Case Managers Can Play Crucial Role in Emergency Department

By Kelly Bilodeau

More than 139 million patients come through the doors of U.S. hospital emergency departments (ED) every year, and many move into inpatient hospital beds. “About 70% of patient hospital admissions go through the ED,” said Marie Stinebuck, MBA, MSN, ACM, COO at Phoenix Medical Management Inc. 

ED case managers can serve as gatekeepers for this high-traffic entry point, ensuring accurate status determinations, preventing unnecessary readmissions, and helping to keep as many inpatient beds open as possible.

The right services for the right patient

Not everyone who arrives at the ED needs to be there or meets the medical criteria required for inpatient admission. Some individuals come in because the patient and/or the family need custodial, not medical support, Stinebuck said. An ED case manager can offer patients more appropriate alternatives. Depending on the patient’s needs, this may include referrals for community services, medical support, or placement resources if home care is not a viable option.

The ED case manager can also intercept potentially avoidable readmissions. Patients discharged from the hospital sometimes reappear in the ED within 30 days for problems that don’t warrant another inpatient admission. “Most electronic medical records have a readmission flag,” Stinebuck said. So, when these patients arrive in the ED, it triggers a notification to the case manager, who can quickly interview and assess the patient. Often, patients come back because of logistical problems that are manageable without a hospital stay—they couldn’t fill a prescription or missed an appointment with the primary care doctor. In other cases, a readmission is unavoidable, but the case manager can decrease or prevent future return visits by creating complex care plans for high-risk patients, including those with substance use disorders or behavioral health challenges, Stinebuck said.

While managing high-risk patient populations is a crucial part of an ED case manager’s role, they must also verify that patients are assigned correctly as inpatients or outpatients with observation services. UR reviews at admission can help ensure the patient receives the right level of care.

Establishing an ED case management program

To begin an ED case management program, assess your existing processes to determine when case management services are most needed, Stinebuck said. Look at the number of ED admits, identify peak hours in the ED, and monitor for high-utilizing patients and inpatient readmissions. Peak ED hours don’t always match 9 a.m. to 5 p.m. schedules. A case management shift could be most beneficial from 10 a.m. to 6:30 p.m., 4:30 p.m. to midnight, or 10 a.m. to 10 p.m. Depending on your community and patient population, you may or may not need an overnight case manager.

“If you want to set up a new program, start during your peak hours, knowing that you're going to get the biggest bang for your buck,” Stinebuck said. Ideally, you should have one case manager for every 30 patients.

In a busy ED that sees 60 to 70 patients at a time, you may need to assign more than one case manager with overlapping shifts to meet demand.

Understanding your patient demographics can also help you determine who is best for this ED case management role, a nurse or a social worker. “If you’re a trauma facility with a high homeless population or drug seekers, social workers have training to deal with this social complexity and psychosocial components and are a better fit in the role than a nurse.” Stinebuck said.

An ED case manager must work closely with ED providers to be effective. “Staff members in the ED really need to have a good understanding of what that case manager does and the support they can offer,” Stinebuck said. Ultimately, a well-structured program can help hospitals manage the large and unpredictable flow of patients entering through one of its busiest departments and help keep hospital beds open for the people who need them the most.

Case Management Corner is your go-to source for insightful discussions on relevant topics in case management. Through an engaging interview-style format, our team members share their expertise, experiences, and best practices to keep you informed and empowered. Whether you're looking for industry updates, practical strategies, or real-world perspectives, we bring you valuable conversations designed to enhance your knowledge and support your professional growth. Stay tuned for expert insights straight from the field! Kelly Bilodeau has been a longtime writer for HCPro’s Case Management Monthly.

Addressing The SDoH in The Emergency Department

By Tiffany Ferguson, LMSW, CMAC, ACM

A recent qualitative study published in the Journal of the American Medical Association (JAMA) explored the implementation of social determinants of health (SDoH) screening in U.S. emergency departments (EDs). The study aimed to identify the main themes that arose with the process of screening, documentation, and addressing SDoH concerns in this setting. 

Researchers conducted in-depth interviews with leaders from 27 EDs across urban, rural, academic, and community settings who reported screening for SDoH. These participants, predominantly female (66.7 percent), held various leadership roles, including chairpersons and medical, nursing, or operation directors. The interviews, conducted between April and September 2023, were conducted with the goal of gathering insights into current practices and challenges related to adverse SDoH screening responses and subsequent referral processes.

