Maternal Deaths are Down – For Everyone Except African Americans

By Tiffany Ferguson, LMSW, CMAC, ACM

The Centers for Disease Control and Prevention (CDC) released its updated stats report in February 2025 on maternal mortality in the United States for 2023, revealing both some positive trends, but also some persistent disparities.

The CDC defines maternal death as “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.” Maternal mortality rates are calculated as the number of maternal deaths per 100,000 live births.

The overall maternal mortality rate decreased to 18.6 deaths per 100,000 live births in 2023, down from 22.3 in 2022. This decline represents a reduction from 817 maternal deaths in 2022 to 669 in 2023.

Despite this overall improvement, significant racial disparities remain. The maternal mortality rate for non-Hispanic Black women was 50.3 deaths per 100,000 live births in 2023, which is significantly higher than the rates for non-Hispanic white women (14.5), Hispanic women (12.4), and non-Hispanic Asian women (10.7).

While the decrease in mortality rates for non-Hispanic white and Hispanic women between 2022 and 2023 was statistically significant, the observed decreases for non-Hispanic Asian women and the increase for non-Hispanic Black women were not statistically significant.

A recent article from Axios, with reference back to a 2023 article, centers on a study published in The Lancet which found that Black women in areas with greater access to maternal healthcare still face disproportionately higher risks of maternal mortality, compared to white women living in underserved areas.

The study uses the U.S. Maternal Vulnerability Index, a system that assigns a score from 0 to 100 to each state and county, with lower scores indicating lower vulnerability to adverse maternal health outcomes. By analyzing data from 13 million births of Black and white women aged 10–44, researchers found that even in less vulnerable areas, Black women remained at higher risk of maternal mortality than white women residing in more vulnerable locations.

See maternal mortality rate, by race and Hispanic origin: United States, 2022 and 2023, here.

Age also continues to play a critical role in maternal mortality. In 2023, women 40 and older experienced a maternal mortality rate of 59.8 deaths per 100,000 live births, nearly five times higher than the rate for women younger than 25, which stood at 12.5. However, this rate is at a significant decrease from 2022, when it was 87.1.

In summary, while the overall decline in maternal mortality rates in 2023 is a positive development, the persistent and significant disparities among different racial and age groups, particularly Black women and women over 40, demonstrate the value in utilizing targeted intervention strategies.

HHS Returns to a Binary System for Gender Definitions

By Tiffany Ferguson, LMSW, CMAC, ACM

The U.S. Department of Health and Human Services (HHS) recently announced policy changes in response to President Trump’s executive order aimed at gender classifications and restricting gender-affirming care for minors.

These actions are a 180-degree change from the Biden Administration, which had previously expanded policies and rights for transgender and non-binary individuals, after the Supreme Court’s ruling in Bostock v. Clayton County (2020).

In alignment with Executive Order 14168, titled “Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government,” HHS issued guidance establishing strict sex-based definitions for gender classifications. According to this guidance, sex is defined as an immutable biological characteristic, categorizing individuals strictly as male or female.

The definitions specify that a female is “a person whose reproductive system is designed to produce eggs,” while a male is “a person whose reproductive system is designed to produce sperm.” This move aims to influence policies across various federal agencies, ensuring that distinctions based on these definitions are recognized and enforced.

Newly confirmed HHS Secretary Robert F. Kennedy Jr. emphasized in a press release the administration’s commitment to what it terms “biological truth,” stating that “this administration is bringing back common sense and restoring biological truth to the federal government.” The guidance also includes definitions for terms such as woman, man, girl, boy, mother, and father, all rooted in biological characteristics.

In conjunction with Executive Order 14187, “Protecting Children from Chemical and Surgical Mutilation,” HHS is implementing policies to prohibit federal support for gender-transition treatments for individuals under 19. This includes withholding federal funding from medical institutions that provide surgeries, hormone therapies, puberty blockers, and other gender-affirming treatments to minors.

Furthering the administration’s agenda, Executive Order 14201, “Keeping Men Out of Women’s Sports,” directs HHS to implement policies ensuring that athletic competitions are segregated based on the newly established biological definitions of sex. This order aims to prevent transgender women and girls from participating in female sports categories, a move proponents argue is necessary to maintain fairness in women’s athletics.

As these policies begin to take effect, the nation remains deeply divided over issues of gender identity, medical autonomy, and the role of government in personal healthcare decisions. The current administrative actions are dramatically different than the prior HHS philosophy. This will likely end up with further legal proceedings over discrimination protections and restricted access to healthcare for transgender individuals, particularly youths. 

When Discharge Orders No Longer Signify Patient Discharge

By Juliet B. Ugarte Hopkins, MD, ACPA-C

As with many other physicians of a certain age, I had the opportunity to practice patient care in both the worlds of paper and electronic charting.  Granted, as a pediatric hospitalist working in a busy, near-tertiary care center with little (purposeful) exposure to utilization management or clinical documentation integrity, my focus then on how my charting impacted other areas of hospital functioning – such as with revenue cycle – was extremely minimal.  This being the case, I hope I am afforded some leniency with my viewpoint that one big difference between the two worlds – paper and electronic – is utilization for processes outside of frank communication between members of the care team. 

On paper, History and Physicals, Progress Notes, Operative Notes, and Discharge Summaries allowed doctors, nurses, physical therapists, pharmacists, etc. to inform each other about what was happening with the patient during the hospitalization.  When paper charting moved to electronic, suddenly those same notes were utilized not only for communication, but also to track quality measures, create claims for the hospital to bill services, and support Diagnosis-Related Group categorization. 

A similar situation happened with placement of orders.  On paper, when a physician wrote the current date and time followed by, “Discharge patient,” this informed the bedside nurse that the process for patient discharge out of the hospital could be undertaken.  Whether the patient was leaving the hospital for home, a rehabilitation facility, or another hospital for a higher level of care, did not matter.  Ultimately, the order’s message was that the patient was ready to leave the hospital that day. 

Just as multi-level connections to hospital operations became tied to documentation, the same happened with placement of clinician orders.  Electronic Health Records (EHR) often evolved to utilize an order for patient discharge to equate an end to hospital billing for the hospital encounter on the calendar day and time the discharge order was placed.  As such, when a discharge order is placed other than on the day when a patient leaves the hospital, this can lead to under-reporting the patient’s length of stay, misidentification of bed availability, and prevent the hospital from understanding where potential opportunities lie buried within categories of avoidable days (days in which patients remain hospitalized without medical necessity).

When a hospital inadvertently makes a connection like this in the EHR it can usually be quickly identified and addressed.  However, when a health system is contracted with an employed group of physicians who are directed by entities outside hospital leadership to follow a specific process, things can get dicey.  Add in an association with a commercial or managed payor and the conflict increases even more.

Such a situation has recently been reported by a number of hospitals and health systems across the country.  Employed hospitalists are being told by their leaders that when a patient is medically ready for discharge, even if they do not have a safe discharge plan in place and hospital services will continue to be provided, including daily physician rounding, an order for discharge should be placed.  This can include a situation where the patient no longer requires hospital care but requires transfer to an Inpatient Rehabilitation Facility (IRF) or other Skilled Nursing Facility (SNF), however there are not yet any accepting location with open beds.  Another situation could involve a patient who is clinically ready to discharge from the hospital with an outpatient plan for prolonged IV antibiotic therapy but who does not yet have outpatient nursing services established to monitor the peripherally inserted central catheter (PICC) in the home setting.

When an order for discharge is used in these instances, it puts the hospital and medical team – especially the nursing staff – in a situation of having to elucidate when a discharge order should be acted on or ignored.  This is a major patient safety issue, as order intent should always be clear and uniform to those reviewing them and carrying them out.  Granted, there IS significant utility in identifying when a patient is medically ready for discharge from the hospital and when the patient actually leaves the hospital.  However, placing a discharge order is not the way to do it.  In at least one EHR system, there is a “Medically Ready for Discharge” identification feature which can be utilized by clinicians, nursing, or case/utilization managers within the record to make the distinction.  Then, when everything is in place for the patient to truly leave the hospital building, a discharge order is placed.

Review of Centers for Medicare and Medicaid Services (CMS) rule uncovers other points which clearly make placement of a discharge order erroneous in these instances.  Per the Code of Federal Regulations, Title 42, Chapter IV, Subchapter B, Part 412, Subpart C, 412.42 (bolding added):

“The hospital (acting directly or through its utilization review committee) determines that the beneficiary no longer requires inpatient hospital care. (The phrase “inpatient hospital care” includes cases where a beneficiary needs a SNF level of care, but, under Medicare criteria, a SNF-level bed is not available. This also means that a hospital may find that a patient awaiting SNF placement no longer requires inpatient hospital care because either a SNF-level bed has become available or the patient no longer requires SNF-level care.)” 

Because of this, a Medicare patient who begins their hospitalization in justifiable Inpatient status and is medically ready for discharge on the third hospital day but does NOT leave on that day because they require SNF placement and there are no available beds, will have three Inpatient midnights pass on the fourth hospital day allowing for use of their Part A SNF benefit.  If a discharge order is placed on hospital day three and the billing is captured as a two-day encounter (not including the “day of discharge” identified by the calendar day the discharge order is placed), the patient will not be able to access their SNF benefit, as demonstrated in the Code of Federal Regulations excerpt, above.

Then, there are issues related to the Important Message from Medicare (IM) and a beneficiary’s rights to appeal their discharge.  As seen in Code of Federal Regulations, Title 42, Chapter IV, Subchapter B, Part 405, Subpart J, 405.1206 (bolding added):

“(a) Beneficiary's right to an expedited determination by the QIO [Quality Improvement Organization]. A beneficiary has a right to request an expedited determination by the QIO when a hospital (acting directly or through its utilization review committee), with physician concurrence, determines that inpatient care is no longer necessary.

....

(c) Burden of proof. When a beneficiary (or his or her representative, if applicable) requests an expedited determination by a QIO, the burden of proof rests with the hospital to demonstrate that discharge is the correct decision, either on the basis of medical necessity, or based on other Medicare coverage policies. Consistent with paragraph (e)(2) of this section, the hospital should supply any and all information that a QIO requires to sustain the hospital's discharge determination.

(d) Procedures the QIO must follow.

(1) When the QIO receives the request for an expedited determination under paragraph (b)(1) of this section, it must immediately notify the hospital that a request for an expedited determination has been made.

(2) The QIO determines whether the hospital delivered valid notice consistent with § 405.1205(b)(3).

