Clinical Care Management
at UNC Hospitals
Medicine House Staff
July 9, 2009
Case Managers (CM)
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Nurses, Social Workers, other
professional specialists
Assigned by service
Facilitators for patient throughput
Coordinate discharge planning
Expert consultants on disposition
settings & regulations
Tell Your Case Manager
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Clinical goals/endpoints
LOS (if you know it)
Post discharge care needs
Barriers you know about
Your Case Manager Can
Tell You
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Discharge options available,
considering
– Payor coverage
– Family/support
– Transportation
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Documentation needs
The status of the discharge plan
Don’t Promise What Can’t
be Delivered
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Home vs SNF for infusion
Home Health vs Outpatient care
Medicare covered placement
Hospital funding
Clinical Social Workers
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Assigned to specific areas
– Psychiatry
– Transplant
– Some pediatric areas
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Psychosocial assessments and
therapeutic interventions
Available as consultants to case
managers
TPN and Infusion
Specialists
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Consultants to Case Managers
Coordinate arrangements for postdischarge
– IV antibiotics
– IV hydration
– TPN
CCM and the UNC Discharge
Summary
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Multidisciplinary
– Physician
– Case Manager
– Other team designees
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Contains
– Traditional discharge summary information
– Post discharge orders and instructions
– Reconciled medications
Utilization Managers
(UM)
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Assigned to every patient in a bed
Perform payor reviews
Depend on clear and precise
documentation
Experts in CMS regulations for
– Bed billing status
– Qualifying stays for placement
Executive Health
Resources (EHR)
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Contracted physician advisor
consultants
Experts on CMS regulations and
reimbursement
Contact physicians to discuss care
plans and documentation
So, Who Decides The
Status?
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Federal Government
– Centers for Medicare and Medicaid Services (CMS)
Policy
– Office of the Inspector General (OIG) Audits &
Retractions
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Evidence based criteria sets
– InterQual
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Expert Physician Advisors
– Executive Health Resources (EHR)
Other CCM Functions
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Payor Authorization
Medical Necessity Denials
Bed Management
Transfer Center
Psychiatry Admissions
Avoidable Delay Tracking
Why CCTs Care About
Bed Billing Status
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Short stays are a government audit focus
Overuse of Observation
– Lost revenue for hospital (& soon physician)
– Inappropriate co-pays to patient
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Inappropriate use of Inpatient
– Subject to fraud charges
– Pay-backs, penalties, & press
Billing Status
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Outpatient
– Extended Recovery (EXR)
– Observation (OBS)
Inpatient (INP)
Patients in any of these statuses can be
“admitted” to a bed in the hospital.
Extended Recovery (EXR)
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Routine or pre-planned post-operative
or procedure recovery
Short stay services following
uncomplicated treatment or procedure
such as chemo or infusion therapy
EXR Characteristics
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Always (almost*) planned/elective
Uncomplicated procedure
No licensed bed required
No physician’s order for billing status required
Billed as outpatient unit price based on procedure
code
No room/board/ancillary billing
May advance to Observation or Inpatient
*Also used for “social admits” , allows billing of some
lab/procedure charges without billing bed charges
Observation (OBS)
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Services & monitoring to evaluate and
determine the need for inpatient admission
Services are covered only by the order of a
physician or other individual… authorized to
admit patients.
OBS Characteristics
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Always unplanned
No licensed bed required
Must have physician’s order for Observation
Billed on a per-hour basis to patient’s outpatient
benefits
Some services billed directly to the patient
Case may advance to inpatient if medical necessity
is established
Not a qualifying stay for SNF placement
OBS Billing Ends When
EITHER:
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Observation status is no longer justified*
– Observation intensity of service criteria no
longer met
– Documentation does not substantiate
medical necessity for continued
observation services
*If the patient remains in-house, hourly room & board
charges cannot be billed.
OR:
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Inpatient status is justified
– Criteria for inpatient status are met
– Documentation substantiates a defensible
need for an inpatient admission.
 Clinical condition change
 Confirmed diagnosis
 Initiation of inpatient treatment
 Intent
The OBS/Inpatient Mix
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Patient begins stay appropriate for
Observation
Information or circumstances arise
that justify an Inpatient admission
Inpatient begins at the time of order
entry
Now, for Inpatient
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May be planned or unplanned
Requires a licensed bed
Requires medical necessity justification
Begins with a physician’s order for
Inpatient billing status
Can be corrected to outpatient under
certain circumstances (Condition Code 44)
Medical Necessity for
Inpatient Status
Criteria + Intent/Risk
Medical Necessity Criteria
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Specialist written
Evidence based
Very specific
Revised annually
InterQual used by Medicare Quality
Improvement Organization (QIO)
Milliman used by RAC (Connelly
Consulting)
Medical Necessity:
Intent/Risk
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Severity of signs and symptoms
Differential diagnosis
Clinical predictability of something
adverse happening
Plan for management that requires an
inpatient setting
Why the Urgency for
Documentation?
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Inpatient billing begins with an
inpatient order
– Inpatient order requires medical necessity
– Medical necessity requires documentation
from the admitting team
– Documentation delay = inpatient order
delay = loss of billable inpatient days
Provider Liable
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Medicare case with inpatient order and no
documented medical necessity
D/C order written
Billing status order cannot be manipulated
Billing for inpatient without documented
medical necessity is fraud
The hospital (and soon the physician)
cannot bill Medicare for the stay
Currently averaging $500,000/month
*Qualifying Hospital Stay
for SNF Placement
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Medically necessary admission
– Severity of Illness and Intensity of Service justify
inpatient level of care (InterQual)
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3 day inpatient stay within the 30 days
preceding SNF admission
Inpatient criteria met for each of 3
consecutive days
3 day stays resulting in SNF are an OIG focus
Summing Up Bed Status
Billing
Status
Planned vs
unplanned
Medical
necessity
required?
EXR
Planned
No
No
OBS
Unplanned
Yes
Some
INP
Either
Yes
Yes
Billable?
Observation Advisory
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Medicare primary patients only
Billing status changed from INP to
OBS
Advises patients of billing status and
implications
Delivered by CCM Utilization Managers
Documentation Pointers
No more “A” word
 Abolish
the “Admit” word
–CMS = Inpatient
–UNC = Place Patient in Bed
–Does not define a billing status
–Has caused payment retractions
Know what Observation
means
 Observation
are different
and Monitoring
–“Observation” is a billing status
–“Monitoring” is a better term for
clinical activity
Avoid Contradictions
 Admit
to OBS
 Admit for observation
 Inpatient Observation
Which Patients are on
What Status?
Summing Up
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Your Case Manager can be your best
friend
Your Case Manager can’t do good
work without good information
Your Utilization Manager helps hospital
& MD get paid for the care we provide
Precise documentation is better than
“more” documentation
Contacts
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Director: Marie Bossert (3-2766)
Managers:
– CM Med/Surg
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Sherri Branski (3-0599)
– UM Med/Surg
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Chris Wehner (6-8290)
– Transfer center, Bed Mmgt
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Andrea Soltau-Talbot (6-6544)