The Final Rule, Implications for Compliance and Risk Management

1. The Final Rule, Implications for Compliance and Risk Management Deloitte & Touche LLP Nancy Perilstein, Senior Manager September 16, 2013

2. CMS Inpatient Prospective Payment System Final Rule

3. Final IPPS Ruling New Definition of Inpatient: In the FY 2014 IPPS Final rule, CMS finalized a significant revision to the definition of inpatient using a time-based presumption of medical necessity based on the beneficiary’s length of stay for discharges on or after October 1st, 2013 (1) For those hospital stays in which the physician expects the beneficiary to require care that crosses at least 2 midnights (at least more than one Medicare utilization day) and admits the beneficiary based upon that expectation, Medicare Part A payment is generally appropriate (2) Conversely, for hospital inpatient admissions in which the physician expects the patient to require care less than 2 midnights, payment under Medicare Part A is generally inappropriate(2) Time + Documented Medical Necessity = Compliance Source: (1) See 42 CFR section 412..3(a)(1) (2) See 42 CFR section 412..3(e)(1) and 412.3(e)(2)

4. Final Ruling CMS (continued) New documentation requirements: The order must specify the admitting practitioners intent to admit “to inpatient”, “as an inpatient”, “for inpatient services” or similar language Physician certification of admission is required (e.g. both the order for inpatient services and documentation of the reason for continued hospitalization)(1) • Must state that, “the services were provided in accordance with 42 CFR section 412.3” (1) • Must state the reasons for either hospitalization of the patient for inpatient medical treatment or medically required inpatient diagnostic study • Does not require any specific procedures or forms (left to the provider to determine/create) • Must be signed and documented in the medical record prior to the hospital discharge (2) Source: 1) See 42 CFR section 424.13(a)(2) (2) See 42 CFR section 424.13(b)

5. New Ordering Screen on Hospital Level of Care Order

6. PA, NP or Resident Can Enter Admit Order; Attending Completes Certification in P.DOC

7. Final Ruling CMS (continued) Other notable points: The ordering practitioner need not be responsible for the patient’s inpatient care but he or she must be knowledgeable about the patient’s hospital course, medical plan of care and current condition (1) No significant changes to Code 44 requirements States that “admissions decisions centered around risk must relate to current disease processes or presenting symptoms, and not merely be part of the beneficiary’s benign or latent or past medical history” (2) Additional guidance will be forthcoming related to transfer situations States that “under this revised policy, CMS’s medical review efforts will focus on inpatient hospital admissions with lengths of stay crossing only 1 midnight or less after admission…” Source: (1) See 42 CFR section 412.3(b) (2) See page 1822 of the final rule

8. Final Ruling CMS Considerations Ability to operationalize rule (e.g., assessing level of care prior to the physician order being written to ensure accuracy of orders as early on in the process as possible) Medical record documentation supporting physician expectation, order and admission, that the beneficiary would need care spanning at least two midnights is required and may only be signed by the physician Sufficient documentation for unforeseen circumstances (death, transfer) resulting in shorter stay Medical review effort focus on undue delays in provision of care in attempt to meet 2-midnight threshold Counting of “midnights” can be used as a benchmark but not as a stand alone determinate of level of care Patients already in a hospital bed but in observation status do not necessarily become inpatients after 2 midnights Impact on 3 day admissions as prerequisite to SNF transfer remains a consideration

9. Case Presentations Clinical Progression

10. HPI Focus vs PMH & Co-morbidities 78 yo M presents to the ED with substernal CP x 2 hours. Non-radiating pain comes and goes. Not relieved by SL NTG, VS stable, EKG – no acute changes, initial Troponin – negative. Injection MS w/ pain relief. Now is lying comfortable in the bed with no further c/o of CP. • PMH: CAD, MI > 5 years ago, CABG 4 years previous. • Co-morbidities: HTN, hypercholesterolemia, ADDM – on medication and under control. • Patient is placed in Observation and kept overnight for monitoring and lab results. • Overnight, patient has no further CP, repeat EKG- no changes, Troponins- negative. Although this patient has a significant PMH & additional co-morbidities, this encounter does not appear to be cardiac related and does not meet medical necessity for an IP level of care .

11. UTI 85 yo F who resides in a NH, presents to the ED with symptoms of a UTI. Documentation from the NH indicates patient had a Temp of 99.8 and WBC’s & RBC’s in the urine dipstick and a Hx of UTI’s. Patient is slightly confused, but cooperative and at her baseline of orientation. • Initial workup indicates elevated WBC @ 18.3, Temp 101 po, Urine RBC’s & WBC’ s. Urine culture done and awaiting results. Given initial dose of IV Antibiotics and IV fluids. Admitted to inpatient with plan to discharge back to NH after responding to treatment. • Overnight the patient received another dose of IV antibiotics, continues with IV fluids and spikes a Temp of 102, becomes very agitated, disoriented and confused .Repeat WBC has elevated to 21.0 and urine culture indicates the antibiotics are not sensitive to the organism identified. • Due to the progression of the patient’s symptoms and concerns about possible sepsis, the patient was appropriate for Inpatient level of care

12. Syncope w/ Clinical Progression 75 yo F presents to the ED after a witnessed syncopal episode. Patient had been outside in the hot weather and felt weak. PMH: CAD, HTN controlled • EKG – normal, no acute changes, B/P – orthostatic without a change from 130 mmHg systolic when going from a sitting to a standing position. Pulse – 80. • Initial Treatment: Cardiac Monitor, IV fluids, Place into Observation status. Patient placed in Observation LOC • Overnight monitoring indicates additional syncopal episodes of HR < 60/min with c/o SOB and continued postural hypotension despite IV fluids. • EKG: New Arrythmias identified – Prolonged QT Interval Plan of Care: Admit to IP. Schedule Echocardiogram and Cardiology Consult

13. COPD 71 y/o F presents to the ED with complaint of shortness of breath, weakness and productive cough.  Positive Hx of COPD. Despite using her inhaler, and nebulizer at home, she has not improved. Physical exam indicated borderline O2 saturations and diminished breath sound with greenish sputum with cough. • Initial treatment w/ IV Antibiotics & IV Prednisone, Nebulization Treatments & Inhaler Treatments. • Close monitoring of O2 Saturation and Respiratory Rate. Admitted to IP Level of Care : The patient was placed on 3L of O2 via NC. Patient was unable to maintain oxygen saturations above 90%. Concern for impending respiratory failure and need to possible intubate. Required to have an Endo to clear secretions as she was not improving with Treatment.

14. Abdominal Pain w/ Clinical Progression 88 y/o F with a PMH of hiatal hernia and gastroparesis, diverticulosis, presented from MD office after she with c/o several days of dry heaves, constipation, and a bloating.  • Abdominal view x-rays showed diffuse gaseous distention of the colon. • Findings are nonspecific and may represent bowel ischemia or possibly colonic ileus.  • Patient is made NPO status and started on IVF at 125cc/hr.  VSS, labs unremarkable.  Patient is placed in Observation LOC: • Overnight the patient does not improve and CT Scan Abdomen indicates a SBO. Patient admitted to IP LOC and plans for surgical intervention.

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