(3) The QIO examines the medical and other records that pertain to the services in dispute.

(4) The QIO must solicit the views of the beneficiary (or the beneficiary's representative) who requested the expedited determination.

(5) The QIO must provide an opportunity for the hospital to explain why the discharge is appropriate.”

If a Medicare or Medicare Advantage patient is given an IM due to placement of a discharge order and the patient appeals to the QIO, what will be hospital’s response when the QIO asks for documentation related to how discharge of the patient is appropriate when in actuality...discharge is NOT appropriate due to lack of an out-of-hospital plan of care?  This is further complicated by verbiage found within the IM itself (bolding added):

“Your Right to Appeal Your Hospital Discharge:

•   You have the right to an immediate, independent medical review (appeal) of the decision to discharge you from the hospital.  If you do this, you will not have to pay for the services you receive during the appeal (except for charges like copays and deductibles).

•   If you choose to appeal, the independent reviewer will ask for your opinion.  The reviewer also will look at your medical records and/or other relevant information.  You do not have to prepare anything in writing, but you have the right to do so if you wish. 

•   If you choose to appeal, you and the reviewer will each receive a copy of a detailed explanation about why your covered hospital stay should not continue.  You will receive this detailed notice only after you request an appeal.”

Just like a clinician would not order, “Dilaudid 2 mg IV Q4 PRN severe pain” if they do not intend for the patient to ever receive the medication, clinicians should not order to “Discharge patient” if they do not intend for the patient to leave the hospital that day.  If aiming to identify the difference between a patient remaining hospitalized with medical necessity versus those who remain hospitalized due to non-medical barriers, there are other ways this can be accomplished. 

One final note – in instances where Medicare patients are medically ready for discharge from the hospital AND either have a discharge plan or are failing to agree with a safe discharge plan and they intend to appeal their discharge, the discharge order should remain while the appeal to the QIO takes place and until the QIO determination is made.

Freezing DEI: What does this mean in terms of healthcare?

By Tiffany Ferguson, LMSW, CMAC, ACM

President Donald Trump recently issued an executive order titled “Ending Radical and Wasteful Government DEI Programs and Preferencing,” aiming to dismantle diversity, equity, and inclusion (DEI) initiatives within federal agencies.

This directive mandates the termination of all DEI-related policies, programs, preferences, and activities. The order also requires agencies to report on all DEI and “environmental justice” positions to the Office of Management and Budget (OMB) within 60 days.

This order has since created considerable confusion between the broadness of the executive order and the general terms in DEI.  For reference, DEI is defined as “the state of having a diverse group of participants as well as policies and norms that are equitable and inclusive. ” This includes racial and ethnic groups, gender, sexual orientation, people with disabilities, religious groups, age groups, and socioeconomic status. 

The executive order’s broad and sweeping language has led to confusion among federal agencies, contractors, and communities as they work to interpret and implement the directive. The requirement for agencies to enumerate and report all DEI-related positions, contractors, and federal grant funding has contributed to some fear and chaos, as stakeholders attempt to understand the full scope of the order’s implications. This uncertainty has resulted in a chilling effect, with some agencies and organizations preemptively halting or dismantling DEI initiatives to avoid potential non-compliance.

For instance, the Department of Health and Human Services (HHS) has been directed to cease all DEI-related activities, resulting in the suspension of programs aimed at reducing health disparities among underserved communities. Furthermore, the Food and Drug Administration (FDA) has quietly rolled back DEI initiatives, raising concerns about underrepresentation in clinical trials and the potential impact on healthcare outcomes.

Some consequences of this confusion and freeze have been recently reported in specific healthcare communities which operate with small margins.  Specifically, Community health centers in rural and underserved areas, especially those serving marginalized populations, have been notably affected. For instance, clinics in Virginia and West Virginia have faced closures or staff layoffs due to challenges in accessing essential federal funding following the implementation of the executive order.

These clinics have been forced to reduce services or shut down entirely, impacting access to primary care for approximately 400,000 patients.

In recent weeks, specifically grants supporting HIV prevention initiatives and services tailored for transgender individuals have been terminated. This has halted services and created confusion for health centers that provide HIV prevention and care for transgender patients leading to new legal challenges for future continued care. 

President Trump’s executive order to end DEI programs represents a significant policy shift from the prior administration.  It is unclear of the full effects of what will happen to these programs and who will be considered inclusive in the DEI freeze, since all federal health communications from the Centers for Disease Control and Prevention (CDC), FDA, and the National Institute of Health (NIH) were halted until the beginning of this month, leading to additional confusion.

While many argue this will eliminate wasteful spending in the federal government, others are fearful that this will undermine years of effort in working towards addressing systemic inequalities and supporting marginalized communities.

Important: Cancer Numbers on the Rise for Young Women

By Tiffany Ferguson, LMSW, CMAC, ACM

Recent studies have shown a troubling increase in cancer rates among women under 50; beyond the genetic factors, more research is exposing the role of lifestyle and environmental factors in this growing health crisis.

According to a report by the American Cancer Society (ACS), the cancer incidence rate for young women was 82 percent higher than for men in the same age group in 2021; this is a significant rise, up from 51 percent in 2002. This concerning trend suggests that external influences such as diet, pollution, and reproductive choices may be key contributors to the spike in cases (NBC News, Advisory).

The study and recent articles in the news show key factors for consideration in women’s health, which include lifestyle habits, environmental exposures, diet, and shifts in reproductive behaviors.

Several lifestyle habits have been linked to increased cancer risk, including obesity, smoking, alcohol consumption, and sedentary behavior. Obesity is particularly concerning, as excess body weight is associated with higher levels of insulin and estrogen, both of which can promote cancer development. Moreover, research from ACS has linked obesity to several types of cancer, including breast and colorectal cancers.

Aside from the well-known linkages to smoking, alcohol consumption is also a risk factor, with growing evidence to support correlations to breast, liver, and digestive tract cancers. In fact, this growing concern is now leading to a push for warning labels on alcohol bottles. Additionally, a sedentary lifestyle can exacerbate these risks, as regular physical activity plays a crucial role in reducing inflammation and maintaining hormonal balance.

Another key factor contributing to rising cancer rates is diet, particularly the consumption of ultra-processed foods. These foods often contain elevated levels of sugar, unhealthy fats, and additives that may negatively impact metabolic health. Studies have linked ultra-processed foods to obesity and altered gut microbiomes, both of which are associated with increased cancer risk. Diets high in processed meats and low in fresh fruits and vegetables are particularly concerning for colorectal cancer.

Beyond lifestyle choices, pollutants such as air pollution, water contamination, and chemicals like per- and polyfluoroalkyl substances (PFASs), also known as “forever chemicals,” are linked to cancer. PFASs are present in various consumer products, and research suggests they can mimic estrogen, increasing the likelihood of breast cancer (National Cancer Institute, 2023).

The ACS also highlighted the impacts from the shifts in reproductive behaviors contributing to the rise in cancer cases among young women. Factors such as delayed childbirth, having fewer children, and reduced breastfeeding duration can lead to prolonged estrogen exposure, which has been linked to a higher risk of breast cancer.

While the rising cancer rates are alarming, there are several steps young women can take to mitigate their risk. Here are five specific things women can do today to lower their risk:

1. Engage in at least 20 minutes of moderate-high intensity exercise per day. Start walking! I got a walking pad for my office.

2. Avoid smoking and limit alcohol intake to no more than one drink per day to significantly decrease your risk of cancer.

3. Consider switching out your plastics for glass or ceramic. Specifically, avoid putting any plastic in the microwave to heat your food. This will help reduce exposure to environmental toxins, including pollutants and endocrine-disrupting chemicals.

4. Limit your intake of processed foods throughout the day.

5. Stay up-to-date with recommended cancer screenings and medical checkups; for women, this is specifically mammograms, pap smears, and colonoscopies.

While more research is needed to fully understand the underlying causes, it is clear that personal and societal changes are essential to combat this growing health threat for young women.

ICE Enforcement Policy Changes Raise Challenges for Hospitals

By Tiffany Ferguson, LMSW, CMAC, ACM

References from this article were obtained from links in the Becker’s article on ICE Enforcement written by Naomi Diaz.

Recent policy changes by the U.S. Department of Homeland Security (DHS) have lifted restrictions on Immigration and Customs Enforcement (ICE) and Customs and Border Protection (CBP) officers, permitting immigration enforcement actions in hospitals and other previously protected “sensitive” areas.

This directive, issued by acting DHS Secretary Benjamin Huffman, has sparked ethical and legal concerns for hospitals and healthcare providers, especially in relation to compliance with the Emergency Medical Treatment and Labor Act (EMTALA) and provider obligations to deliver care without discrimination.

Under these changes, ICE and CBP officers are now permitted to conduct enforcement activities, including arrests, in hospitals, schools, and places of worship that were previously protected to ensure public safety and maintain public access to essential services. DHS has defended this shift by claiming that the prior restrictions under the Biden Administration obstructed enforcement efforts. 

The directive also restricts the use of humanitarian parole, limiting its application to case-by-case evaluations, which may decrease temporary legal protections for migrants seeking medical care. Advocacy groups caution that these changes could discourage undocumented individuals from pursuing healthcare, even in emergencies, due to the fear of detention.

Conflict with EMTALA

EMTALA, a federal law enacted in 1986, mandates that hospitals provide emergency medical care to all individuals, irrespective of their immigration status or financial capability. This law ensures that those experiencing medical emergencies receive stabilization and treatment prior to any transfer or discharge.

However, recent directives from DHS have created some confusion with EMTALA. If ICE conducts enforcement actions within hospitals, patients may refrain from seeking urgent care due to fears of arrest. Additionally, hospitals could experience interruptions in patient care if ICE agents intervene during treatment.

This situation places healthcare providers in a challenging ethical and legal position: they are required to adhere to EMTALA while also managing the risks associated with potential ICE actions that could jeopardize patient trust and safety.

Ethical Implications for Hospitals

The presence of ICE officers in hospitals undermines the role of healthcare facilities as safe spaces for healing and care. Hospitals are bound by ethical principles, including patient confidentiality, nonmaleficence (do no harm), and justice. When immigration enforcement occurs in healthcare settings, it erodes the trust necessary for vulnerable populations, particularly undocumented immigrants, to seek timely care.