Not surprisingly, the study found significant variability in how EDs screen for and document SDoH factors. This inconsistency reflects the absence of standardized protocols, leading to diverse approaches in identifying and recording patients’ social needs. The article noted that some ED leaders expressed doubts about the effectiveness of screening – and referring patients to services within the ED environment. The most significant concern was centered around the ED’s capacity to address these identified social needs effectively, given its primary focus on acute medical care. The findings go on to identify challenges related to lack of resources, staffing, and time to conduct screenings and facilitate appropriate referrals. These limitations hinder the ED’s ability to address patients’ social needs comprehensively. However, like a notion explored in the survey, the question remains: is the ED the best place to address these needs? Identifying issues and conducting follow-up do not have to happen at the same time if there is nothing urgent. Outside of personal safety, the questions surrounding the SDoH are not recent nuances to care; they are longstanding issues that patients have been facing.

The study did provide some recommendations:

They suggested revisiting the screening tools to align better with the fast-paced ED environment. They suggested involving ED personnel in the design and implementation process to ensure that the tools and workflows are practical and contextually appropriate. Finally, they requested employing additional staff, particularly social workers, to focus on the screening results to help alleviate the burden on medical staffs. Social workers are also skilled in identifying community resources and supporting patients and clinical staff with the moral distress that unmet SDoH needs create in a healthcare environment. Finally, they recommended aligning more with community resources and existing non-ED SDoH initiatives to facilitate effective referrals and patient support needs. 

As we consider the continued requirements for SDoH screening in hospital outpatient departments, such as EDs, it is essential to consider key questions:

1. Does the patient want assistance with their unmet needs? 

2. Is the patient already working with an agency or organization to address their unmet needs?

Given that these questions are being asked across nearly every healthcare setting, many patients may already be engaged with available services to address their SDoH concerns.

This study is commendable for emphasizing that resolving positive SDoH screenings does not necessarily need to occur in the ED, particularly if it does not impact the immediate medical care being provided. A potential approach could involve establishing post-ED outreach, where case managers and/or community health workers follow up with patients who screen positive, providing resources and referrals. If a patient’s needs are more complex, they could then be escalated to a social worker for further support.

Implementing SDoH screening in U.S. EDs presents both challenges and opportunities. While there is variability in current practices and skepticism about the utility of such screenings, targeted strategies such as improving screening tools, involving ED staff in process design, improving staffing models to address needs and requirements, and enhancing community collaborations can improve the effectiveness of these initiatives.

When Is a Hospital Delay Okay?

By Juliet Ugarte Hopkins, MD, ACPA-C

There are few perfect things in this world, and hospital operations are not one of them. While multitudes of individuals – clinical and non-clinical – work diligently to carry out the most efficient and effective processes to provide patient care, often, their efforts fall short.

Many of these shortcomings are related to staffing and the availability of services on weekends and evenings. “Differentials” in pay for these time periods often apply to employees needed to carry out these services across the spectrum, from environmental service technicians to surgical nurses. This can lead to decisions by hospital leadership to cut back on testing, imaging, procedures, and surgeries outside of “banker’s hours.”

These kinds of delays should be a focus of your utilization management team’s assessment of avoidable days. While different from the patient who is medically ready for discharge but still waiting for a skilled nursing facility bed to open up, they are still delays. A patient might medically require a cardiac catheterization before he can be safely cleared to discharge home, but the delay in procedure on a Saturday and Sunday until it can be performed on Monday has nothing to do with the patient’s condition. The delay is due to the hospital’s lack of resources over the weekend. 

These avoidable days should not only be captured by reason – for example, EEG, PICC line placement, upper endoscopy, etc. – but also include the average financial impact. What cost did the hospital incur by caring for that patient an additional two days while waiting for a nuclear stress test? Or, in the case of a patient in outpatient status, how many observation hours were erroneously billed or written off because the hospital doesn’t perform MRIs after 4 p.m.? In order to present a strong case supporting increased availability of services, you must have data showing the impacts to length of stay, bed availability, and cost.

