Clinical Care Management Clinical Care Management at UNC Hospitals at UNC Hospitals

Medicine House Staff

July 9, 2009

Case Managers (CM)Case Managers (CM)

Nurses, Social Workers, other Nurses, Social Workers, other professional specialistsprofessional specialists

Assigned by serviceAssigned by service Facilitators for patient throughputFacilitators for patient throughput Coordinate discharge planning Coordinate discharge planning Expert consultants on disposition Expert consultants on disposition

settings & regulations settings & regulations

Tell Your Case Manager Tell Your Case Manager

Clinical goals/endpoints Clinical goals/endpoints LOS (if you know it) LOS (if you know it) Post discharge care needs Post discharge care needs Barriers you know about Barriers you know about

Your Case Manager Your Case Manager Can Tell YouCan Tell You Discharge options available, Discharge options available,

consideringconsidering– Payor coverage Payor coverage – Family/support Family/support – Transportation Transportation

Documentation needs Documentation needs The status of the discharge plan The status of the discharge plan

Don’t Promise What Don’t Promise What Can’t be Delivered Can’t be Delivered Home vs SNF for infusion Home vs SNF for infusion Home Health vs Outpatient careHome Health vs Outpatient care Medicare covered placement Medicare covered placement Hospital funding Hospital funding

Clinical Social WorkersClinical Social Workers

Assigned to specific areasAssigned to specific areas– PsychiatryPsychiatry– TransplantTransplant– Some pediatric areasSome pediatric areas

Psychosocial assessments and Psychosocial assessments and therapeutic interventions therapeutic interventions

Available as consultants to case Available as consultants to case managersmanagers

TPN and Infusion TPN and Infusion Specialists Specialists Consultants to Case ManagersConsultants to Case Managers Coordinate arrangements for Coordinate arrangements for

post-dischargepost-discharge– IV antibioticsIV antibiotics– IV hydrationIV hydration– TPN TPN

CCM and the UNC CCM and the UNC Discharge SummaryDischarge Summary

MultidisciplinaryMultidisciplinary– PhysicianPhysician– Case Manager Case Manager – Other team designees Other team designees

Contains Contains – Traditional discharge summary informationTraditional discharge summary information– Post discharge orders and instructionsPost discharge orders and instructions– Reconciled medications Reconciled medications

Utilization Managers Utilization Managers (UM)(UM) Assigned to every patient in a bedAssigned to every patient in a bed Perform payor reviewsPerform payor reviews Depend on clear and precise Depend on clear and precise

documentation documentation Experts in CMS regulations for Experts in CMS regulations for

– Bed billing status Bed billing status – Qualifying stays for placement Qualifying stays for placement

Executive Health Executive Health Resources (EHR) Resources (EHR) Contracted physician advisor Contracted physician advisor

consultantsconsultants Experts on CMS regulations and Experts on CMS regulations and

reimbursementreimbursement Contact physicians to discuss care Contact physicians to discuss care

plans and documentation plans and documentation

So, Who Decides The So, Who Decides The Status? Status?

Federal Government Federal Government – Centers for Medicare and Medicaid Services Centers for Medicare and Medicaid Services

(CMS) Policy(CMS) Policy– Office of the Inspector General (OIG) Audits Office of the Inspector General (OIG) Audits

& Retractions & Retractions Evidence based criteria sets Evidence based criteria sets

– InterQual InterQual Expert Physician Advisors Expert Physician Advisors

– Executive Health Resources (EHR)Executive Health Resources (EHR)

Other CCM Functions Other CCM Functions

Payor AuthorizationPayor Authorization Medical Necessity DenialsMedical Necessity Denials Bed Management Bed Management Transfer CenterTransfer Center Psychiatry AdmissionsPsychiatry Admissions Avoidable Delay Tracking Avoidable Delay Tracking

Why CCTs Care AboutWhy CCTs Care AboutBed Billing Status Bed Billing Status

Short stays are a government audit focusShort stays are a government audit focus Overuse of Observation Overuse of Observation

– Lost revenue for hospital (& soon physician)Lost revenue for hospital (& soon physician)– Inappropriate co-pays to patient Inappropriate co-pays to patient

Inappropriate use of Inpatient Inappropriate use of Inpatient – Subject to fraud charges Subject to fraud charges – Pay-backs, penalties, & press Pay-backs, penalties, & press

Billing StatusBilling Status

Outpatient Outpatient – Extended Recovery (EXR)Extended Recovery (EXR)– Observation (OBS)Observation (OBS)

Inpatient (INP)Inpatient (INP)

Patients in any of these statuses can be Patients in any of these statuses can be “admitted” to a bed in the hospital. “admitted” to a bed in the hospital.