Hospitals in states like California and Massachusetts have taken proactive steps to mitigate these challenges. Measures include prioritizing patient privacy by avoiding the documentation of immigration status on medical records or bills, training staff to recognize ICE warrants and enforce patient confidentiality, and displaying multilingual information on privacy rights to reassure patients.

In contrast, states like Texas and Florida have introduced policies requiring hospitals to inquire about immigration status, creating a polarization of responses to this requirement nationwide.

Beyond individual patient care, this policy change has significant implications for public health. The essential roles of disease surveillance, immunization programs, and preventative measures serve all individuals, regardless of their status, to mitigate community health risks. Fear of detention may deter individuals from seeking vaccinations, prenatal care, or treatment for infectious diseases, potentially leading to outbreaks or worsening public health conditions.

Building trust within communities, particularly among marginalized populations, is crucial for public health.

This policy change poses a fundamental challenge to the healthcare system: balancing federal enforcement with the moral and legal obligations to provide equitable care.

Hospitals must navigate the current political landscape to maintain trust while complying with federal and state enforcement requirements, all while reinforcing their commitment to treating patients without discrimination or fear.

Farewell My Friends and Colleagues

By Erica Remer, MD, FACEP, CCDS, ACPA-C

Note: Dr. Erica Remer was, for nearly seven years, the cohost with Chuck Buck on Talk Ten Tuesday and a member of the ICD10monitor editorial board. This is her final editorial contribution to ICD10Monitor.

This is my last contribution to ICD10monitor. Taking care of my father’s and my in-laws’ medical situations and financial affairs has become overwhelming for me, and I am essentially retiring from my consulting practice and ongoing responsibilities, like Talk Ten Tuesdays. It has been my honor and privilege to spend Tuesday mornings with all of you for the past seven years, and I thank Chuck Buck and MedLearn Media for the opportunity. I’d like to single out Dr. Ronald Hirsch, who was my connector to Chuck and has been a wonderful friend and support during my career. Thank you!

I’d like to leave you, my readers, with some thoughts.

The most important word in clinical documentation integrity (CDI) is “integrity.” Documentation should be an accurate reflection of the patient encounter, and coding should be an accurate representation of the conditions that were present during the encounter. The role of the clinical documentation integrity specialist (CDIS) is to ensure that the documentation is telling the story accurately and completely.

I always had trouble defining exactly what “compliance” meant – I understood it could be translated as, “follow the rules and regulations, and don’t lie.” I guess that is good enough. If a CDIS were intentionally to encourage a provider to fudge documentation so it supported a risk-adjusting condition that was not present or seemed to support a higher level of service than was medically necessary, that action might violate the False Claims Act.

Providers often don’t know that a query is a question – they sometimes think the CDIS is trying to persuade them to change their documentation. That’s why you can’t do “yes/no” queries, in many scenarios – and why you don’t reveal reimbursement or quality implications that might sway the provider. That’s why leading them is strictly prohibited. Give the clinician the facts they need to make a good decision, and give them solid choices, consistent with the clinical indicators. If they don’t understand the question, educate them first. This is why I recommend that physician advisors not pose queries. I think physician advisors (PAs) should educate their colleagues and allow the CDIS or coder to perform the query.

Clinical validation queries are an important tool in the CDI arsenal. If the clinical indicators don’t seem to support a claimed diagnosis to the CDIS or coder, they probably won’t pass a sniff test to an auditor, either. We want the record to accurately depict the patient encounter, regardless of where the coding will fall or which DRG the patient will land in. Fighting denials is soul-sucking, and if a clinical validation query can prevent a clinical validation denial, it is highly preferable.

The same principles we hold dear for inpatients carry over into the Hierarchical Condition Categories (HCCs) world. Plopping a random diagnosis into a patient chart with no clinical relevance is not permitted. If a provider believes a diagnosis is clinically significant, they must demonstrate it in the documentation. Why is it relevant? How is it going to be evaluated, monitored, or treated? Two seconds of documentation can save a world of hurt from the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) or an auditor.

Providers shouldn’t just diagnose conditions to capture risk-adjustment factors, but only if they think it is important. Job one is to take care of the patient.

There is no question that artificial intelligence (AI) is here to stay. AI is going to become more and more integral to the practice of medicine. It will be great if it offloads some of the menial tasks and improves patient care. It will be dangerous if the providers, CDISs, or coders just relegate important activities to the computer without doing any oversight.

It will be worse than not mindfully editing copied-and-pasted text. Don’t let AI try to practice medicine without a license.

Finally, I recently came across a very scary article asserting that antimicrobial resistance is one of the greatest health threats of this century, and could lead to more deaths than cancer by 2050. Vaccine hesitancy is a huge contributor.

Appropriate antimicrobials to treat a bacterial infection would be unnecessary had the individual not developed the infection in the first place, but also, we doctors often use empiric (yet ultimately inappropriate) antibiotics to treat a viral infection that could also have been prevented by vaccination. I can’t understand why anyone would want to contract an infection that could have been avoided – being sick sucks! Folks, get your flu and COVID shots!

In conclusion, thank you all for letting me try to contribute to your lives and practices. I have done my best to impart my medical knowledge and have shared my insights from my personal experience with COVID and my interaction with the medical establishment. You have all been there on my journey with my father and his diagnosis of dementia, and now, my father-in-law. Thanks for your support and compassion!

I wish you all well in the future. I think that there are going to be particularly challenging times for the medical community over the next few years. I am not sorry to miss that.

Considering Inpatient Status For Medicare Total Knee and Hip Patients

By Juliet Ugarte Hopkins, MD, ACPA-C

The Centers for Medicare and Medicaid Services (CMS) have provided guidance on when patients undergoing total hip and total knee arthroplasty—typically outpatient procedures—may qualify for Inpatient status. In this article we explore these scenarios and the documentation requirements which would support Inpatient status. Key factors include the presence of significant co-morbidities, anticipation of a complex procedure related to the patient’s anatomy, patient history of anesthesia complications, or the surgeon’s anticipation that the patient will require Skilled Nursing Facility (SNF) placement post-procedure. This insight can also be used as a utilization management screening tool to assist with pre-operative clinical reviews to ensure appropriate authorization and level of care is made.

Potential Considerations to Hospitalize as Inpatient

If any of these conditions are present, the increased risk associated with the procedure and higher potential of post-operative complications will likely support Inpatient, even if there is not a two-midnight anticipation.  Other patient-specific medical conditions with a two-midnight anticipation of need for hospitalization before the patient is safe to discharge would also be appropriate for Inpatient status, per the Medicare Two-Midnight Rule.  However, patients who are anticipated to discharge on the day of the procedure are not appropriate for Inpatient and should remain Outpatient.

1. Surgical expectation patient will require transfer to a SNF post-procedure for skilled care

• Issue: Situations CMS has provided in the past include no family or friends to assist the patient at home, multiple stairs in the residence, or other unmanageable obstacles in the home environment. 

• Documentation Tip: Detail the reasons why the patient will need skilled care in a facility and will not be appropriate for discharge to home post-procedure. 

2. Body Mass Index (BMI) ≥ 40:

• Issue: Elevated BMI can lead to increased surgical and anesthesia risks, necessitating closer post-operative monitoring.

• Documentation Tip: Provide the current BMI contributing to heightened risk and detail the monitoring provided.

3. Poorly Controlled Diabetes Mellitus (HbA1C > 7.5%):

• Issue: Heightened risks of post-operative hyperglycemia and wound infection.

• Documentation Tip: Include the date and result of the patient’s most recent HbA1C and the associated surgical risks.  Include the plan for a specific cadence of blood glucose and wound monitoring.

4. Chronic Anemia (Hemoglobin < 11):

• Issue: Baseline anemia necessitates careful monitoring for blood loss and post-operative monitoring for signs and symptoms of escalated anemia possibly requiring transfusion.

• Documentation Tip: Specify the patient’s last hemoglobin level before the procedure and the plan for monitoring for escalated anemia post-operatively.  Document hemoglobin levels following the procedure and any signs/symptoms possibly related to worsening anemia.

5. Chronic Kidney Disease Stage 4 or 5 (CKD IV/V):

• Issue: Presence of advanced CKD requires close monitoring for anesthesia-related risks, fluid balance issues, and potential development of acute kidney injury.

• Documentation Tip: Highlight the pre- and post-procedure creatinine levels.  Detail plans for escalated fluid delivery or potential need for nephrology consultation.

6. Coronary Artery Disease (CAD) requiring chronic medication management:

• Issue: Increased surgical risks requiring close post-operative monitoring.

• Documentation Tip: List the routine medications the patient takes for CAD and the potential for increased surgical complications related to this condition.  Detail the plan for close monitoring for cardiac decompensation.

7. Uncontrolled Hypertension despite chronic medication management (BP > 140/90):

• Issue: Increased surgical and bleeding risks.

• Documentation Tip: Include the patient’s blood pressure readings pre-operatively in the clinic setting and the plan for close monitoring post-operatively.

8. Chronic Obstructive Pulmonary Disease (COPD) on routinely administered oral or inhaled medications:

• Issue: Increased risk of perioperative respiratory failure and other complications.

• Documentation Tip: List the routine medications the patient takes for COPD and the potential for development of respiratory compromise related to this condition.  Detail the plan for close monitoring for pulmonary decompensation.

9. Baseline Abnormal Mental Status:

• Issue: Patients with pre-existing cognitive issues often develop escalated decompensation in mental status following administration of anesthesia and in relation to many medications given for pain control post-operatively.

• Documentation Tip: Describe the patient’s baseline mental status and the monitoring protocols planned while the post-operative pain management regimen is established and tailored to the patient’s needs.

Key Takeaways

• Initial Documentation is Crucial: Justification of Inpatient hospitalization requires documentation in the History and Physical or post-operative note which thoroughly explains why the patient’s condition warrants closer monitoring or additional care.

• Length of Stay: While a two-midnight stay is not always necessary, the rationale must clearly establish why there is increased risk or complexity associated with the patient’s condition.  Even in cases where there is documented risk, patients who are anticipated to discharge on the day of the procedure should remain Outpatient.

• Daily Documentation Especially for Patients Requiring SNF Transfer: Daily records must reflect the patient’s ongoing need for hospital services and what hospital services are being provided.  “Waiting for transfer to SNF” is not acceptable.

Navigating Reclassification from Inpatient to Outpatient Observation

By Tiffany Ferguson, LMSW, CMAC, ACM

You have heard Dr. Ronald Hirsch, and I present on CMS-4204-F which introduces a process for expedited determinations for traditional Medicare beneficiaries who are reclassified from inpatient to outpatient observation services.