Are there any delays in imaging, testing, or procedure that can be medically justified? Absolutely! Examples include a brittle diabetic who’s quick to develop significant hypoglycemia during bowel prep before a colonoscopy, leading to a slower cleanout with close titration of IV fluids with dextrose – or an anticoagulated patient who requires time off their medication before proceeding with a surgical procedure to avoid excessive bleeding. Both of these instances are medically justified, and as such, should be documented in detail by the clinician to clearly support the medical need of the delay. Without such documentation, there is a risk auditors will assume a capacity or timing delay instead. 

As with other scenarios involving documentation, it’s incredibly easy for a physician to overlook these specifics involving medically necessary delays, because at face value, they seem to be obvious and relatively inconsequential. Case and utilization review nurses should keep an eye out for these potential omissions as they review patient charts and inquire either the attending physician or physician advisor when clarification is required. Similarly, physician advisors should track commonly missed documentation related to specific situations and create standardized education for hospitalist, cardiology, GI, and surgical groups.

Finally, an insidious factor contributing to avoidable days related to service delays involves testing, imaging, and procedures that are not required. While grossly unnecessary services are likely uncommon, if you look closely, you’ll probably find quite a few situations where the services did not have to take place during the hospitalization, and instead could have been scheduled in the outpatient setting following discharge. Convenience for the patient or patient’s caregiver is often a major factor, but poor accessibility and availability of outpatient services is another. These issues should also be investigated when found to be leading to avoidable days, as outpatient solutions could positively impact inpatient lengths of stay.

Warning: Significant Changes at CMS Innovation Center

By Tiffany Ferguson, LMSW, CMAC, ACM

On March 12, The Centers for Medicare & Medicaid Services (CMS) Innovation Center announced significant changes to its model portfolio to better align with its “statutory obligations and strategic goals,” noting that it will “protect taxpayers and enhance the health of Americans by focusing on models that demonstrate cost savings and improved quality of care.”

This initiative involves the early termination of underperforming models, modifications to existing models, and the discontinuation of planned initiatives. CMS reported that these changes will result in taxpayer savings of nearly $750 million; however, the math seems a little unclear.

The CMS Innovation Center was established under the Patient Protection and Affordable Care Act to develop and test innovative payment and service delivery models. These models aim to reduce expenditures within Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), while ensuring high-quality care.

However, after a recent assessment, CMS determined that some models were not delivering sufficient cost savings or quality improvements. As a result, the agency has decided to conclude certain models by the end of 2025 and modify others to align with its long-term objectives.

As part of the realignment, CMS will terminate the following models ahead of their original end dates:

• Maryland Total Cost of Care (2019–2026): This program will move over to the AHEAD program, so while listed as a termination and cost savings, this really looks like a change in title and official move to the AHEAD program, which already lists Maryland as part of Cohort 1.

• Primary Care First (2021–2026): Focused on enhancing primary care services to improve patient care and reduce Medicare expenditures.

• End-Stage Renal Disease (ESRD) Treatment Choices (2021–2027): Encouraged increased use of home dialysis and kidney transplants for ESRD patients; CMS will propose its termination through rulemaking, so more to come on if this will be discontinued, but it is officially on alert.

• Making Care Primary (2024–2034): Intended to strengthen primary care services and build upon previous initiatives, but will end prematurely. This program focused on incorporating health-related social needs into primary care infrastructure for risk stratification.

CMS also mentioned that it is evaluating potential adjustments to the Integrated Care for Kids (2020–2026) model, which may include reducing the scope of awards or implementing structural changes to better align with strategic goals. This model operates in seven states and is an integrated approach for physical and behavioral health services.

The announcement also cited that CMS will no longer move forward with the following initiatives:

• Medicare $2 Drug List: This initiative aimed to provide certain generic drugs to Medicare beneficiaries at a $2 price point.

• Accelerating Clinical Evidence: Designed to incentivize drug manufacturers to complete confirmatory trials for drugs receiving accelerated approval.

The limited briefing did state that CMS will provide guidance and technical assistance to affected participants to ensure a smooth transition and continuity of care for beneficiaries.

Although new programs have yet to be offered, CMS stated that they are shifting their strategy to emphasize preventive care, patient empowerment, and competition within the healthcare system.

Study Shows Higher Infant Mortality Rates for States with Abortion Bans

By Tiffany Ferguson, LMSW, CMAC, ACM

The political movement to restrict abortion access following the U.S. Supreme Court’s 2022 decision in Dobbs v. Jackson Women’s Health Organization, which overturned Roe v. Wade, has been quite active.

