One of the most frustrating parts of being involved in regulation and compliance is the prevalence of double-speak. Recently someone posed the question on a Recovery Auditor- (RA-) related user group asking if an order that reads “admit to the service of Dr. Smith” is a valid inpatient order. I provided the answer that it is valid, but not optimal. If the patient has that order and stays in facility longer than two midnights, it is fine, but if they go home prior to the second midnight, an auditor conceivably could say that the doctor meant to admit to observation and deny the stay.

Paul Arias from Loma Linda Medical Center in California then was kind enough to post the reference from the Centers for Medicare & Medicaid Services (CMS). CMS took four paragraphs and 510 words to say the exact same thing. In one sentence, the agency said, “while we are not requiring specific language, we believe it is in the interest of the hospital that the practitioner use language that clearly expresses intent to admit the patient as inpatient that will be commonly understood by any individual that could potentially review documentation of the inpatient stay.”

“However, in order for the documentation to provide acceptable evidence to support the hospital inpatient admission, thus satisfying the requirement for the physician order,” CMS continued, “there can be no uncertainty regarding the intent, decision, and recommendation by the physician or other practitioner who can order inpatient services to admit the beneficiary as an inpatient, and no reasonable possibility that the care could have been provided in an outpatient setting.” Just those two sentences comprised 117 words to say what I said in six words: “it is valid, but not optimal.”

But double-speak is not limited to federal agencies. The Medicaid agency in California, Medi-Cal, recently issued a memo stating that “Medi-Cal has never recognized outpatient observation as a legitimate status within the hospital, therefore a patient ordered to observation status by Medi-Cal providers is determined to be admitted as inpatient status by Medi-Cal for purposes of reimbursement.”

“Since Medi-Cal does not recognize observation status outside of inpatient admission,” the statement continued, “the observation codes should never be used.” Observation status outside of inpatient admission? Now what the heck does that mean? Does that mean that doctors can order observation status (which by the way we all know is not a status) and the hospital can just go ahead and bill the stay as inpatient even without an inpatient order? Or that observation status is not recognized, so if a doctor orders it, the hospital gets paid nothing?

It’s confusing enough for doctors when commercial plans violate CMS, Interqual, and MCG rules demanding that patients stay in observation for days upon end after they spent hours learning the two-midnight rule. But to also explain to doctors that for Medi-Cal they need to always admit as inpatient every patient that needs to stay in the facility, no matter the expected length of stay, is just crazy – yet that is what California hospitals apparently are doing, because they don’t understand what the heck Medi-Cal is trying to say.

This needs to stop.

The government wants providers to produce patient education materials at the sixth-grade reading level, so maybe they should be required to write their communications without using double-speak.

About the Author

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American Case Management Association and a Fellow of the American College of Physicians. 

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