This process does not apply to Medicare Advantage enrollees and this process does not apply to patients who do not receive observation services after conversion from inpatient to outpatient.

On Dec. 5, the Centers for Medicare & Medicaid Services (CMS) provided additional guidance with the expectation that the Medicare Change of Status Notice (MCSN) that hospitals must start to provide this notice to qualifying individuals no later than Feb. 14, 2025.

Here’s an overview of what information we have thus far. 

The expedited determination process is codified at 42 CFR Part 405.1210 through 405.1212. It applies to Original Medicare beneficiaries formally admitted as inpatients but later reclassified to outpatient observation while still hospitalized.

Eligibility criteria differ based on Part B enrollment:

• With Part B: A minimum three-day hospital stay is required with less than 3 days of inpatient status. The admission is considered day one, but the discharge day is not (like the SNF 3-day rule).

• Without Part B: No stay requirement applies. Thus, notice is given as soon as the status is changed from inpatient to outpatient with observation services.

This process is relevant for all inpatient-level facilities, including Critical Access Hospitals (CAHs). Beneficiaries may act through representatives as needed.

Hospitals must document delivery of the MCSN form with a signature, offer paper copies upon request, and ensure the MCSN is provided within specific timeframes:

• With Part B: Deliver after reclassification and by the third hospital day.

• Without Part B: Deliver immediately after reclassification.

• All cases: Delivery must occur at least four hours before discharge.

The MCSN must remain two pages, but hospitals can add logos and contact details. Beneficiary-specific notes can be included in the “Additional Information” section. Beneficiaries who refuse to sign still retain expedited determination rights. Hospitals should document the refusal with the date.

Hospitals must use interpreters, translators, and assistive devices to ensure comprehension, adhering to the Affordable Care Act and Civil Rights Act requirements. Hospitals must retain signed MCSNs in the medical record, with electronic storage permitted. The notice must be given similar to the guidelines for the Important Message from Medicare (IMM), no later than the 4-hour discharge window, however the patient does not have to stay for the four hours if they have no intention of appealing.

Beneficiaries and hospitals share responsibilities during the expedited determination process.

Beneficiary Responsibilities:

• Timely Requests: Must be made before leaving the hospital.

• Untimely Requests: Allowed post-discharge or even after claim submission.

• Provide Information: Respond promptly to BFCC-QIO requests and submit relevant details.

Hospital Responsibilities:

• Submit the MCSN and additional documentation to the BFCC-QIO by noon the next calendar day.

• Provide a copy of the submitted documentation to beneficiaries if requested.

• They may not be able to submit a claim/ patient bill on timely requests until QIO determination has been made, but the patient does not have to remain hospitalized during this time period either.

BFCC- QIO (Livanta or Acentra Health pending your region) must be available 24/7 to accept requests and notify hospitals of receipt. The review will consist of validating the MCSN delivery and document and reviewing the appropriate documentation. 

They will be required to issue their determinations within one calendar day for timely requests and two days for untimely ones.  Their notifications must detail the determination rationale, payment consequences, and appeal procedures.

BFCC-QIO determinations are binding unless a beneficiary request’s expedited reconsideration. These requests must adhere to specified timeframes, allowing dissatisfied beneficiaries another opportunity to challenge the reclassification decision.

Clarification still needed:

In the final ruling but NOT mentioned in the Medicare Claims Processing Manual or the MLN 

The final ruling confirmed that the MOON is not required for delivery of the MCSN as not every applicable patient that is changed from inpatient to observation, meets the MOON qualification of the anticipated 24 hours of observation services. 

So, there could be rare instances where a Medicare Part A only patient who is changed from inpatient to outpatient receive a condition code 44 notification, then have observation services ordered, which requires an MCSN and if observation is expected to continue for the estimated 24 hours, would then receive a MOON. 

The ruling also stated that if the patient qualified for the MCSN, appeals to the BFCC-QIO and wins, which means the inpatient admission is appropriate.  The ruling comments state that the “beneficiary would be deemed an inpatient under the original hospital admission order” and thus would appropriately need to receive an IMM notice prior to discharge since they have returned to inpatient status.

Example Scenarios:

Medicare Pt A-only patient admitted as inpatient, next day converts to outpatient and OBS services started - CC44 process & MCSN is given.  The patient discharges later that day - no MOON needed.

Medicare Pt A & B patient admitted as inpatient, next day converts to outpatient and OBS services started - CC44 process, patient will stay overnight MOON given, discharged in a.m., no MCSN given because it is less than 3 days.  

CMS Clarifies Medicare Advantage Concurrent Review Process

By Tiffany Ferguson, LMSW, CMAC, ACM

The Centers for Medicare & Medicaid Services (CMS) has outlined critical updates to clarify the definition and processes surrounding organization determinations, particularly in inpatient settings. The proposed rule reaffirms that decisions made during concurrent reviews in inpatient settings, such as reclassification from inpatient to outpatient or denial of inpatient coverage, are organization determinations under § 422.566.

These determinations must comply with notification and appeal requirements to protect enrollees. CMS highlights past inconsistencies where enrollees were not informed of such decisions, leading to unexpected financial liabilities. This change emphasizes transparency and timely communication of decisions to enrollees, fostering better protection and equity. For further information please see page 378 of the proposed rule.

What Is an Organization Determination?

An organization determination, as defined in §422.566 of the Code of Federal Regulations, refers to any decision by an MA organization regarding the benefits an enrollee is entitled to receive under their plan and the associated costs. This encompasses various scenarios, including:

• Refusals to provide or pay for services, either wholly or partially.

• Reduction or premature discontinuation of previously authorized treatments.

• Decisions regarding inpatient admission status or level of care appropriateness.

Such determinations can occur before, during, or after services are rendered, applying to both contracted and non-contracted providers. Notably, these decisions are legally binding unless reconsidered, reopened, or revised.

When an MA organization issues an adverse organization determination, such as denying coverage for a service, CMS reminds MA plans in the proposed ruling that they must:

• Provide timely notice to the enrollee in a CMS-prescribed format (Integrated Denial Notice (IDN) or Explanation of Benefits (EOB)- or a yet to be determined notice which is open for public comment by CMS.

• Ensure decisions based on medical necessity are reviewed by a qualified healthcare professional.

• Allow the enrollee or their physician to request an expedited reconsideration if the adverse determination pertains to necessary services.

Clarification on Concurrent Review Decisions

CMS has identified significant issues with how some MA organizations handle concurrent review decisions. Concurrent reviews evaluate the appropriateness of ongoing care while the enrollee is actively receiving inpatient or similar services. Examples of these include:

• Rescinding previously approved inpatient admissions.

• Downgrading inpatient status to outpatient observation.

• Denying coverage for inpatient services while suggesting reclassification to outpatient services.

CMS made it clear that there appears to be some confusion in denial practices by the MA plans when care is being rendered for a patient as inpatient, but the MA plan is notifying the hospital that care is not approved at the inpatient level, despite services already being delivered.  They go on to provide further discussion about concerns of MA plans recommended lower levels of care, despite a request for payment having been provided to the payer yet blurring the lines between a coverage decision and a payment decision (see page 386).  Despite the legal requirement to notify enrollees of these decisions and afford them the opportunity to appeal, CMS audits reveal that enrollees are often left uninformed. For instance, hospitals may reclassify an enrollee’s status based on the MA organization’s decision without notifying the patient, leaving them unaware until they face potential cost-sharing or deductible requirements.

For example, a patient is admitted to an in-network hospital under inpatient status, as ordered by their treating physician. The hospital submits a Notice of Admission to the MA organization. During the hospitalization, the MA organization conducts a concurrent review and determines the inpatient admission does not meet coverage criteria. Without informing the enrollee, the MA organization denies inpatient coverage but approves outpatient observation services. The hospital, in response, may reclassify the admission as outpatient or continue providing non-covered inpatient services. The enrollee is left unaware of these changes.

To address these discrepancies, CMS is working to reiterate that concurrent review decisions constitute organization determinations under existing regulations.  CMS is proposing mandates by MA plans for timely notice to enrollees regarding such decisions and strengthening audit protocols to ensure compliance with notice and appeal requirements.  It is important to also note that appeals on the beneficiary behalf were called out several times as only applicable if the beneficiary is impacted financially, including cost-sharing responsibilities which is likely going to impact hospital’s strategy for appealing on the member’s behalf.

Clarifying the definition of organization determinations and reinforcing compliance in concurrent review decisions are vital steps toward safeguarding the integrity of the Medicare Advantage program. By holding MA organizations accountable for transparent, timely, and equitable decision-making, CMS ensures enrollees are informed, empowered, and protected in their healthcare journeys.

As these updates are implemented, enrollees can expect greater clarity, fewer surprises, and enhanced confidence in their coverage.

Potentially Suspicious Link Uncovered

By Tiffany Ferguson, LMSW, CMAC, ACM

There has been a noticeable increase in payer actions regarding readmission denials, often justified as efforts to enhance quality of care and align with Medicare’s Hospital Readmissions Reduction Program (HRRP) for 30-day readmissions.

Many Medicare Advantage (MA) plans have adopted stricter policies, including Aetna’s recent update to deny readmissions across hospitals within the same healthcare system if they share the same Taxpayer Identification Number (TIN).

In an effort to hold MA plans accountable for quality, the Centers for Medicare & Medicaid Services (CMS) has tied 40 distinct quality and performance metrics to the Star Ratings methodology. These metrics influence member selection and determine quality bonus payments. Among the most heavily weighted measures is the Plan All-Cause Readmission (PACR) metric.

A higher rate of hospital readmissions can negatively affect a plan’s Star Rating, potentially jeopardizing its eligibility for quality bonuses, which require a rating of four stars or higher. To put this into perspective, the Kaiser Family Foundation (KFF) estimates that MA quality bonus payments will total at least $11.8 billion in 2024.

Based on this information, I was curious: if an MA payer denies a readmission, does this count towards their quality reporting?  If the encounter does not exist to the payer, or it is bundled by the payer to the index admission, how does this translate to a reportable encounter? 

To answer this question, I turned to the June 24 MedPAC Report to Congress – specifically, in Chapter 3, near the assessment of data sources, detailed findings are provided on the discrepancies in data reporting by MA plans, especially in relation to Healthcare Effectiveness Data and Information Set (HEDIS) measures and hospital readmissions. One significant issue highlighted is the misrepresentation of care quality, which creates a false impression of superior performance by MA plans compared to traditional Medicare.

