Documenting Inpatient Cases: One Word Matters
Inpatient or observation? Ordering and documenting that one-word patient status
incorrectly can result in the hospital owing Medicare millions of dollars.
"According to Medicare regulations this documentation cannot
be fixed retrospectively," said Chief Medical Officer Stan Ashley, MD, who
chairs the Utilization Review Committee. "Physician documentation in orders and
progress notes that support the need for the patient's stay are critically
important because that's Medicare's primary and often only source of
information."
Inpatient short stays must be adequately documented to
support proper billing for an inpatient or observation encounter, and the
medical record documentation must clearly explain why.
Not all patients in a hospital bed can or should be billed
as inpatients. There are three different statuses that patients in hospital
beds can be billed as:
-
Inpatient:
when the patient has complex, unstable clinical issues not expected to resolve
in 24 hours
-
Outpatient,
or in a bed while experiencing Routine Recovery from a Procedure RPPR: this applies to surgical or diagnostic
procedures with expected stay of less than 24 hours
-
Place In
Observation: when we need to further evaluate the patient's condition or
symptoms to determine if he or she can go home safely within 24hours
In order to determine which admission status is appropriate
for your patient, there are two considerations:
- Intensity
of care. With the information available at the time of
admission, you must anticipate the intensity of care the
patient will require.
- How
long you expect it should take to provide necessary care?
Physicians must document in the Medical Record a statement
about their thought process pertaining to admission status selection. They must
also include a note regarding any change in the original anticipated admission
status, and clinical documentation to justify continued hospital treatment,
including the patient's progress and response to medications and services.
A physician may freely change an observation order to acute
inpatient admission at anytime during the patient's stay. The patient's inpatient status may be
changed to observation prior to patient discharge; however, the change is cumbersome and must be done by
the attending in collaboration with a care coordinator and physician advisor
from the BWH Utilization Review Committee.
To help ensure that patient status is documented correctly,
BWH care coordinators perform concurrent review while the patient is in the
hospital and may ask attending physicians for more documentation in the record. Care coordinators will also escalate cases to a
physician advisors and the Utilization Review Committee if there is a disagreement
regarding the appropriate level of care. After collaboration amongst physicians,
final status decision is the responsibility of physician advisors.
"This is not meant to interfere with care, but to ensure
that we comply with Medicare policy," said Associate Chief Nurse Joanne Hogan,
RN, MS, who sits on the Utilization Review Committee. "This is something that
all physicians must pay attention to."