Upload File

the clinical face of medical necessity - american … · the clinical face of medical necessity 2...

  • Home
  • Documents
  • The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina
20
1 Using Clinical Criteria for Evaluating Short Stays and Beyond Georgeann Edford, RN, MBA, CCS-P The Clinical Face of Medical Necessity

Upload: trinhlien

Post on 06-Sep-2018

215 views

Category:

Documents


0 download

Report

TRANSCRIPT

Page 1: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

1

Using Clinical Criteria for Evaluating Short Stays and

Beyond

Georgeann Edford, RN, MBA, CCS-P

The Clinical Face of Medical Necessity

Page 2: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

2

ç3

The Documentation Faces of Medical Necessity

SettingtheStage SSA§1862(a)(1)(A)Coverage “…itemsorservicesnecessaryforthediagnosisortreatmentofanillnessorinjuryortoimprovethefunctioning ofamalformedbodymember.”

SSA§1156(a)(3) “…willbesupportedbyevidenceofmedicalnecessityandqualityinsuchformandfashionandatsuchtimeasmayreasonablyberequiredbyareviewingpeerrevieworganizationintheexerciseofitsdutiesandresponsibilities.”

3

Page 3: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

3

PhysicianCertificationFederalRegister/Volume68,No216 “…However,wecontinuetobelievethatthebeneficiary’streatingphysician‐notanytreatingpractitioner‐isbestsituatedtodetermine“inneed”status,bothbecauseheorsheistheprimarycaregiverandalsoisresponsibleforthebeneficiary’soverallcare”

5

MedicalNecessityCriteriaInpatientStays

UseofscreeningCriteria QIO’suseInterQualorsimilar NotwithstandingCMS’scharacterizingthedecisiontoadmitas:• Complex• Madebythepatient’sphysician• Basedoninformationavailableatthetimethedecisiontoadmitismade

Conversely,notmeetingscreeningcriteriadoesnotmeanadmissionwasunnecessary

6

Page 4: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

4

AMAPolicyHealthcareservicesthataprudentphysicianwouldprovidetoapatientforpreventing,diagnosisortreatinganillness,injury,diseaseorsymptomsthatis: Accordingtogenerallyacceptedstandards

ofmedicalpractice Clinicallyappropriateintermsoflocation,

type,frequency,durationand Notfortheconvenienceofthephysician,

patientoranother.

7

InpatientHospitalAdmissionMedicareBenefitPolicyManualdefinesinpatientadmissionas:FormallyadmittedasaninpatientExpectationthatpatientwillremainatleastovernightevenifdischargedortransferredbeforethenPhysicianisresponsiblefordecidingPhysicianshouldusea24‐hourperiodasabenchmark

8

Page 5: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

5

InpatientAdmissionContinued

9

FactorsPhysiciansShouldTakeIntoAccount: “Thedecisiontoadmitapatientisacomplexmedicaljudgment”• Severityofsignsandsymptoms• Medicalpredictabilityofadverseevent• Canneededtestsbedoneonanoutpatientbasis?

• Availabilityofdiagnosticprocedureswhenandwherethepatientpresents

• NoteabsenceofreferencetoInterQual

ObservationCMSdefinesobservationas:

Periodoftimeinwhichapatientishelduntilsuchtimethatadecisioncanbemadethatthepatientcanbesafelydischargedhomeoradmittedasaninpatientforfurthertreatment. Maximumperiodoftime48hours

Observationisnotanadmissionstatus;it’salevelofcareforoutpatients

10

Page 6: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

6

Outpatient

MedicareBenefitPolicydefinesoutpatientas:

Anoutpatientisapersonwhohasnotbeenadmittedbythehospitalasaninpatientbutisregisteredonthehospitalrecordsasanoutpatientandreceivesservices(ratherthansuppliesalone)fromthehospital.

11

What’sReallytheDifferenceBetweenInpatientandObservation Notwhetherthepatientisinabed Notthetypeofbedused Nottheintensityofservices Differenceisabilling/coveragedistinction;

Thedifferenceisnotinherentlyadifferenceincare

12

Page 7: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

7

InpatientVSObservation

Inpatient Observation Admittedfortreatmentandassessment

Formallyadmittedasaninpatient

AttendingPhysicianisresponsiblefordeciding

Physicianshouldusea24‐hourperiodasabenchmark

Servicesforshorttermtreatmentandassessment

Clinically,patientneedstobeobservedandmonitored

Reassessmentbeforeadecisionismaderegardingapatient’sneedforinpatientadmission

Usuallydecisionismadeinlessthan48hours,mostlessthan24hours

Nolengthoftimethatdeterminesapatient’sstatus

13

ReviewCriteria

InterQual®hashadcontractwithCMSsince1999

forallinpatienthospitalservices.