MedPAC emphasized the incomplete and inaccurate nature of encounter data reported by MA plans. In several instances, encounter data were found to be inconsistent with Medicare Provider Analysis and Review (MedPAR) data, which tracks inpatient stays across the Medicare program. For example, the completeness of MA encounter data improved only slightly from 2020 to 2021, yet substantial variation remained across MA plans.

Some plans met only 80 percent of the data completeness thresholds set by MedPAC, indicating that significant gaps persist​.

The report also reveals that some MA plans underreport hospital readmissions, a key HEDIS measure related to care quality. Traditional Medicare data indicated a readmission rate of 15.3 percent for patients discharged after acute-care episodes, while MA plans reported readmission rates averaging around 12 percent. Further investigation would be needed as to why this is the case; however, data calculation is not unified between Traditional Medicare and MA plans. Analysis of beneficiaries found in both data sources show that the data included 11 percent more hospitalizations and 19 percent more readmissions than what was found in the HEDIS data submissions from MA plans.

When specifically linking concerns to denials, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) raised similar concerns in 2023.

“MA organizations (MAOs) are required to submit encounter data for all items and services provided to their members, including those for which the MA plan denied payment to the provider (e.g., out-of-network care or instances in which the plan acted as a secondary payer,” a 2022 CMS report read. “In contrast, MA bids reflect only the items and services for which the MA plan made payment. The encounter data do not include a reliable way to identify denied claims (Office of Inspector General, 2023).” 

The endnote went on to note that “MA encounter data do not include an indicator for identifying payment denials, and no standardized algorithm exists for identifying such claims.”

MedPAC has called for more stringent data validation measures, including enhanced audit protocols and penalties for plans that fail to meet data reporting standards. The report recommends that CMS require MA plans to align their reporting criteria more closely with those used in Traditional Medicare.

Furthermore, MedPAC suggests increasing the transparency of quality data, and incorporating more robust cross-references between HEDIS measures and real-world patient outcomes​.

Patient Status Versus Patient Class Distinction in Hospital Billing

By Juliet Ugarte Hopkins, MD, ACPA-C

Hospital billing revolves around a universal category known as patient status, with only two options: Inpatient and Outpatient. This distinction isn’t just about payment—it directly ties into quality reporting and metrics, such as hospital readmissions, which only involve patients classified as Inpatient. While some find this approach flawed, it underscores the need for precise status identification.

Observation services sound like a vague term but they are, in fact, well-defined by the Centers for Medicare and Medicaid Services (CMS) as a specific order for care—just like an order for "Morphine 1 mg IV Q4 PRN severe pain."  For billing purposes, Observation services are reimbursed only on Outpatient claims, starting from the time the order is placed, unless stated otherwise in the payor contract with the hospital. This means any services rendered prior to placement of the Observation services order won’t be reimbursed, emphasizing the importance of proper documentation and timely order entry.

In contrast, patient class refers to location and/or service categories within electronic health record systems. Patient classes like "Emergency," "Hospice," or "Extended Recovery" are customizable to each hospital's needs but are unrelated to billing tied to patient status. Here’s where confusion arises: While class may remain constant, status can shift depending on the condition and care provided to the hospitalized patient.

Take the example of "Extended Recovery." This patient class might apply to patients coming to the hospital for a scheduled surgery who are expected to require overnight monitoring during a routine recovery period. Since patient status is Outpatient for an Outpatient surgery, it would be easy to equate "Extended Recovery" with Outpatient.  However, if the patient develops even minor recovery complications, an Observation services order should be placed.  This addition of an Observation services order might not be considered because the patient is already "in Extended Recovery" and indeed, their extended recovery is being monitored.  Similarly, a patient expected to be discharged on the first post-operative day might be placed into Extended Recovery class when in reality, Inpatient status is appropriate due to the Medicare Inpatient-Only list or payor prior-authorization.  In those instances, it does not matter if the patient will only be hospitalized for a single overnight.  But, if the mentality of hospital staff includes Extended Recovery = patient only staying overnight = Outpatient, then you will miss billing an Inpatient claim.  

Failing to recognize these nuances can result in incorrect claims, missed reimbursements, and potential compliance issues. Hospitals must ensure staff understands these distinctions between patient class and patient status to align billing with actual patient care and regulatory requirements, avoiding costly errors in the process.

Clear communication and vigilance are essential in navigating these complexities for optimal patient care and financial outcomes.

CMS: Plans for New OB Services Conditions of Participation (CoP)

By Tiffany Ferguson, LMSW, CMAC, ACM

The Centers for Medicare & Medicaid Services (CMS) released in its 2025 Outpatient Prospective Payment System (OPPS) Final Rule a new Conditions of Participation (CoPs) for hospitals and Critical Access Hospitals (CAHs) offering obstetrical (OB) services.

This initiative is part of the CMS strategy to improve maternal health outcomes, particularly considering the United States’ ongoing maternal health crisis, which has resulted in some of the highest maternal mortality rates among high-income countries worldwide, disproportionately affecting communities of color.

The proposed CoP generally defines some of the coming provisions that will be expected in the coming document, so hospitals can start preparing.

Organization and Staffing: CMS has finalized requirements ensuring that OB services are well-structured, adhering to nationally recognized standards. The OB care department/unit must integrate with other departments in the facility, and OB patient care units must be supervised by qualified personnel, such as experienced registered nurses, certified midwives, nurse practitioners, or physicians. The granting of OB care privileges must follow written criteria, ensuring that only appropriately credentialed practitioners provide OB services.

Delivery of Services: To ensure the effective and timely treatment of obstetrical cases, CMS requires that facilities maintain essential OB equipment, such as fetal monitors and cardiac equipment. The level of equipment should reflect the facility’s volume and complexity of OB services. CMS recognizes that low-volume facilities may need fewer resources, compared to high-volume ones, allowing for flexibility while maintaining minimum standards. The requirements also include having protocols consistent with evidence-based guidelines for OB emergencies, ensuring comprehensive preparedness.

Staff Training: CMS mandates that hospitals and CAHs develop training policies tailored to the scope of services offered. This training must be evidence-based and informed by the facility’s Quality Assessment and Performance Improvement (QAPI) programs. New staff must receive initial training, and relevant existing staff must complete training every two years. This approach aims to maintain a high level of competence in maternal care delivery across all staff.

Quality Assessment and Performance Improvement (QAPI) Program: CMS is requiring hospitals and CAHs to use their QAPI programs to address health disparities among OB patients. Facilities must analyze data and quality indicators across different subpopulations; measure and track patient outcomes; and prioritize initiatives to reduce disparities. At least one performance improvement project focusing on OB patient outcomes is required annually. Additionally, facilities must incorporate information from Maternal Mortality Review Committees (MMRCs) where available, integrating public data to enhance their QAPI programs.

Enhancements in Emergency Services Readiness: CMS has revised emergency readiness standards, requiring hospitals and CAHs to have provisions aligned with nationally recognized guidelines for treating emergency patients, including pregnant and postpartum women. This includes maintaining essential emergency supplies, such as drugs and equipment necessary for lifesaving procedures. Staff training on these protocols is mandatory, with annual documentation of successful completion.

Discharge Planning Requirements: CMS is recommending adding Transfer Protocols to § 482.43. However, they will be including mandates that hospitals establish comprehensive written policies covering intra-hospital transfers and transfers between facilities. This would be inclusive of hospital inpatients (for example, transfers from the emergency department to inpatient admission, transfers between inpatient units in the same hospital, or transfers between inpatient units at different hospitals). Annual training on these protocols will be included in the emergency readiness standards, as it appears that final determination on this requirement is not yet solidified.  

To accommodate feedback and address concerns about the potential burden of these new requirements, CMS is implementing the CoPs in three phases over two years:

• Phase 1 (Six months post-rule effective date): Emergency readiness and transfer protocols.

• Phase 2 (One-year post-rule effective date): Organization, staffing, and delivery of OB services.

• Phase 3 (Two years post-rule effective date): OB staff training and full implementation of QAPI programs for OB services.

These new CoPs reflect the CMS commitment to addressing the maternal health crisis through enhanced quality and safety standards for OB services. By implementing these standards, CMS aims to reduce maternal mortality, improve health equity, and ensure consistent, high-quality care for pregnant, birthing, and postpartum patients across the United States.

Now is the time for hospitals with OB services to start preparing for these standards to ensure they are meeting all the CMS requirements as they are released.

New Appeals Process for Reclassified Medicare Beneficiaries

By Tiffany Ferguson, LMSW, CMAC, ACM

On Oct. 11, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (CMS 4204-F) establishing a new appeals process for Medicare beneficiaries who are initially admitted to a hospital as inpatients, but later reclassified as outpatients receiving observation services.

This rule is the result of the Alexander v. Azar class-action lawsuit, which sought to establish appeal rights for such patients.

While the court initially ruled against automatic appeal rights, it mandated the creation of additional appeals processes for affected beneficiaries. This new rule will have a significant impact on protecting a subset of beneficiaries from coverage denials due to hospital reclassifications.

The Alexander v. Azar case was filed in 2011 to address Medicare’s lack of appeals rights for patients whose hospital status changed from inpatient to outpatient under observation services. Reclassifying patients can lead to the denial of Medicare Part A coverage for hospital stays and skilled nursing facility (SNF) care, leaving patients with unexpected costs. As stated in numerous broadcasts and articles, Medicare does strive to protect their beneficiaries, which is why this ruling is so timely. Fast-forward to March 2020, the District Court of Connecticut ruled that beneficiaries were not entitled to automatic appeal rights, but directed the Secretary of the U.S. Department of Health and Human Services (HHS) to establish appeals processes for a specific class of beneficiaries.

Eligible beneficiaries for this appeals process include Medicare beneficiaries who, on or after Jan. 1, 2009:

• Have been or will have been formally admitted as a hospital inpatient;

• Have been or will have been subsequently reclassified by the hospital as an outpatient receiving observation services; and

• Have received or will have received an initial determination or Medicare Outpatient Observation Notice (MOON) indicating that the observation services are not covered under Medicare Part A.

• Also, eligible beneficiaries either:

  1. Were not enrolled in Part B at the time of their hospitalization; or

  2. Stayed at the hospital for three or more consecutive days, but were designated as inpatients for fewer than three days, unless more than 30 days have passed without admission to a skilled nursing facility (SNF) following the hospital stay.