Extended Recovery Extended Recovery (EXR) (EXR)

Routine or pre-planned post-Routine or pre-planned post-operative or procedure recoveryoperative or procedure recovery

Short stay services following Short stay services following uncomplicated treatment or uncomplicated treatment or procedure such as chemo or procedure such as chemo or infusion therapy infusion therapy

EXR CharacteristicsEXR Characteristics Always (almost*) Always (almost*) planned/electiveplanned/elective Uncomplicated procedure Uncomplicated procedure No licensed bed requiredNo licensed bed required No physician’s order for billing status required No physician’s order for billing status required Billed as outpatient unit price based on procedure Billed as outpatient unit price based on procedure

codecode No room/board/ancillary billing No room/board/ancillary billing May advance to Observation or InpatientMay advance to Observation or Inpatient

*Also used for “social admits” , allows billing of some *Also used for “social admits” , allows billing of some lab/procedure charges without billing bed charges lab/procedure charges without billing bed charges

Observation (OBS)Observation (OBS) Services & monitoring to evaluate and Services & monitoring to evaluate and

determine the need for inpatient determine the need for inpatient admissionadmission

Services are covered only by the order Services are covered only by the order

of a physician or other individual… of a physician or other individual… authorized to admit patients. authorized to admit patients.

OBS CharacteristicsOBS Characteristics Always unplannedAlways unplanned No licensed bed requiredNo licensed bed required Must have physician’s order for Observation Must have physician’s order for Observation Billed on a per-hour basis to patient’s Billed on a per-hour basis to patient’s

outpatient benefitsoutpatient benefits Some services billed directly to the patient Some services billed directly to the patient Case may advance to inpatient if medical Case may advance to inpatient if medical

necessity is establishednecessity is established Not a qualifying stay for SNF placement Not a qualifying stay for SNF placement

OBS Billing Ends When OBS Billing Ends When EITHER:EITHER: Observation status is no longer justified* Observation status is no longer justified*

– Observation intensity of service Observation intensity of service criteria no longer metcriteria no longer met

– Documentation does not substantiate Documentation does not substantiate medical necessity for continued medical necessity for continued observation services observation services

**If the patient remains in-house, hourly room & board If the patient remains in-house, hourly room & board

charges cannot be billed.charges cannot be billed.

OR: OR: Inpatient status is justified Inpatient status is justified

– Criteria for inpatient status are metCriteria for inpatient status are met– Documentation substantiates a Documentation substantiates a

defensible need for an inpatient defensible need for an inpatient admission. admission. Clinical condition changeClinical condition change Confirmed diagnosisConfirmed diagnosis Initiation of inpatient treatmentInitiation of inpatient treatment IntentIntent

The OBS/Inpatient MixThe OBS/Inpatient Mix Patient begins stay appropriate Patient begins stay appropriate

for Observation for Observation Information or circumstances Information or circumstances

arise that justify an Inpatient arise that justify an Inpatient admissionadmission

Inpatient begins Inpatient begins at the time of at the time of order entryorder entry

Now, for InpatientNow, for Inpatient May be planned or unplannedMay be planned or unplanned Requires a licensed bedRequires a licensed bed Requires medical necessity Requires medical necessity

justificationjustification Begins with a physician’s order for Begins with a physician’s order for

Inpatient billing statusInpatient billing status Can be corrected to outpatient under Can be corrected to outpatient under

certain circumstances certain circumstances (Condition Code 44)(Condition Code 44)

Medical Necessity for Medical Necessity for Inpatient Status Inpatient Status

Criteria + Intent/Risk

Medical Necessity Medical Necessity CriteriaCriteria Specialist written Specialist written Evidence based Evidence based Very specificVery specific Revised annually Revised annually InterQualInterQual used by Medicare Quality used by Medicare Quality

Improvement Organization (QIO)Improvement Organization (QIO) MillimanMilliman used by RAC (Connelly used by RAC (Connelly

Consulting) Consulting)

Medical Necessity: Medical Necessity: Intent/Risk Intent/Risk

Severity of signs and symptoms Severity of signs and symptoms Differential diagnosis Differential diagnosis Clinical predictability of something adverse happeningClinical predictability of something adverse happening Plan for management that requires an inpatient setting Plan for management that requires an inpatient setting

*Documentation of intent and risk must come from the admitting team. *Documentation of intent and risk must come from the admitting team.