Thecontractwasrenewedin2003andcontinuestobeusedtoday.

ThemajorityofStateMedicaidprogramsutilizepreviousversionsofInterQual

©foritsreviews.

14

Page 8: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

8

InterQual® ReviewInterQual® reviewsarefocusedontheintensityofwhichthepatientisbeingtreated

Theinformationisbroken‐downin2ways LevelofCare BodySystem

Furtherbreakdownwithinthelevelofcareandbodysystemareadditionalsubsets

SeverityofillnessorSI IntensityofserviceorIS DischargeScreen

15

SeverityofIllnessHowsickarethey? Focusonpatient’spresentationratherthandiagnosis

PresentationClinicalIndicatorsthatrepresentanillness: Mainclinicalissues‐chiefcomplaint Abnormalvitalsigns, Painlocation,type,cause,relief Neurologicalstatusalert,alternatelevelofconsciousness Descriptionofdiagnostictestslabsorx‐rays Consultsorevaluations

16

Page 9: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

9

IntensityofService

Typeoftreatmentbeingadministered:

Medicationsrouteandfrequency• IVFluids Blood/bloodproducts Oxygen DietWoundCare

17

InterQual® CriteriaComponents

DischargeScreens Criteriathatmustbemetfordischarge

Utilizedwhentheintensityofserviceisnotmetforthatday

Patientisunsafefordischarge.

18

Page 10: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

10

ProblematicChiefComplaint

Chestpain‐ Couldbecausedby:• GERD‐ indigestion,reflux• Angina• HeartAttack• Musculoskeletal‐ strain,pulledmuscle• Anxiety‐ unrelated• Respiratory‐ pneumonia,pleurisy• Renal‐ kidneystones

ç19

Chiefcomplaintchestpaincomparisonofdocumentation

Observation InpatientEpisodeDay1

SeverityofIllness

Acutecoronarysyndromesuspected

• Initialcardiacmarkersnegative,continuetomonitor

• EKGnon‐diagnostic

• SystolicB/Patbaseline

• Painresolved/resolving

EpisodeDay1

SeverityofIllness(1)

AcuteMyocardialInfarction

UnstableAnginaandcontrolledpain,

EKG,≥one:

Postobservationlevelofcareandischemiaonstresstest

20

çCHESTPAIN

Page 11: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

11

Intensity of Service Requirements ‐Chest Pain

Observation• Aspirin/Antiplateletadministeredorcontraindicated

• Cardiacmonitoring

InpatientTreatment,ALL• Betablocker/CAChannelblockeradministered/contraindicated

• Aspirinadministered/contraindicated

• Antiplateletadministered/contraindicated

• Anticoagulantadministered/contraindicated

• Cardiacmonitoring

21

EpisodeDay2Observation;One:Responder,dischargeexpectedtodayifstablefor12hoursall• NSTEMIandSTEMIruledout

• Painresolved• Objectivecardiacriskassessment,one:Completedpriortodischarge

Lowcardiacriskandscheduledoutpatient

AssessmentnotindicatedasACSruledout

InpatientTreatment,ALL• Betablocker/CAChannelblockeradministered/contraindicated

• Aspirinadministered/contraindicated

• Antiplateletadministered/contraindicated

• Anticoagulantadministered/contraindicated

• Cardiacmonitoring

ç22

Page 12: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

12

SupportingtheAdmission BothSIandIScriteriamustbemettosupportthemedicalnecessityforadmission,observation,oranotherserviceinthesystem.Thesecriteriaaresimilar,butinpatientadmissionSIandIScriteriaindicateahigheracuitylevel.

Thecriteriaforobservationvs.inpatientadmissionarenotalwaysclearcutandfallstophysicianjudgment.

Physiciandocumentationisakeycomponenttosupporthighacuity.

23

Documentation Unlikethe“intent”foradmission,

diagnosisneedstobespecifictoaccuratelyreflecttheseverityofillnessandtheresourcesused.

Provideadetailedsystembysystemassessmentincludingvitalsigns,testresults,symptoms

Provideaplanforalltreateddiagnosis.

