Medical Necessity & Charting Guidelines

(1)

(2)

In most cases we are told the rules up

front - or will be told if we ask

Like most games, the one who knows the

rules the best

WINS

(3)

Nationally Recognized

Industry Guidelines for determination

of Medical Necessity used by payor

sources: sources:

Milliman

®

InterQual

®

Payors will approve day/s for patient

stay based on these guidelines.

Hospital and physicians have signed

(4)

InterQual Guidelines for

Medical Necessity

Utilized for Medicare patientUtilized for Medicare patient

Acute Care inpatient or Observation Acute Care inpatient or Observation

–

– Severity of Illness (SI)Severity of Illness (SI)

–

– Intensity of Service (IS)Intensity of Service (IS)

Used for Adult and Pediatric ServicesUsed for Adult and Pediatric Services

Offers Discharge ScreensOffers Discharge Screens

Criteria are specific forCriteria are specific for

–

– Body Systems: Neuro, Cardiac, etc.Body Systems: Neuro, Cardiac, etc.

–

– Care Units: ICU, Intermediate, Medical, Care Units: ICU, Intermediate, Medical,

Monitored bed

(5)

InterQual Guidelines for

Medical Necessity

Criteria for Alternative Level Of

Care (ALOC)

–

– Long Term acute Care Long Term acute Care

–

– RehabRehab

–

– SNF: Skilled Nursing facilitySNF: Skilled Nursing facility

–

– Hospice: Hospice: Not limited to cancer Not limited to cancer patient

patient

–

– Home HealthHome Health

(6)

Severity of Illness (SI)

What brought the patient to

the hospital?

Does the patient

’

s condition

require stay in ACUTE CARE

settings? WHY?

Has the patient FAILED

(7)

Intensity of Service (IS)

What are we doing for the

patient that requires an

ACUTE CARE setting?

Can treatment safely be

performed in an Alternate

Level Of Care (ALOC)?

(8)

Discharge Screens

–

Examples

of Next Level of Care

Pain Controlled with PO Meds

Heart Rate 50

-

100

100 PO Fluids Tolerated

PO Fluids Tolerated

Temperature Resolving

Anemia Resolving

(9)

InterQual

®

_®

-

_-

Alternate

_Alternate

Level Of Care (ALOC)

Long Term Acute care (Kindred)Long Term Acute care (Kindred)

Acute Rehabilitation (Siskin, Acute Rehabilitation (Siskin,

HEALTHSOUTH)

Subacute Rehabilitation (Siskin)Subacute Rehabilitation (Siskin)

Skilled Nursing Facilities (SNF)Skilled Nursing Facilities (SNF)

Intermediate Care Facilities (ICF) Intermediate Care Facilities (ICF) ––

Nursing Home

(10)

ALOC Determination

Determine, with the

assistance of the Case

Manager, the Level of Care

required based upon

–

– Stability of PatientStability of Patient

–

– Proposed ServicesProposed Services

–

– Safety IssuesSafety Issues

–

(11)

DOCUMENTATION

It is very important document and It is very important document and

communicate with other care givers

about what you are planning to do,

reasons for admission to acute care

as inpatient or as an observation,

treatment plan (plan of care), reasons

for continued stay and discharge plan.

Review examples shown in next few Review examples shown in next few

slides

(12)

Charting Medical Necessity

–

– Patient Status (Admit, Obs, Outpatient)Patient Status (Admit, Obs, Outpatient)

–

– Time and Date (both required)Time and Date (both required)

–

– Legible Orders (reduce errors and Legible Orders (reduce errors and

interruptions)

–

– Legible SignatureLegible Signature

–

– Pager NumberPager Number

–

– Severity of Illness (SI) Severity of Illness (SI) - - Condition, H&PCondition, H&P

–

– Intensity of Service (IS) Intensity of Service (IS) – – OrdersOrders Note

Note – – Intent to admit should be Intent to admit should be documented

(13)

Charting Guidelines

If a patient is to be placed in an If a patient is to be placed in an

inpatient status write

inpatient status write ””Admit to Admit to inpatient

inpatient””

If a patient is to be in observation If a patient is to be in observation

status write

status write ““Place (or hold) in Place (or hold) in observation

observation”” avoid writing avoid writing ““Admit to Admit to 23 hour observation.