This ruling granted states the authority to regulate abortion without federal oversight, leading to a wave of restrictive laws, including total bans and six-week gestational limits. A recent study published in the Journal of the American Medical Association (JAMA) by Dr. Alison Gemmill, titled US Abortion Bans and Infant Mortality, examines a potential consequence related to the abortion bans in more restrictive states, specifically pertaining to infant mortality rates.

The study conducted a population-based, cross-sectional analysis using national statistics data from 2012 through 2023. The focus was on 14 states that enacted either total abortion bans or restrictions at six weeks of gestation. These states were Alabama, Arkansas, Florida, Georgia, Idaho, Indiana, Iowa, Kentucky, Louisiana, Mississippi, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, and West Virginia.

By comparing observed infant mortality rates post-ban with expected rates, based on historical trends, the researchers assessed the impact of these restrictive policies on neonatal and infant health outcomes.

The study found a statistically significant increase in infant mortality rates in states with restrictive abortion laws. Specially, there was an overall rise in infant mortality in these states, from an expected 5.93 per 1,000 live births to an observed 6.26 per 1,000 live births, which represents a 5.6-percent rise, or 478 excess infant deaths.

The study also found that Black infants experienced the largest increase in mortality rates compared to their non-black demographic groups. Finally, the study also found that the deaths due to congenital anomalies rose by 10.87 percent, from 1.24 per l,000 live births to 1.37.

The findings of this study suggest that restrictive abortion laws may have unintended negative consequences on maternal and infant health. Many public health experts argued that abortion restrictions would lead to an increase in high-risk pregnancies.

Without the option to terminate nonviable or medically complex pregnancies, this study confirms the unintended consequences that have led to more infants being born with severe health conditions – and a concerning increase in infant mortality rates.

Case Management Corner: CMS Notice May Create Hurdles

By Kelly Bilodeau

As of February 14, hospitals have a new CMS notification to contend with. But unlike the Medicare Outpatient Observation Notice (MOON) or the Important Message from Medicare, the Medicare Change of Status Notice (MCSN) might not be as easy to automate and could create operational challenges, said Sara Williams, MSN, RN, ACM-RN, vice president of clinical strategy at Phoenix.

CMS created the notification to let Medicare patients know that they can appeal if a doctor admits them as an inpatient, but later downgrades them to observation services. Patients sued CMS for the right to challenge these reassignments, which can lead to significant out-of-pocket costs. Patients with only Part A Medicare coverage shifted from inpatient to observation may be on the hook for the entire hospital stay if they do not also have supplemental coverage. Patients with Part A and B may not meet the three-day qualifying inpatient stay needed to unlock Medicare coverage for a subsequent skilled nursing facility stay, which may force them to forgo care or to pay out-of-pocket.  

Challenges ahead

While the decision was a welcome one for patients, Williams said, the MCSN is likely to present some hurdles for hospitals. “Operationalizing this is going to be a challenge,” she said. For one, the notice only applies to a sliver of Medicare patients, including Medicare Part A patients who were downgraded from inpatient status to outpatient with observation services and does not address patients with Medicare Part A whose status changes to OP, such as patients undergoing elective procedures. It also applies to Medicare Part A and B beneficiaries receiving observation services who are still in the hospital three days or more after the original inpatient order. The notice is only issued after they meet this criterion.

Because of these constraints, hospitals can’t establish a pre-set list of patients to receive the MCSN and may need to weed through individual cases to determine when it applies— leaving more opportunity for lapses. CMS requires staff members to give patients the notice “as soon as possible,” but no later than four hours before discharge. It will be important for hospitals to look for innovative strategies to use technology to alert staff to patients who should receive this notice.

Before the MCSN, the hospital would give a downgraded patient a MOON or a Condition Code 44 letter, Williams said. While some suggest substituting the MCSN for the Condition Code 44, questions linger because neither CMS nor the Quality Improvement Organizations (QIOs) have offered specific guidance. “My recommendation is to continue their current patient process and to provide this notice in addition,” Williams said.

Preparing for retroactive appeals

Hospital Health Information Management Departments will also need to field requests related to retroactive status change appeals because the court approved them in cases extending back to January 1, 2009. As a result, hospitals will also need a process to ensure patients can obtain related records, which will be an additional challenge. “Make sure that internal teams are educated to understand what these requests are and why,” Williams said.