Beneficiaries who pursued an administrative appeal and received a final decision before Sept. 4, 2011, are excluded from the class. The court determined that this group of beneficiaries was deprived of due process, and ordered the creation of a new appeals framework for them.

New Appeals Processes

1. Expedited Appeals Process: Beneficiaries who wish to appeal while still in the hospital can now file an expedited appeal with a Beneficiary & Family Centered Care-Quality Improvement Organization (BFCC-QIO). The BFCC-QIO will review the patient’s medical records within one day to determine if the inpatient admission met Medicare Part A coverage criteria. This is particularly important for class members who stayed in the hospital for three or more consecutive days, but were classified as inpatients for fewer than three days, potentially affecting their eligibility for SNF coverage.

2. Standard Appeals Process: For beneficiaries who do not appeal while still in the hospital, a standard appeals process is available. This allows those applicable beneficiaries to challenge reclassification after discharge, following the processing of the hospital’s Part B outpatient claim. The process is similar to the expedited version, but offers extended timeframes for filing and decision-making by the QIO.

3. Retrospective Appeals Process: CMS also introduced a retrospective process for beneficiaries with hospital admissions as far back as Jan. 1, 2009, where status changes occurred before the new appeals processes were in place. Beneficiaries must show that their inpatient admission met the criteria for Medicare Part A coverage. An eligibility contractor will determine if they qualify for an appeal. Once eligibility is established, the appeals will follow Medicare’s existing five-level claim appeals procedures.

Applicable beneficiaries who prevail in their appeal can have their reclassification as outpatients disregarded for determining Part A benefits, including hospital and SNF coverage. The court also mandated that beneficiaries must be provided effective notice of their appeal rights, ensuring they are aware of the protections available to them under the new rule.

Although the guidelines and official notice(s) have not been released yet, CMS has stated that they are intending for them to be available in early 2025. CMS has also confirmed that future guidance will be released on CMS.gov and Medicare.gov. 

Coding Info: Risk Adjustment and Congenital Conditions

By Erica Remer, MD, FACEP, CCDS, ACPA-C

A listener, who is a risk adjustment program manager, asked me to elucidate when a congenital condition code is appropriate. She was most interested in the cardiac conditions in the context of pediatric patients, but I thought it would be useful to go over all the aspects.

Congenital means a patient is born with an anomaly, or abnormality. It can be a physical deformity or a genetic or chromosomal abnormality. This is in contradistinction to an acquired condition which means the patient was born intact, but something happened, either accidentally or intentionally, and there is now an abnormal condition.

A good example is Q71.21, Congenital absence of both forearm and hand, right upper limb, versus Z89.211, Acquired absence of right upper limb below elbow. The latter could be from a farming accident, for instance, or by surgical amputation for a malignancy. Additional codes might provide those etiologic details.

According to the Coding and Reporting Guidelines, similar to codes from Chapter 16, Certain Conditions Originating in the Perinatal Period (the P codes), codes from Chapter 17, Congenital malformations, deformations, and chromosomal abnormalities (Q codes), are permitted to be used throughout the life of the patient.

In the current state of technology, a patient who has Trisomy 21 will always have Trisomy 21 coded. I say, “in the current state,” because there are new gene therapies that can effectively cure a genetic disease, like cystic fibrosis or sickle cell disease, and it is not out of the realm of possibility that other genetic or even chromosomal abnormalities may be conquered in the future.

Let’s address the conditions which interested Mary, congenital heart disorders. A musculoskeletal abnormality like the one noted above may be permanent and ongoing, so it is understandable that the code applies for the patient’s entire life.  There are conditions which might be amenable to surgery, might require multiple surgeries, but even with those interventions, the condition may not be completely eliminated. For instance, hypoplastic heart syndrome (e.g., Q22.6, Hypoplastic right heart syndrome) may require multiple surgeries, and it may be alleviated, but the heart may never be rendered normal. That patient would continue to have Q22.6 for the duration of their life.

There are congenital heart defects which are diagnosed very early on, like ventricular septal defect (VSD) or patent ductus arteriosus (PDA), which may resolve spontaneously and completely without any treatment (I call that, “tincture of time”). Once the condition has resolved, the code to represent that will be found in Z87.7-, Personal history of (corrected) congenital malformations.

The parenthetical, “corrected,” is where the nuance of diagnosis and coding falls. If the VSD is large and doesn’t close on its own, surgery might be necessary to accomplish the closure. If it is successful, and the VSD no longer exists and is no longer clinically relevant, then it is “corrected.” Z87.74, Personal history of (corrected) congenital malformations of heart and circulatory system, would apply.

If, however, a congenital condition has been addressed but not “corrected,” it should still be coded as being present. Providers don’t understand the concept of “history of” as it is defined in coding. “History of” means old, resolved, no longer active, not being treated, and no longer impacting the patient, but may have the potential for recurrence or may influence the provision of future care. Maybe having that congenital issue and the surgery to correct it might portend problems in the future, like a higher likelihood of development of heart failure. That is why knowing the patient had a personal history of the condition and its repair is clinically significant, and a Z code is appropriate.

When should a coder pick up the condition? When the provider (hopefully accurately) documents that the condition is still present. If they document “history of” and it isn’t clear to the coder whether it is “chronic condition of” or “resolved historical condition of,” a query is indicated. I strongly recommend ensuring that the provider understands the “history of” concept before they respond to a query.

For risk adjustment purposes, any year when the condition still is present, the diagnosis should be documented and the code picked up. The year following successful and complete repair, the provider should document that the condition was “corrected,” and the Z code would then be applicable.

So, for instance, if a patient undergoes a successful reconstruction in February, for that entire year for risk adjustment purposes, the Q code would continue to be valid although after the recovery period is complete, the Z code demonstrating “history of” would then be appropriate for that given encounter. The following January, there would no longer be risk adjustment as only the Z code would be captured in that calendar year.

Don’t continue to pick up Q codes just because they have risk adjustment implications. You may get a financial boost at the time, but the compliance jeopardy is just not worth the risk.

Updates on Observation Services & Orders: United Health

By Tiffany Ferguson, LMSW, CMAC, ACM

UnitedHealthcare (UHC) updated their hospital guidelines for observation services. This seemingly small update made Sept. 22, 2024, has led to notable behavioral changes regarding peer-to-peer conversations, claim denials, and rebills.

Previously, when hospitals received inpatient care denials, UHC permitted them to “rebill” the claim with observation services, according to their denial letters. However, it now appears that UHC is applying a similar approach to Humana, requiring an official order for observation services to be in place prior to patient discharge.

This shift indicates that the updated guidelines may reinforce the operational framework outlined in the December 2023 policy, which emphasizes the necessity of having an official physician order for observation services before discharging a patient. The policy clearly states that an observation status (UHC’s wording; this writer is well-aware that observation is not a status) must be established and documented with an order to avoid reimbursement denials.

A physician or qualified healthcare provider must place this order before discharge to ensure that services are appropriately billed. The absence of this order can lead to rejected claims and a lack of reimbursement for the hospital.

While the policy is explicit about the compliance requirements for observation, including not extending beyond 48 hours, it falls short in addressing situations in which a physician believes that a patient requires inpatient admission; UHC denies this authorization for their members.

According to UHC’s provider manual for coverage determination, the organization utilizes tools such as “UnitedHealthcare medical policies and third-party resources (like InterQual® criteria) to administer health benefits and determine coverage.” Notably, InterQual is owned by UHC, which raises questions about the independence of the criteria.

For patients whose inpatient status is denied by UHC, the hospital’s ability to adjust the claim hinges entirely on whether an observation order was placed before the patient left the facility – because the policy lacks clarity regarding the turnaround time for the reconsideration process if a denial is received. Typically, this occurs during the peer-to-peer process, which is scheduled “at a timeline provided by the UHC nurse on the call.”(2024, UHC Provider Manual).

Unfortunately, this could take place after a patient has already been discharged, making it impossible for the hospital to change the status determination prior to the patient’s departure if the peer-to-peer review upholds the denial. This practice and strict policy run the risk of hospitals defaulting to a conservative stance to place observation orders when there is any uncertainty about the patient’s status, because of the anticipation of a potential UHC denial.

However, without an observation order in place before the patient discharge, when clinically appropriate, hospitals face significant challenges in obtaining reimbursement. In such cases, the claim may be denied entirely, leaving the hospital to absorb the financial burden.

It is the continued practices of payers that are requiring hospital utilization review teams and physician advisors to up their games and work with providers to balance the clinical needs of patients with the behind-the-scenes requirements of insurers like UHC, ensuring that an observation order is placed, when necessary, and that it is well-documented and correctly coded.

The practice of utilization review is continuing to evolve, and requires a team of experts that are highly skilled and proactively efficient in regulatory guidelines and payor requirements to appropriately ensure the medical necessity and reimbursement for hospital services.

This is particularly true when payers such as UHC continue to evolve their policies and practices, making it harder for providers to achieve appropriate reimbursement for services.

Evaluating the Acute Hospital Care at Home (AHCAH) Initiative

By Tiffany Ferguson, LMSW, CMAC, ACM

The Centers for Medicare & Medicaid Services (CMS) has released a report on the Acute Hospital Care at Home (AHCAH) initiative, a program allowing select Medicare-certified hospitals to provide inpatient-level care within patients’ homes.

Originally launched to address hospital capacity challenges during the COVID-19 pandemic, the initiative has continued under the Consolidated Appropriations Act of 2023 (CAA), which extended the program’s flexibilities until Dec. 31, 2024. The recent report fulfills a mandate from the CAA to evaluate AHCAH and analyze its impact across multiple areas, including patient demographics, quality of care, and cost-effectiveness.

The study found that participating hospitals used a range of criteria to identify eligible AHCAH patients. These criteria, based on established hospital-at-home literature, ensure that selected patients are clinically appropriate for home care, and that their home environments are safe and conducive to receiving such care.

The report also highlighted demographic differences between AHCAH patients and traditional inpatients, showing that AHCAH patients were more likely to be white, live in urban areas, and have higher incomes, with fewer receiving Medicaid or low-income subsidies.

The report found that AHCAH primarily treated patients with a relatively small set of conditions, including respiratory and circulatory conditions, renal conditions, and infectious diseases. By grouping these conditions under MS-DRGs, CMS was able to compare treatment outcomes in AHCAH versus traditional inpatient settings. The findings provided insight into the types of cases that were most suitable for home-based acute care, suggesting that AHCAH may be particularly effective for certain known manageable conditions.