23 hour observation.”” Follow up in Follow up in timely manner to determine the

timely manner to determine the

patient

patient’’s progress and continued stay s progress and continued stay need to admit or discharge the

(14)

Charting Guidelines

When charting concerning the patientWhen charting concerning the patient’’s s

condition,

chart

“

patient improving

”

not

“

patient stable

”

.

““StableStable”” denotes that the patient is in good denotes that the patient is in good

enough condition to be discharged and the

hospital day will be disallowed due to

hospital day will be disallowed due to ““lack lack of severity of illness

of severity of illness””. Write why the . Write why the patient has to remain in the hospital

patient has to remain in the hospital----what what acute care services are being provided or

acute care services are being provided or

the severity of the patient

(15)

Charting Guidelines

Avoid charting Avoid charting ““awaiting IMCU bed awaiting IMCU bed

transfer

transfer””. Rather, chart . Rather, chart ““patient to patient to IMCU soon

IMCU soon””. The first entry will . The first entry will qualify as a non

qualify as a non--acute ICU bed day. acute ICU bed day. Avoid charting

Avoid charting ““patient doing well, patient doing well, will discharge in a.m.

will discharge in a.m.”” This denotes This denotes that the patient no longer meets

that the patient no longer meets

“

“severity of illnessseverity of illness”” criteria to criteria to

warrant his/her stay in an acute care

(16)

Charting Guidelines

Avoid charting

“

will observe,

and discharge in 1 or 2 days

”

.

Again, this denotes

“

lack of

severity of illness

”

_”

and

_and

“

(17)

Do Chart

…

_…

Why the patient remains in the

hospital in terms of Severity of

Illness (SI) and Intensity of

Service (IS):

–

– What is his/her What is his/her condition condition that can that can only

only be treated in an acute care be treated in an acute care facility?

facility?

–

– What What treatment treatment is being provided is being provided that can only be performed in an

(18)

Do Chart

…

_…

Co

-

morbidities, complications,

and contributing factors (CC

’s)

’

s)

Patient

’

s History and Physical

(H&P)

Treatment received prior to

being placed in a bed

–

–MD Office, ED, other MD Office, ED, other treatment facility

(19)

Charting Guidelines

Do chart in the admit note the

initial hospital treatment plan.

Discharge summary should

include all diagnosis, co

-

-morbidity

morbidity

’

s and hospital course.

Be very specific, i.e., identify the

type of pneumonia, location, and

(20)

Charting Guidelines

IM and PO medications without IM and PO medications without

documentation of strong severity of illness

does not meet criteria for continued stay.

A patient admitted on Friday or Saturday A patient admitted on Friday or Saturday

must meet

must meet ““severity of illnessseverity of illness”” and and “

“intensity of serviceintensity of service”” and have supporting and have supporting documentation for the entire weekend to be

documentation for the entire weekend to be

determined

determined ““medically necessary.medically necessary.”” If the If the patient is stable and outpatient treatment is

patient is stable and outpatient treatment is

appropriate then evaluate patient for

outpatient procedure and consider

discharging the patient

(21)

Timely Follow Up

If you are part of the admitting team If you are part of the admitting team

and write

and write ““OK to discharge if OK with OK to discharge if OK with surgery,

surgery,”” then then followfollow--up laterup later in the in the day for the discharge order.

day for the discharge order.

If a patient is almost ready to be If a patient is almost ready to be

discharged except for his diet

tolerance then you may write the

order

order ““May be discharged if eating May be discharged if eating OK.

OK.”” Follow upFollow up and write the and write the discharge order.

(22)

Charting Guidelines

Attending physicians must write

a progress note daily on a

patient

’

s chart

--

not just co

-

sign

a resident

’

s note.

–

– Please note that the these are suggestions based Please note that the these are suggestions based on InterQual criteria and Milliman criteria used by

on InterQual criteria and Milliman criteria used by

Medicare,

Medicare, TennCare TennCare and most of the major and most of the major payers. If you have any questions, you may

payers. If you have any questions, you may

contact Resource Management staff at 2520 for

Erlanger or call 6296 for questions at TCTCH.