As I discussed in my RACmonitor article published last week, the Centers for Medicare & Medicaid Services (CMS) has left the mechanics of the two-midnight rule intact in its proposed Inpatient Prospective Payment System (IPPS) rule for 2018. That means that for at least another year, we will have to do our best to determine which patients should be admitted as inpatients and which should be treated as outpatients.

Many utilization review staff and physician advisors continue to feel pressure from finance departments to “find more inpatients.” At last week’s National Physician Advisor Conference presented by the American College of Physician Advisors and Spartanburg Regional Health System, we heard one physician advisor tell the audience that the chief financial officer (CFO) at his hospital wanted them to admit more patients as inpatient, adding that they would take their chances if they are audited. Does that make sense? Well, if we consider just fee-for-service Medicare, since October 2013 most hospitals have had no more than 30 or 40 inpatient admissions audited. That’s a tiny percentage of the total admissions.

It also seems likely that the Recovery Audit Contractors (RACs) won’t be able to start auditing status determinations for almost a year under the new short inpatient admission audit process that starts this month, further reducing risk. So why not admit almost everyone, and take on the tiny risk you will be audited? Because it is non-compliant! It doesn’t matter how many police are out patrolling the streets, you still have to obey the law.

So, is there any wiggle room to get more inpatients and get the CFO off your back? Well, the exception for physician judgment CMS added in 2016 is always available. As you may know, that allows a physician to determine on a case-by-case basis whether a patient who is expected to require only one midnight of care should be admitted as an inpatient. 

Although CMS will not give any examples of patients who would fit this description (and many have tried to get such examples, including a Medicare Administrative Contractor (MAC) medical director with whom I recently spoke), we are starting to get some information from the audits performed by the Quality Improvement Organizations (QIOs).

The two main factors a physician is supposed to consider are the “risk of an adverse event” and the “severity of signs and symptoms.” It seems reasonable to eliminate severity of symptoms right away.

We have all seen patients with 11-out-of-10 pain who are comfortably sitting in bed reviewing their Facebook pages. Symptoms are subjective, and using them as a measure is fraught with danger. 

So, what about severity of signs and risk of an adverse event? These two go hand-in-hand; the patient with the very high potassium level has a very high risk of an adverse event. But at what level of risk and severity is inpatient admission warranted? It is unclear, but I will give you an example of what would not qualify: a patient with a transient ischemic attack (TIA) who is elderly, diabetic, and hypertensive, and considered at high risk of having a stroke over the next two days. The standard of care is to monitor such a patient in the hospital for 24 hours, which is obviously care lasting fewer than two midnights. But the risk of a stroke is only 8 percent: higher than a TIA in a younger patient or a non-diabetic, but not so high that that is likely to be accepted as an exception by the auditors.

On the other hand, consider a dialysis patient with a potassium of 7 and EKG changes. Now, their risk of dying in the hospital without treatment is approximately 80 percent, so that should be considered high-risk. Likewise, a patient with a heart attack going emergently to the catheterization lab is at high risk; without intervention, risk of death or disability is huge. Other diagnoses to consider would be diabetic ketoacidosis, complete heart block, and anaphylactic shock.

So, it seems reasonable at this time to take a second look at that exception, work with your doctors to properly document the risk to the patient (the better the documentation, the higher the odds of passing an audit), and talk to your compliance team.

But remember, without explicit guidance and case examples from CMS, approval of these short stays is not guaranteed, especially if you get audited by a RAC. 

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