beneficiaries,
OEI-02-12-00040
• Found that Medicare beneficiaries had
– 1.5 million observation stays in 2012, spending 1 night
or more in the hospital.
– An additional 1.4 million long outpatient stays, some of
which may have been observation stays
• Of the observation stays
– 11% of observation stays were at least 3 nights
– 26% of observation stays were two nights
•
Most common problems associated with longer observation
stays (in descending order) –
– Back problems
– Signs and symptoms – Nutritional disorders – Digestive disorders – Circulatory disorders – Dizziness
– Fainting
– Respiratory Signs and Symptoms – Irregular heartbeat
– Chest pain (#1 reason for observation and short inpatient stays)
•
Most long outpatient stays began in the ED.
Characteristics of Longer
Observation Stays
• Denial of coverage for post-acute
care
• Denial of coverage for inpatient
drugs
• Additional coinsurance cost to
patient
Consequences of Conversion to
Observation
• Medicare generally pays more for a short inpatient stay than an
observation stay.
• But beneficiaries may pay more.
– There is no cap on the aggregate outpatient 20%
coinsurance amount
– Coinsurance is charged separately with respect to each
service/item received in observation
– Self-administered drugs are not covered during an
outpatient visit (but they are covered during an inpatient
visit
– Thus, coinsurance charges and charges for non-covered
services may be higher than the inpatient deductible.
• “Beneficiaries in observation stays sometimes
paid more than the deductible charged to
beneficiaries in inpatient stays.
• For 6 percent of all observation stays, or
83,747 stays, beneficiaries paid more than the
inpatient deductible.
• Notably, for 3,439 observation stays,
beneficiaries paid more than two times the
inpatient deductible.”
• SNF benefits depend on a qualifying
inpatient hospital stay
• “The beneficiary must have been
hospitalized . . . for medically necessary
inpatient hospital care . . . for at least 3
consecutive calendar days, not counting
the day of discharge.” 42 C.F.R.
§409.30(a)(1)
Coverage Consequences for
Patients
• Time spent in observation status in the
emergency room prior to (or instead of) an
inpatient admission does not count toward
the 3-day qualifying inpatient stay.
• Medicare Benefit Policy Manual, CMS Pub.
No. 100-02, Ch. 8, §20.1.
Coverage Consequences for
Patients
• If the patient is admitted as Inpatient after
Observation, it is effective at time of the
admitting order
• This means that generally only certain “Part B
only” services can be billed before the
inpatient admission
• This means there is no compensation for
routine services/bed and board prior to
inpatient admission
• Condition code 44 changes a patient's initial inpatient status to
outpatient for purposes of billing and payment.
• Must meet the following criteria –
– UR Committee decides inpatient criteria are not satisfied – A physician concurs with the utilization review committee’s
decision
– Change is made before discharge
– Patient rights, notice and participation interpretation – Hospital has not submitted a Medicare claim
• Observation time starts when the physician orders observation
and nursing begins to implement it.
• Not retroactive; time on inpatient status does not count
• Patients may begin as inpatients and end up
outpatients prior to discharge.
• Patient notice of retroactive changes is not required
because a change in status is not considered a
denial of coverage.
• Some hospitals have special observation units but
many do not.
• So patients on observation may be in a bed on a
regular inpatient unit, getting treatment and
services exactly the same as inpatients.
• Physician determines need for hospital care
– Orders: “Admit to Case Management Protocol”
• Possibly standing orders
• – “Hold” status for X hours (e.g., 2, 6, 12) while
Utilization Management assigns status using
established criteria
• – Default to Outpatient/Observation if not assigned
during the hold period
• If assigned to Observation, physician re-evaluates
within 24-48 hours for possible inpatient admission or
discharge
Case Management Assignment
Protocol (CMAP)
• CMS has not approved the use of CMAP
• A specific physician order is required for
either Inpatient Admission or Observation
• CMS has stated concern that standing
orders remove the physician from the
decision making process
• There is physician involvement
– Medical staff involved in creation of the protocol
even if not in individual decision
• Physicians not educated in intricacies of
patient status
– Hospitals generally use InterQual criteria
(McKesson Corp.) to make status decisions
– Criteria is based on severity of illness and intensity
of service
•
No standing orders
•
No defaults
•
Case management reviews/recommends
•
Recommendation communicated to
physician
•
Requires separate physician’s order
accepting the recommendation after it is
made
Modified Case Management
Approach
• Audit presumption that stays lasting two midnights or longer are reasonable and necessary and will qualify for inpatient admission under Medicare Part A. • Stays lasting less than two midnights will not be presumed to qualify as
inpatient stays and instead will be paid under Medicare Part B, which covers outpatient services.
• When the physician “expects to keep the patient in the hospital for only a limited period of time that does not cross two midnights, the services are generally inappropriate for [inpatient] payment under Medicare Part A, regardless of the hour that the patient came to the hospital or whether the patient used a bed.”
• Physician must sign an admitting order, which must be “supported by the physician admission and progress notes, in order for the hospital to be paid for hospital inpatient services under Medicare Part A.”
• The two midnight “clock” begins when the patient starts receiving hospital services (including observation services).
• September 26 open-door forum, CMS clarification –
– If a patient stays one midnight in observation and the physician expects that the patient will require at least another midnight in the hospital, the patient can be appropriately admitted despite the fact that it will be a one-day inpatient stay.
– If a patient is admitted but ultimately doesn’t stay two midnights, clear physician documentation supporting the order and expectation of two midnights will be required.
– RAC auditors will review cases with stays less than two midnights. If a facility is audited, the reviewers will look for a codified physician order and certification, plus supportive documentation.
• However, the clock for beneficiary qualification for SNF services remains the same, only from the time of the inpatient admission.
• Expected to result in a net increase of around
40,000 admissions nationally, with a substantial
increase in two-day cases.
• CMS proposed a 2% payment cut to pay for the
increase in admissions.
• Legal Challenges –
– Hospital systems and trade associations filed suit
– Disagree that all stays shorter than two midnights are
inappropriate
– Physician judgment should be the only factor
considered for an inpatient admission.
Carrie Valiant, Esq. Partner
Epstein Becker Green
1227 25th Street NW, Suite 700 Washington, D.C. 20037
202-861-1857
CValiant@ebglaw.com
Epstein Becker Green is one of the largest health care law firms in the United States. Our firm represents a wide range of organizations in the health care industry including health professionals, management companies, equipment suppliers, health systems, payors and manufacturers.
For more information, please visit our website at: www.ebglaw.com
38 Proprietary to CCMC®
Commission for Case Manager Certification
15000 Commerce Parkway, Suite C, Mount Laurel, NJ 08054
1-856-380-6836 • Email: ccmchq@ccmcertification.org
www.ccmcertification.org
Thank you!
39 Proprietary to CCMC®