24

Page 13: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

13

LookingForIntentKeyclinicaldescriptorsandassessmentofriskforanadverseeventcanmakethedifferencebetweeninpatientandoutpatientadmissionstatus.

ComorbidconditionsPotentialriskPhysicianOrders

25

Example1Jane,a70–yearoldfemale,presentedtotheEDwithseverechestpain. Onemonthduration– resolvedonitsown. Today– non‐resolving B/P188/90,pulse110respirations28,PO294% EKG– STchanges;ageindeterminate Onesetofcardiacmarkersdrawn;normal TreatedwithO2,aspirinandNitrodrip. Painresolved Physicianordered“transfertocardiaccareforobservation”

26

Page 14: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

14

WASINPATIENTADMISSIONCORRECT?

27

WAS THERE MEDICAL NECESSITY?

28

Page 15: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

15

Example2Johna64‐yearoldmalepresentedtotheEDexperiencingadrycoughfor3daysassociatedwithwheezingfor1day. B/P120/72,pulse108,respirations20withanO2

satof84% EKG– normal CBC– normal Chestx‐ray– COPD(chronicobstructivepulmonary

disease) Hewastreatedwithsteroidsandalbuterolinhaler

X3.Hecontinuestohavewheezing.

29

OBSERVATIONORADMISSION?

30

Page 16: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

16

Example3Arthur,a72‐yearoldmalepresentedtotheERwithahistoryofdizzinessandfaintingfivehourspriortoarrival. VitalsignswereB/P90/60,pulse132,PO2

90% CBC– mildanemia Nasogastrictube– brightredfluid IVstarted150cc/hour Physicianordersforfurthertesting Transferredtomedicalfloor

31

INTENT

32

Page 17: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

17

InpatientOnlyProceduresAprocedureisdesignatedas“inpatientonly”forthreereasons:• Thenatureoftheprocedure• Theneedforatleast24hoursofpostoperativerecoverytimeormonitoringbeforethepatientcanbesafelybedischarged

• Theunderlyingphysicalconditionofthepatientrequiringsurgery

An“inpatientonly”procedurewillbepaidonlywhenthepatientisaninpatientatthetimetheprocedureisperformed

33

InpatientVs.OutpatientAnnually,CMSidentifiescertainproceduresas“Inpatientonly”

• ProceduresgetonthelistbymeansofdataclaimsanalysisofproceduresandtheLOSassociatedwiththem

InterQualalsohasan“inpatientonly”procedureslist

• Theproceduresgetonthelistifsomeonecallsorwritesintoaskaboutaprocedure

34

Page 18: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

18

Outpatientvs.ObservationOutpatientSurgicalProcedures

• Normalpostoperativerecoveryperiodis4‐6hours

“Observation”followingoutpatientsurgicalprocedurerequires:

• Adverse/unexpectedevent• Eventmustberecognizedasarisktothepatient• Requiresadditionalobservationandassessmentbeyondthestandardrecoveryperiod

• Hasadiagnosisthatis separateanddistinctfromtheoperativeprocedure

OutpatientProcedureRequiringObservation

Fredawasa74yearoldwhohadacardiaccatheterizationasanoutpatient.Thereisnosignificantpasthistoryotherthanintermittentchestpainandquestionablestresstestresults.Postprocedureinrecoverythepatientdevelopedanintractableheadache.ShewasgivenIVpainmedicationandmonitored.SevenhourslatersheisstillexperiencingseverepainandmetcriteriaforObservationLevelwith:

SeverityofIllness

Postambulatorysurgery/procedure,≥One:

• Pain/Headache/Vomitinguncontrolled

IntensityofService

Medication(s)≥2doses:

• Analgesics

36

Page 19: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

19

ContinuedStayThenextdaythepatientcontinuedtohavepain.Shenolongerrequiredtheintensityofservicesprovidedasshewasnowreceivingoralpainmedication.

HOWEVERShecannotbedischargedasshedoesnotmeetthedischargescreenofpaincontrolledandmanageable.AnotherdayofObservationisthecorrectlevelofcareforthispatient.

37

Conclusion

Documentationfoundinthemedicalrecordcanprovidetheinformationneededtosupportmedicalnecessityandbeyond.

EHRisnotthepanacea! Utilizingqualitativeclinicaldocumentationcriteriacanbeafriendwhenjustifyingalevelofcare.

2012criteriaisfarmorerigid.

