By Juliet B. Ugarte Hopkins, MD, ACPA-C
No matter how skilled your physician advisors and utilization management team may be, your patient status efforts will not succeed unless you actively educate the medical staff.
Under the Code of Federal Regulations, Title 42, Chapter IV, Subchapter B, Part 412, Subpart A, § 412.3, an Inpatient order must be provided by a practitioner who has admitting privileges and is “knowledgeable about the patient’s hospital course, medical plan of care, and current condition.” If, based on the “patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event,” the practitioner anticipates that the patient will require hospital care spanning two midnights, Inpatient status is supported. Nowhere in this rule does it say that a utilization review nurse can review laboratory and imaging results, ordered and administered medications, and incomplete physician notes, and then recommend a specific status order for the admitting attending physician.
Yes, collaboration among the utilization review nurse, a physician advisor when appropriate, and the attending physician is often a key part of the process for assigning hospitalized patients to the correct status. Even before that collaboration occurs, however, the initial key to success is ensuring that the attending physician has a solid understanding of the Medicare Two-Midnight Rule and knows how to apply it.
Physicians did not attend medical school to learn the business of medicine. They went to learn how to care for patients; to diagnose, treat, and alleviate illness. However, the days when physicians could turn a blind eye to matters outside direct clinical care are long over. When the Centers for Medicare and Medicaid Services (CMS) put the Medicare Two-Midnight Rule into effect just over 13 years ago, it essentially mandated clinician education on the Rule. Yet, 13 years later, I continue to work with hospitals and health systems across the country that have failed to provide this training.
Set aside MCG and InterQual criteria: your physicians do not need to be versed in them, although your physician advisors should be. The intricacies of assigning status to commercial and Medicaid patients should remain with utilization review nurses; clinicians need only understand that utilization managers will routinely contact them when those patients require a status change. What I want the admitting and attending medical staff to know is the Two-Midnight Rule. According to CMS, this education is not optional, and hospitals should recognize it as a compliance issue.
The foundational elements of the Two-Midnight Rule that should be taught include the following:
1) The Rule literally takes the number of midnights crossed into account; it is not a 48-hour rule.
2) Which midnights are applicable to the two-midnight count.
3) What “medically necessary hospital care” means.
Physicians and advanced practice providers (APPs) who should receive this education include anyone who could be responsible for a patient’s hospitalization. The initial and most concentrated educational effort should begin with the following groups:
1) Hospitalists
2) Cardiologists
3) General surgeons
4) Orthopedic surgeons
The best method for disseminating this education depends largely on the size of the hospital, the structure and scheduling of departmental meetings, and the number of physician advisors available to provide the training. Smaller and mid-sized hospitals may find that offering several in-person or virtual presentations allows clinicians to choose the dates and times that work best with their schedules. Larger health systems may benefit from creating recorded modules that medical staff can watch on demand. In every setting, after a comprehensive effort to educate existing clinicians, the organization should establish a plan to ensure that the material is incorporated into the onboarding process for all new medical staff members going forward.
Not to overlook my pediatric colleagues, these concepts apply to children’s hospitals and to hospitals with large pediatric and neonatal populations as well. The Medicare Two-Midnight Rule will not be the focus in those settings, but the applicable state Medicaid rules governing patient status certainly should be. Comprehensive, detailed clinician documentation is important across all patient populations to support appropriate reimbursement and avoid medical-necessity denials, but I believe it is even more critical for pediatric patients. Children may arrive at the hospital on death’s door and then, almost miraculously, recover quickly after receiving excellent medical care, allowing discharge within a day or two. Because of these common “rapid recoveries,” children’s hospital claims are notoriously denied for Inpatient status.
Neonatal Intensive Care Unit (NICU) statusing should not be overlooked, either. Because the appropriate level of care must be established day by day based on the baby’s condition and treatment needs, consistent and precise categorization is essential. If you are a physician advisor at a hospital with a NICU and are not involved with this patient population, now is the time to begin asking questions. In my travels across the country, this is yet another service gap I frequently encounter in physician advisory services and utilization review. Claims involving these tiny patients can leave a serious dent in a hospital’s finances: NICU care is extremely expensive, and the corresponding denials are equally costly. Just as adult intensivists should understand the connection between their documentation and hospital reimbursement, neonatologists should understand that connection as well. If particular documentation elements support a higher level of statusing but are often missing, those points should also become a focused area of education for these physicians and providers.