While the new appeal process could benefit patients, Williams said it might not always hit the mark. For example, the notice requirement doesn’t apply to patients reassigned to outpatient status, just observation, which could limit appeal rights for surgical patients who commonly run into trouble with these status changes. If a surgical patient with only Part A coverage came into the hospital for inpatient surgery and the doctor reassigned them to outpatient status, they would have no coverage and can’t appeal the decision, Williams said.

However, this outpatient/observation distinction can also allow facilities to avoid the notification requirement in some situations, Williams said. “If you have a Condition Code 44 patient who is being discharged within an hour, instead of making them outpatient with observation services, it's safer to just make them an outpatient,” she said. The facility can’t bill for the observation hours anyway because the stay is under the eight-hour threshold, and they aren’t required to provide the MCSN.  

Strategies for compliance

When the notification is required, hospitals should ensure that they comply with CMS specifications, which include:

·       Incorporating an unaltered notification into the electronic medical record system

·       Including the expiration date and a general phone number that the patient can use to contact the QIO

If staff members deliver the notification to a patient representative, they should establish a process to document verbal and/or written receipt.

Ultimately, while this new notification is well-intentioned, CMS and hospitals still need to iron out some kinks and overcome logistical hurdles to achieve its intended goal.

Case Management Corner is your go-to source for insightful discussions on relevant topics in case management. Through an engaging interview-style format, our team members share their expertise, experiences, and best practices to keep you informed and empowered. Whether you're looking for industry updates, practical strategies, or real-world perspectives, we bring you valuable conversations designed to enhance your knowledge and support your professional growth. Stay tuned for expert insights straight from the field! Kelly Bilodeau has been a longtime writer for HCPro’s Case Management Monthly.

Gaining a Better Understanding of Social Workers

By Tiffany Ferguson, LMSW, CMAC, ACM

March is Social Work month, a time to recognize the contributions of my fellow social workers in various fields, particularly healthcare.

Social workers play a crucial role in ensuring that patients receive not only medical treatment, but also psychosocial support, and that our healthcare providers receive clarity regarding social barriers our patients face.

The field of medical social work owes much to Ida Cannon, who is recognized as the first medical social worker. In the early 20th century, Cannon revolutionized the integration of social work into healthcare by establishing the first medical social work department at Mass General in 1912. It was Ida and her Medical Director, Dr. Richard Cabot, who believed that the integration of social considerations in medical care would “make medical care effective” and “cure consumption”. She believed that addressing the social and emotional needs of patients was just as important as treating their physical ailments.

Through her advocacy and inclusion of social services work in healthcare settings, Cannon laid the foundation for modern healthcare social work, emphasizing patient-centered care and interdisciplinary collaboration.

Healthcare social workers often assist patients in facing life-altering diagnoses, chronic illnesses, or terminal conditions. They offer counseling and emotional support to help patients, and their families cope with stress, anxiety, and grief. It is often the social worker who is guiding the patient and family through difficult decisions and addressing social complexities.

With the additional need to address the social determinants of health (SDoH) in the acute-care setting, social workers help coordinate care by connecting patients with community resources, arranging post-acute transitional care services, and ensuring a smooth transition from the hospital. Their involvement reduces hospital readmissions and enhances patients’ overall well-being.

Starting with our foundational leaders such as Jane Addams and Ida Cannon, social workers recognize that health outcomes are influenced by more than just medical care. Economic stability, access to nutritious food, safe housing, and social support all play a role in a person’s health. The inclusion and consideration of social risk factors is ingrained in our social work clinical training, ensuring a comprehensive approach to patient care.

Social workers are present in hospitals, hospice care, rehabilitation centers, mental health clinics, skilled nursing homes, home health, and among other settings. In a 2017 study (Steketee, Ross & Watchman) looking at three decades of studies on the outcomes of social workers and patient health outcomes across 16 studies, they found that “social work services had positive benefits for both health and economic outcomes for vulnerable adults, children, pregnant women, and older adults.

The quality of the research was higher when social workers were leaders of the health services rather than members of a team.”

I am likely biased, but I believe that social workers are an indispensable part of the healthcare system, providing holistic support to patients. Their work is a testament to the profound impact that compassion, advocacy, and social responsibility can have on individuals and communities alike.

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.