38

Page 20: The Clinical Face of Medical Necessity - American … · The Clinical Face of Medical Necessity 2 ç3 The Documentation Faces of Medical Necessity Setting the Stage ... Unstable Angina

20

THANK YOU FOR ALLOWING ME TO SHARE OUR EXPERIENCE WITH

YOU!

Georgeann Edford

39


Prescription & Letter of Medical Necessity

Clinical Documentation Standards...Medical Necessity: Providing the Rationale for Services 6 Relevance of Medical Necessity for Documentation Medical Necessity Determination Clinical

5.01.520 Antidepressants: Pharmacy Medical Necessity

DOCUMENTING MEDICAL NECESSITY FOR ASAM …

2020 MAGELLAN CLINICAL GUIDELINES MEDICAL NECESSITY …

Illinois Medical Necessity for Nursing Services … Medical Necessity for Nursing Services Reference Manual 1 Table of Contents Medical Necessity Determination Process ..... 2

Wheeled Mobility Letter of Medical Necessity Form

Medical Necessity Defense by State2 - NORML...State-by-State Look at the Medical Necessity Defense Below is a state-by-state look at the medical necessity defense. There were only

Medical Necessity: Avoid Costly Audits

Medical Necessity Cheat Sheet

Sample Letter of Medical Necessity - English

Massachusetts Medical Necessity Criteria · Massachusetts - Medical Necessity Criteria (08-07-2019) (Beacon Health Strategies, LLC) 2 Medical Necessity Criteria Beacon Health Option’s

5E-Medical Necessity - What Is It

1F-ICD09 Coding for Medical Necessity-be

BCN Medical Necessity Criteria and Benefits Review Requirementsereferrals.bcbsm.com/BCN_medical_necessity_criteria_nondrugs.pdf · 1 BCN Clinical Review Medical Necessity Criteria

Medical use of cannabis in Australia: “Medical necessity ...amcsignpost.net/wp-content/uploads/2017/07/JLM_875-1.pdf · Medical use of cannabis in Australia: “Medical necessity”

5.01.547 Medical Necessity Criteria and Dispensing ... · PHARMACY POLICY – 5.01.547 Medical Necessity Criteria and Dispensing Quantity Limits for Exchange Formulary Benefits Effective

MEDICAL NECESSITY IN AN ECONOMIC …heylroyster.com/_data/files/Seminar_2009WC/2009 05...E-1 MEDICAL NECESSITY IN AN ECONOMIC SLOWDOWN: CONTROLLING MEDICAL TREATMENT COSTS Presented

Medical Necessity 4-29-14

Certificate of Medical Necessity DME 484...Certificate of Medical Necessity DME 484.3 Subject Certificate of Medical Necessity DME 484.3 Created Date 11/29/2011 9:58:08 AM

Medical Necessity Determinations in the Medicare · PDF fileMedical Necessity Determinations in the Medicare ... Medicare policies concerning medical necessity determinations in

Applied behavior analysis medical necessity guide

Statement of Medical Necessity (SMN) - Genentech BioOncology Access Solutions SMN, Genentech BioOncology Access Solutions statement of medical necessity, reimbursement form, genentech

Medical Necessity Criteria - Magellan Provider · Family Functional Therapy ... Magellan Medical Necessity criteria do not supersede state or ... (e.g., individual, conjoint, family

Fast Facts Medical Necessity

Medical Necessity Criteria · 2020. 11. 18. · Medical Necessity Please refer to the controlling specific health plan and/or group documents for the definition of Medical Necessity

%2-!.ç3+2)0.)#%.+/ - Gerger.sk/cv.pdf · '%2-!.ç3+2)0.)#%.+/ 02/&),%) mçoptimisticçandçenergetic çopençmindedçandçcreative çrationalç andçlogical çreliableçandçtrustworthyçperson

Hydration Infusions: Charge Capture & Medical Necessity

Documenting Medical Necessity - LTRAX · PDF fileDocumenting Medical Necessity. ... History of present illness ... Patient off unit for ortho follow-up appointment

Medicare Medical Necessity JK.pdfNational Government Services, Inc. – Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont Medical Necessity Policies

1F-ICD09 Coding for Medical Necessity-be - AAPCstatic.aapc.com/a3c7c3fe-6fa1-4d67-8534-a3c9c8315... · 1 ICD-9-CM Coding for Medical Necessity Professional Medical Billing Agency

Physician’s Guide to Documenting Medical Necessity

Medical Necessity for Child Case Managers[1]

Irf Medical Necessity

Physician Primer for Medical Necessity Documentation