Inpatient only procedures

laura.bohls@prairielakes.comlaura.bohls@prairielakes.com
in CDI Expansion
My director has asked me to think outside of the box and look into if CDI can help at all with catching the occasional inpatient only procedure that gets done as an outpatient.  I'm obviously not much on out of the box thinking today because I have no idea how CDI could have any impact on this topic.  Anyone out there have any ideas?
Thanks,
Laura Bohls, RN
Prairie Lakes Healthcare System

Comments

  • katysuegood@gmail.comkatysuegood@gmail.com
    do you review OP/OBS patients?
  • laura.bohls@prairielakes.comlaura.bohls@prairielakes.com
    Our program does not review OBS until/if they convert to inpatient.  I'm reluctant to even give much input on this question anyway as we have a utilization review department and I feel this is their area of expertise and not something that CDI should be responsible for. 
  • katysuegood@gmail.comkatysuegood@gmail.com

    I agree with you and am not sure why you would be asked if you have a UR program. They should be reviewing these OBS patients and assessing patient placement. If you are not reviewing OBS, there really is no way for you to have impact as part of your regular work flow. And it seems superfluous to ask you to review if you already have a UR team performing this task.

    We do loosely look for patients in IP that shouldn't be. Its not really 'our responsibility' but we do send cases to UR if they are in IP status and we are concerned that they may not meet criteria. But we have no involvement in what you are describing as we also do not review OBS cases.


    Good luck!


    Katy

  • kawelch@cfhalliance.orgkawelch@cfhalliance.org

    One of the ways to "catch" a possible inpatient only procedure that is scheduled as outpatient is to have someone review the surgery schedule for the next day.  They could look for any procedures that are on the inpatient only list.  I would suggest that task be assigned to someone in the UR Dept.  You could also provide education to the schedulers on the inpatient only list to try and catch these cases on the front end.  I would also involve the PACU staff and educate them to call UR/Case Management if a patient who is there for an outpatient procedure has anything else done during the surgery (a lap chole that has a repair of the bowel done during the procedure, etc.).  Again, this should be done by the UR/Case Management staff. 


    Hope this helps!

    Kathy

  • katysuegood@gmail.comkatysuegood@gmail.com
    Totally agree Kathy! our UR team does this exactly how you have described :)
  • cericson1cericson1
    What a great discussion.  As a former UR manager and CDI manager I have a few thoughts to add.  Depending on the size of the organization, many organizations struggle with the inpatient only list even if the UR department has a process in place.  The reason why many feel this is a UR issue is many screening tools, like Interqual, have an "inpatient" only list.  UR typically verifies the patient's admission status i.e., inpatient or outpatient.  The issue with inpatient only procedures is they are billed to Medicare Part B (outpatient) when they should have been billed to Medicare Part A (inpatient).  The inpatient only list is a "safety" because hospitals have different resources/requirements than ambulatory surgery centers.  The other issue is that the patient MUST BE ADMITTED PRIOR to the surgery.  CMS does not allow retrospective orders so the admission order must precede the surgery unless an issue arises during the surgery that changes it from one that can be performed in the outpatient setting to one on the inpatient only list.  The most common example is when a laparoscopic procedure become an open procedure.  Again, because the UR department typically deals with admission orders, this is why they are tasked with this responsibility.  Let me reiterate that surgical patient (prior to surgery) is either an inpatient or a same day surgery.  There is not an observation level of care associated with surgery, which is why many organization now have "extended recovery" options for those patients who require a room post surgery, but who don't meet an observation level of care, so only the ambulatory surgery is billed.  So, reviewing OBs surgical patients (following surgery) is unlikely to be an effective solution because they cannot be "admitted" after the fact/surgery. 

    So the question becomes what is the issue with inpatient only procedures in your organization and why do they think CDI can help?  If the issue is a lack of admission orders, then it is likely a UR issue.  If the issue is the providers aren't documenting the acuity to support an inpatient admission then CDI efforts could help.  It might also be that CDI is better at data analytics and provider education so maybe it is a matter of identifying those procedures that are most likely to billed incorrectly i.e., billed as outpatient, and developing provider education so they understand that patients having "X" surgery MUST ALWAYS be admitted with an order written prior to surgery).  

    Hope this helps.  Cheryl Ericson


  • jdowney@beaconhealthsystem.orgjdowney@beaconhealthsystem.org

    It's true this is not an area where CDI talents are put to good use because the order has to be in place prior to surgery but there is some ability to assist if your CDSs review outpatient cases.  If they're only reviewing IP cases they probably can't help because those aren't the ones you need to catch.  Medicare, and some Medicaids who follow Medicare guidelines, will not reimburse anything for a procedure that should have been done as IP status.

    Here are some suggestions from someone who's been there and done that.

    1. Have the schedulers request the surgeon's office provide them with a CPT code for the procedure at the time of scheduling so they can use it to screen for inpatient only procedures.  Physicians offices are very familiar with their CPT codes.  Most of the time they have already used them to get authorization from the payers.  The 2017 IP only list can be found on the CMS website, in addenda E here:

    https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1656-FC.html   

    2. Make sure the OR schedule indicates somewhere that it is an IP only procedure (we call them MIPOs at our facility).  Sometimes mistakes are made with the orders if the case is not clearly identified as IP only somehow.  This is especially true for cases where the patients usually go home the same day like for a carotid endarterectomy.  If it's not clearly visible that it needs to be in IP status it could get changed inadvertently by someone who doesn't know any better (like a doctor). 

    3. Where CDI could help is to review the procedure notes for OPS cases postoperatively to make sure the intended procedure was carried out.  This is one time when it is acceptable to have an order changed to IP after the surgery begins.  A good example is a lap chole that gets converted to an open chole.  Lap is okay as an OP.  Open is not. Then you must decide what to do when these situations arise.  Usually UR is taxed with getting the correct order for IP status.  How will you notify them? 

    Our facility has an email distribution list for when a procedure is either scheduled with the wrong status or the procedure changed and is now requiring IP status.  On that list are the surgery schedulers, UR folks, and the manager and director of surgery.  Those folks will need clear direction for who is responsible for getting the order fixed after they have been notified via the distribution list.

    I hope this helps you get started.  Good luck!

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