The CMS report also examined the quality of care provided under the AHCAH initiative. It assessed metrics like 30-day mortality rates, 30-day readmission rates, and the occurrence of hospital-acquired conditions (HACs). The findings indicate that AHCAH patients generally had lower mortality rates than their hospital-based counterparts.

Readmission rates, however, varied by condition, with AHCAH patients showing significantly higher rates for some conditions and lower rates for others; however, these specific conditions were not mentioned in the publicly released fact sheet. HAC rates were lower for AHCAH patients, although differences were not statistically significant.

When evaluating cost and utilization, the report focused on factors like length of stay, Medicare spending after discharge, and hospital service use, including telehealth services. AHCAH patients typically had longer lengths of stay, but incurred lower Medicare spending, in the 30 days following discharge. While these findings suggest cost benefits, the complex nature of AHCAH’s patient selection and clinical conditions makes it difficult to draw definitive conclusions about overall savings compared to inpatient hospital settings, according to CMS.

CMS hosted virtual listening sessions to gather feedback from patients and caregivers involved in AHCAH. The responses were generally positive, with patients appreciating the convenience and personal nature of home-based care. Clinicians, too, reported favorable experiences, which aligned with broader hospital-at-home research indicating high satisfaction rates among patients receiving care at home.

The report concluded with a need for further research and development, including refining cost, quality, and utilization metrics.

With the AHCAH initiative set to expire at the end of 2024, its continuation depends on future congressional action.

Having a Patient Advocate is Critical to Optimize Patient Care

By Erica Remer, MD, FACEP, CCDS, ACPA-C

I have been dealing with family issues since the end of September. My father-in-law (FIL) fell ill, and I have had to help out. Many of you also know my father is in a memory care unit, and I visit him daily and manage his affairs. I constantly wonder what people do if they don’t have a me. Today I am going to talk about how to be a healthcare advocate for another individual (I will refer to this as “your person.”).

The first thing you should do is get a notebook to keep ongoing records. Taking meticulous notes is critical. I suggest you start right now, before an acute incident occurs or as soon as you are recruited to be a medical advocate. Having an accurate medical history (past medical history, history of present illness) is very helpful for the healthcare provider (HCP). If something happens which leads to a medical encounter, document the sequence of events as you understand them. You will need to repeat them over and over again.

Your person needs to give HIPAA permission for you to be privy to their protected health information. If they are conscious and competent, they can do it verbally. The HCP should ask something like, “Is it ok if we discuss your condition in front of your daughter?” If the patient agrees, that is considered consent.

You might consider having a formal HIPAA release form signed so the healthcare providers know you are entitled to be engaged in healthcare discussions. A sample is found here: https://www.hipaajournal.com/hipaa-release-form/. My interpretation is that Section I should have “anyone”, and Section IV should have your name and information. Again, do this proactively – once your person is unconscious, it is too late. Have a printed physical copy and a digital copy in a cloud somewhere.

Arrange to have electronic access to their portal if you can. It is great to be able to access a medication list, notes from prior visits, names of physicians, etc. on the fly.

Being an advocate, you will be exposed to information about your person that they might want kept confidential. You should consider it your duty to keep anything you hear or witness private unless your person allows you to share it (e.g., you are the family contact person).

What if your person makes plans set out in a living will? That’s great; they are expressing their wishes, but living wills are legal documents specifying decisions if a person becomes terminally ill or permanently unconscious. It is also useful to have a durable power of attorney for health care (DPOAHC). This document names surrogates who are given permission to make all medical decisions for the individual in the case that they deemed not competent to make their own decisions, but the patient doesn’t necessarily need to be terminally ill or in a vegetative state. The healthcare proxy is supposed to make decisions according to their understanding of what the patient would want. The living will often helps guide their decisions. These documents should be crafted long before they are needed. If you wait too long, it may be too late. If you are the DPOAHC, you have the legal authority to make medical decisions for the patient if the patient is not capable of making their own decisions, as opposed to just sitting in and giving advice as an advocate.

As an advocate, you may consider requesting permission to record discussions with doctors. 50-80% of medical information provided by HCPs is forgotten immediately after the interaction. Explain you have a concern that you will not understand all of the jargon or not be able to remember the details. Many states permit you to record even without the other party’s consent, but not all; in any case, providers would appreciate the heads up. Cell phones are ubiquitous; if legally permissible, you can use ‘voice memos’ or some other function that can record audio.

When you take notes in your notebook, try to make them as legible as possible. My sister-in-law and I were tag-team advocating for my FIL, so the notebook was communal as we switched off. If there are details that you want to be able to recall from home without access to the notebook, take a picture on your phone or take notes from the notes.

What should be in the notes? Write down the date and time of the interaction, the HCP’s name and specialty, and what they say. They often use doctor-speak and if you are not clinical, it can be confounding. DO NOT HESITATE TO ASK FOR CLARIFICATION! Do not feel stupid or silly or like you are bothering them. The point is for you and the patient to understand what is going on and to be able to make informed decisions about their care. Read back what you understood the provider to have said and what you documented, to ensure accuracy. If you can’t spell something, ask the clinician to spell it for you. Most likely, you will want to confer with Dr. Google later.

You should try to take yourself out of the equation and ensure that it is all about the patient. Start sentences off with “The patient needs to know…” to keep it patient-centric.

Don’t reserve note-taking for the doctors or nurse practitioners. Take notes when you speak to the case managers or the physical therapist or the nurses. If your person is left in bed calling for a nurse for 35 minutes, that is important information. Is it a once-off or a pattern of neglect? Is it a single individual or the entire staff? If there is an adverse interaction, try to take direct quotes as opposed to paraphrasing.

Don’t divide your attention. When the HCP is in the room, don’t look at your phone to review texts or scroll through social media. Don’t be chatting with someone else. You will have a limited amount of time with any given practitioner; don’t squander it.

Speaking of which, many providers have a routine as to when they round. If you can, find out what it is and try to be present when they do. If you can’t be there then or their rounding is unpredictable and you missed their visit, ask the nurse to page them and request them come at their convenience to talk to you and the patient again.

I think one of the most important roles an advocate has is to educate the HCP as to the patient’s baseline. As an emergency physician, I saw patients at their most vulnerable and worst times. It was crucial for someone to let me know that this patient with metabolic encephalopathy from overwhelming sepsis was driving and calculating his taxes two days before presentation. It helps inform expectations for recovery.

If you have a question, ASK IT! You don’t want to have that little detail be the reason something untoward happens when it is not addressed, like you noticed your person’s speech was garbled for 5 minutes after they got back to the bed from the bathroom but no one else witnessed it, or “Why hasn’t he gone to the bathroom for the last 10 hours while I’ve been here? I’ve had to go twice.” (The answer was he had urinary retention and there was 1400 cc of urine in his massively distended bladder) “Why is my father’s pacemaker pocket red?” led to the discovery of a pacemaker infection. If I had assumed they had noticed it and not asked…

Be tuned in to your person. If they get a quizzical look on their face, ask the provider to repeat whatever just confused them. If they are hard of hearing and you are familiar with the behavior of them saying they heard you when they didn’t, ask the provider to speak louder and more slowly (I also taught a nurse the trick of the poor-man’s hearing aids. You flip a stethoscope around, put the earpieces into the patient’s ears, and speak into the diaphragm). If there is a language barrier, it is not your responsibility to translate. The patient has a right to translation services. Exercise that. It is your job to advocate for your person, not to translate for the staff.

There are certain basic issues which need to be addressed. Make sure you bring the hearing aid charger and remind the nursing staff to charge hearing aids overnight. It is exasperating for your person to not be able to hear because their hearing aids are dead. It is a reasonable expectation that dentures will be removed and cleansed overnight. Bring a long charging cord for your person’s phone so they can have it charging and can reach it whether they are in the bed or the chair. Bring wipes to clean glasses, a glasses case for night-time, and encourage the nursing staff to make sure their glasses are on their face in the morning. Make sure everything is labeled. If you don’t have access to a label maker or Sharpie, you could ask the nurse for a hospital sticker and use that.

My FIL was becoming psychotic because his day-night cycles were all confused. His room had a window into a central enclosed atrium so there were no light cues as to time of day. There was a remote-controlled electronic window shade for privacy which made it look like nighttime, which was often left in the down position. I purchased him a digital clock “for dementia patients” (although he doesn’t have dementia) which has a visual cue as to time of day (morning, afternoon, night).

One of the most important things an advocate can do is ensure that basic hygiene needs are attended to. Patients need to brush their teeth and shave. The advocate doesn’t need to perform these tasks, but they can ensure that the nursing staff does. Make sure the electric razor is charged, and the charger and razor are labeled. I kept chargers (e.g., razor, phone) corralled in a canvas bag.

As an aside, take care of yourself, too. Bring a water bottle, your cell phone charger, and snacks. Bring a sweater or jacket because it may be chilly or hot in the patient’s room. Bring a book or work because there is likely to be down-time while your person dozes.

It is critical that the patient mobilizes as soon as it is safe, and they are able. The difference between being discharged to home or going to a rehab facility can be getting up and moving around. It is easier for aides to use devices to get the patient to the bathroom or only having them transfer 3 steps to a chair. It takes more time to walk the patient to the bathroom or out into the hallway, and all facilities are understaffed. You might think that physical therapy will effectuate this, but often their role is to assess the patient’s function for discharge planning purposes. They may only see the patient once or twice in a stay. If you are capable and it is safe to do so, get your person up and around as soon as possible.

Most of the points I am making were my observations and thoughts from my own experience. However, I did some research and was reminded that it is a great practice to ask anyone preparing to touch your person to wash their hands (Tips for the Advocate When Talking to the Doctor (or another clinician). Regarding their checklist, I personally wouldn’t ask my person if I should ask the question; I would phrase it as, “Is it ok with you if I ask clinicians to wash their hands before they touch you, because there are many unnecessary deaths from hospital-acquired infections every year?”

If you have a healthcare provider in your life, e.g., your brother is a paramedic, your aunt is a doctor, your friend is a nurse, now is the time to ask them to help you make sense of what is going on. They may be able to give you insight or advice. They may lead you to a website or society which can be helpful. I also recommend making sure that your person’s primary care physician or other caregiver is aware of the situation. They may have information useful to the current HCP.

The last thing I would like to address is examples of questions you might be thinking about and asking:

• Do we know why this is happening now?

• The last time this happened, they had to do [X procedure] or they gave her [X medication]. Do they need it again?

