By now, most hospitals have received chart requests for the short-stay inpatient admission audits being conducted by the Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIOs).

To this end, I previously reported on the KEPRO educational webinars on Today I have to tell you about the recent presentation by Livanta on these audits and how to apply the two-midnight rule. I should preface this by noting that the presentation was done jointly with MCG Care Guidelines, so part of the intent may have been to show how Livanta will be using guidelines, but despite this, the webinar did nothing to give providers any useful information or confidence in Livanta.

First of all, the presenter was a coder with absolutely no clinical background at all. Coders play a crucial role on hospitals; in fact I have absolutely no idea how they are able to translate hospital admissions or a multi-page operative report into a set of ICD-10-CM and CPT® or ICD-10-PCS codes.

But coding and medical necessity are not the same. The most recently published Coding Guidelines state that “the assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists and that code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

If the coder community itself asserts that a coder does not have the clinical knowledge to determine whether a documented diagnosis is clinically supported, how can a coder possibly determine if hospital care is medically necessary and the expectation of two midnights clinically sound? Those decisions absolutely require someone with clinical training. Does the fact that they used a coder as the public face of their audit process mean that Livanta is doing their reviews with coders and not registered nurses? I can’t imagine that the Centers for Medicare & Medicaid Services (CMS) would approve of that.

Second, a few case examples were presented. One was a patient suffering from leg weakness after falling off a ladder. The presenter showed how she used MCG guidelines to approve inpatient admission based solely on the fact that the neurologist documented “3 out of 5 weakness.” Not one word was spoken about determining whether the patient actually had an expectation of two midnights of hospital care (which in this case, with normal imaging, is questionable).

Then, during question-and-answer time, several people asked about how to apply the new exception for physician judgment that a patient warrants inpatient admission despite an expectation of fewer than two midnights.

As with KEPRO, listeners were provided a non-answer. But this one was worse; the presenter’s response was “um, that’s a good one. You should check the CMS frequently asked questions on that one. I think there might be cases out there.” But we all know that in a past open door forum, CMS referred providers to the QIOs for those same case examples. 

And to top it all off, several questions were asked about a hypothetical patient with no safe discharge plan, and whether that warrants inpatient admission. The answer provided was “if there is documentation of why they cannot be safely discharged, that is acceptable.” And when asked if that is in writing somewhere, from the QIO or CMS, the response was “no, but CMS did give us that guidance during training.”

Yet CMS has told hospitals repeatedly that its “longstanding instruction has been and continues to be that hospital care that is custodial, rendered for social purposes or reasons of convenience, and is not required for the diagnosis or treatment of illness or injury, should be excluded from Part A payment.” It is clear that most patients who do not have a safe discharge plan do not require hospital care; they are receiving custodial care until a safe plan can be identified.

So we are batting 0-for-2. The QIOs who are responsible for determining which hospitals get referred to the Recovery Auditors (RAs) for widespread auditing provided incorrect information during their so-called education sessions.

The prospects for a smooth and accurate audit process going forward are not looking good.

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 College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians.

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