Why the Urgency for Why the Urgency for Documentation? Documentation? Inpatient billing begins with an Inpatient billing begins with an

inpatient order inpatient order – Inpatient order requires medical Inpatient order requires medical

necessitynecessity– Medical necessity requires Medical necessity requires

documentation from the documentation from the admitting admitting teamteam

– Documentation delay = inpatient order Documentation delay = inpatient order delay = loss of billable inpatient days delay = loss of billable inpatient days

Provider Liable Provider Liable Medicare case with inpatient order and no Medicare case with inpatient order and no

documented medical necessity documented medical necessity D/C order written D/C order written Billing status order cannot be manipulatedBilling status order cannot be manipulated Billing for inpatient without documented Billing for inpatient without documented

medical necessity is fraudmedical necessity is fraud The hospital (and soon the physician) cannot The hospital (and soon the physician) cannot

bill Medicare for the staybill Medicare for the stay Currently averaging $500,000/monthCurrently averaging $500,000/month

*Qualifying Hospital *Qualifying Hospital Stay Stay for SNF Placementfor SNF Placement Medically necessary admissionMedically necessary admission

– Severity of Illness and Intensity of Service Severity of Illness and Intensity of Service justify inpatient level of care (InterQual) justify inpatient level of care (InterQual)

3 day inpatient stay within the 30 days 3 day inpatient stay within the 30 days preceding SNF admission preceding SNF admission

Inpatient criteria met for each of 3 Inpatient criteria met for each of 3 consecutive daysconsecutive days

3 day stays resulting in SNF are an OIG 3 day stays resulting in SNF are an OIG focusfocus

Summing Up Bed Summing Up Bed Status Status

BillingBillingStatusStatus

Planned vs Planned vs unplanned unplanned

Medical Medical necessity necessity required? required? Billable? Billable?

EXR EXR Planned Planned NoNo NoNo

OBS OBS Unplanned Unplanned YesYes SomeSome

INP INP Either Either YesYes YesYes

Observation Advisory Observation Advisory

Medicare primary patients onlyMedicare primary patients only Billing status changed from INP to Billing status changed from INP to

OBSOBS Advises patients of billing status Advises patients of billing status

and implicationsand implications Delivered by CCM Utilization Delivered by CCM Utilization

Managers Managers

Documentation Documentation Pointers Pointers

No more “A” word No more “A” word

Abolish the “Admit” wordAbolish the “Admit” word – CMS = Inpatient CMS = Inpatient – UNC = Place Patient in Bed UNC = Place Patient in Bed – Does not define a billing Does not define a billing

statusstatus– Has caused payment Has caused payment

retractions retractions

Know what Observation Know what Observation means means

Observation and Observation and Monitoring are differentMonitoring are different – ““Observation” Observation” is a billing status is a billing status

– ““Monitoring” Monitoring” is a better term for is a better term for clinical activity clinical activity

Avoid Contradictions Avoid Contradictions

Admit to OBS Admit to OBS Admit for observationAdmit for observation Inpatient Observation Inpatient Observation

Which Patients are Which Patients are on What Status? on What Status?

Summing UpSumming Up

Your Case Manager can be your Your Case Manager can be your best friend best friend

Your Case Manager can’t do good Your Case Manager can’t do good work without good informationwork without good information

Your Utilization Manager helps Your Utilization Manager helps hospital & MD get paid for the care hospital & MD get paid for the care we provide we provide

Precise documentation is better Precise documentation is better than “more” documentationthan “more” documentation

Contacts Contacts

Director: Marie Bossert (3-2766)Director: Marie Bossert (3-2766) Managers: Managers:

– CM Med/Surg CM Med/Surg Sherri Branski (3-0599)Sherri Branski (3-0599)

– UM Med/SurgUM Med/Surg Chris Wehner (6-8290) Chris Wehner (6-8290)

– Transfer center, Bed MmgtTransfer center, Bed Mmgt Andrea Soltau-Talbot (6-6544)Andrea Soltau-Talbot (6-6544)