• Could this be medication related? Could this be related to the new medication that was started last week?

• What did the tests show? What do those results mean? Can the patient have a copy of those reports/tests?

• Do we need a [specialty] consultant to see him here in the hospital?

• You said you were going to start him on [medication X] yesterday? Did he get his first dose of it? How long before we should see effects?

• Could we try removing the Foley catheter and see if he can void spontaneously prior to transfer to rehab?

• What exactly is the diagnosis? What is the prognosis?

• When do you think she will be discharged? I know PT recommended a skilled nursing facility, but could it be accomplished safely at home with home health care?

It would be optimal for everyone to have an advocate as they try to navigate the morass which is our healthcare system. I hope this article will give you some tips on how to be an advocate for your person. I wish you all the best of luck.

References:

Patient Advocate Checklist

Step 5: Use and Advocate, Be an Advocate for Others

Joint Commission: Use and Advocate or Be an Advocate for Others

Discharge Summaries Make a Difference

By Erica Remer, MD, FACEP, CCDS, ACPA-C

My husband was speaking in Maui at the beginning of March 2020, and I came down with COVID-19 on the airplane. After a serendipitous dinner with his brother, who lives in Dallas, I was quite ill, and my infection limited our activities. The weather was delightfully tropical. On our last day in Maui, we went whale watching, which was spectacular. We saw a collection of approximately 15 whales, which swam under our boat. Erick got miserably seasick, which threatened our flight to Oahu. There, we had a somber visit to Pearl Harbor, punctuated with about 10 glorious rainbows. Our penultimate day, we did an island tour.

You just read a summary of my vacation. I condensed the entire encounter of 10 days into eight sentences. Did you get enough information about the trip?

It depends what you are going to use the information for. If you are just being caught up on my travels, sure. Are you going to try to replicate our itinerary and activities? Then, no. If I had journaled our adventures, there would have been more specifics I could have shared with you, if you were so inclined to read them. Where we went, how much it cost, what we saw. However, if your trip was scheduled two weeks after mine, but you didn’t receive my trip summary until a month later, it wouldn’t be at all helpful.

Why do providers generate a discharge summary? The short answer: because they have to. It might be even more important to determine what the provider perceives a discharge summary is for. If they think it is busy work, and just fulfilling the directive of some administrative body, then the quality might suffer. If they believe it is valuable communication of the patient encounter for the follow-up physician and anyone else who might be reading it, then it is more likely to be detailed and illuminating.

Discharge summaries have elements mandated by the Joint Commission:

1. Reason for hospitalization (patient presented complaining of fevers, rigors, and cough);

2. Significant findings (physical exam demonstrated hypoxemia and confusion. CXR demonstrated a large RML pneumonia and blood cultures grew out Streptococcal pneumoniae. Diagnosis: Sepsis due to S. pneumoniae pneumonia with hypoxemia and metabolic encephalopathy);

3. Procedures and treatment provided (supplemental oxygen, intravenous fluids, and ceftriaxone administered. Sepsis protocol followed and infectious disease consult obtained. Sepsis resolved on Day 2.);

4. Discharge condition (discharged in improved and good condition);

5. Patient and family instructions (finish course of antibiotics, follow up with PCP next week, and return to ED for shortness of breath or concerning symptoms); and

6. Attending physician’s signature.

It strikes me that the mandated elements are sparse. If I had determined the required elements, I would have explicitly included the hospital course, outstanding issues of which the follow-up professional needs to be aware, and a list of final discharge diagnoses.

The Transitions of Care Consensus Conference (TOCCC) attempted to develop standards for transitions of care from the inpatient to outpatient setting. They also recommended the following elements, which would be included in the “ideal transition record,” and isn’t that what a discharge summary should be?

• Patient’s cognitive status;

• Emergency plan, person and contact number;

• Treatment and diagnostic plan, including a current, reconciled medication list;

• Prognosis and goals of care;

• Advance directives, power of attorney, consent;

• Planned interventions, durable medical equipment, wound care, etc.;

• Assessment of caregiver status; and

• Inclusion of the patient and caregivers in the development of the transition record to take into consideration the patient’s health literacy, insurance status, and cultural sensitivity.

Some of these seem more appropriate for the transition to another institution (e.g., skilled nursing or assisted living facility) than to home, but the essence is: provide the information that will be useful for the receiving clinician and/or institution.

The literature focuses on the need for aftercare providers to receive information, and on medicolegal considerations. It fails to mention that coders and billers also rely on accurate, complete, and timely discharge summaries. On the inpatient technical side, diagnoses are eligible for coding if they are present at the time of discharge or demise, and the discharge summary represents the prime and final opportunity to record diagnoses destined to be coded. My philosophy is that a correct and complete set of discharge diagnoses can be used to reconstruct the entire patient encounter. This ensures that the patient lands in the appropriate Diagnosis-Related Group (DRG) and the correct tier, for reimbursement.

Many institutions have templates for necessary components of a discharge summary. To design the ideal document, involve the appropriate parties. This should, at very least, include the people who will be generating the document and a representative of the folks who will be relying on the document, post-discharge. Compliance should ensure that the mandated elements are included. Information technology needs to be present to determine how to operationalize the endeavor.

If it were possible to start generating upon admission a discharge summary that could be finalized, dated, and inserted in the appropriate location in the medical record upon discharge, I would support that. It could be leisurely composed in a stepwise and thoughtful fashion.

At admission, the chief complaint and a brief history of present illness could be introduced. As the patient encounter progressed, the hospital course could be recorded in real-time. Each day, a sentence or two could be added, with revisions of the previous days’ entries for accuracy and clarity.

(e.g.,
Day 1: Awaiting ID consult.

Day 2: ID consult considering necrotizing fasciitis. Ordered CT scan.

Day 3: ID consult ruled out necrotizing fasciitis when CT scan did not reveal gas in soft tissue.).

A running summary could serve dual purposes; in addition to ultimately being inserted as the synopsis for the discharge summary, it could also inform caregivers during the encounter. If a patient crumps, the provider doesn’t have the time or inclination to read the entire chart – they just want the down and dirty, which will help them care for the patient right now. A concise running summary would be just the ticket.

When I was a physician advisor, we implemented an electronic summary. It drew in elements from multiple already established electronic sources to try to minimize duplicative effort. It pulled in the current medications from the MAR (medication administration record), and the provider could notate which ones were indicated for homegoing. It imported recommendations for physical and occupational therapy.

If labs or other tests were pending or scheduled, it recorded them. It was (and probably still is) very useful and timesaving. My contribution was to create a radio button that the provider had to click, which indicated whether the patient had expired. If so, it prevented the discharge (now, death) summary from including homegoing medication and instructions and follow-up appointments, now unnecessary and misleading.

Having the ability to construct a discharge summary rapidly from different sources can result in disjointed information if no one ensures that it is edited, revised, and accurate. It can, however, also result in a discharge summary being promptly available for review. Maybe it will be an opportunity for artificial intelligence (AI), to ensure that the narrative reads fluently.

Consider surveying your end-users (e.g., PCPs, nursing home providers) as to whether the data delivered to them was complete, succinct, timely, and usable. You could share their responses with your practitioners, and that might encourage the clinicians to craft excellent and useful discharge summaries.

A final tool in your armamentarium could be targeted feedback. Design an audit tool for discharge summaries and task those individuals who read the summaries to use the tool to assess the quality of the documents. There should be a section on the audit tool for comments and suggestions. Compile statistics and share the information and examples with the summaries’ authors.

Remind the providers that someone is reading these documents, they care what the discharge summary says, and it makes a difference in the patient’s longitudinal care.

Building the Bridge Between UR and CDI

By Tiffany Ferguson, LMSW, CMAC, ACM

Dr. Erica Remer and I had the pleasure of co-presenting at the Healthcare Financial Management Association (HFMA) Region 6 Conference in September in Columbus, Ohio. Our topic was the intersection of utilization review (UR) and clinical documentation improvement (CDI), examining the current state of these disciplines and offering predictions about their future directions.

Our presentation aimed to provide clinical relevance to a healthcare financial and revenue cycle audience.

In previous articles, I have explored why these two disciplines have historically been separate. Key reasons include differences in technology and the distinct roles UR and CDI play; UR traditionally aligns with case management, and CDI with coding. However, the landscape is evolving. Technology firms such as Iodine are making significant strides in bridging UR and CDI, enhancing transparency and efficiency in collaborative learning.

Other technology platforms are also recognizing the importance of uniting these two areas to form a cohesive clinical revenue cycle.

While the partnership between case management and utilization review remains essential, the increasing focus on the social determinants of health (SDoH) and transitional care across the care continuum is continuing to shift case management’s role. It is becoming more integrated with population health, creating new opportunities for collaboration with outpatient services.

To foster greater collaboration between UR and CDI, and to improve efficiency, I recommend the following steps for consideration today:

1. Incorporate Collective Learning: Include both UR and CDI teams in shared educational sessions. For example, webinars aimed at CDI should also include UR staff, and vice versa.

2. Build Unified Dashboards: Develop dashboards that provide a comprehensive view of both UR and CDI activities. For example, patient status conversions affect CDI review times, and short-stay conversions to inpatient status influence CDI’s capture rate of chronic conditions (and ultimately impact case mix index) – putting both groups at risk for denials, either for medical necessity or DRG downgrades.

3. Expand Outpatient CDI: Consider having your CDI specialists review observation cases to identify opportunities for capturing Hierarchical Condition Categories (HCCs) or even help with queries to support improved documentation, which may create greater defensibility for inpatient conversion.

4. Align Physician Communication: Ensure that documentation improvement efforts convey unified messages from both UR and CDI. This can reduce confusion and reinforce the importance of thorough documentation for multiple areas, including quality, level of care, denial management, and coding.

5. Integrate CDI into UR Reviews: Explore how the UR team can incorporate CDI initial reviews into their concurrent review process for payers. Greater transparency to see what the CDI specialists are querying may help the UR team see potential risks in the continued stay.

The convergence of UR and CDI is essential as we move toward a more integrated healthcare model. Technology is playing a pivotal role in bringing these traditionally separate disciplines together, allowing for better communication, efficiency, and financial outcomes. By fostering collaboration through shared learning, data transparency, and unified communication efforts, healthcare organizations can enhance their clinical revenue cycle while delivering high-quality patient care.

The future of UR and CDI lies in breaking down silos and working cohesively to adapt to the rapidly changing demands of healthcare.