Anuja Mohla (amohla@christianacare.org) is Senior Physician Advisor and Medical Director Patient Access & Flow at ChristianaCare Health Care System in Newark, DE, and Patty Resnik (presnik@christianacare.org) is Vice President, Operations, at ChristianaCare Center for Virtual Health in Wilmington, DE.
The Centers for Medicare & Medicaid Services (CMS) implemented the two-midnight rule as part of the fiscal year 2014 Inpatient Prospective Payment System final rule. In December 2016, the Office of Inspector General (OIG) published a report identifying remaining vulnerabilities in healthcare systems since the two-midnight rule.[1] OIG expressed concerns regarding acute hospitals submitting costlier Part A inpatient claims instead of Part B outpatient claims for “short stays,” defined as hospital stays of less than two midnights. Thus, the OIG recommended CMS conduct a routine review of short-stay admissions and target hospitals with high numbers of these potentially inappropriate claims.
History of short-stay audits
In October 2013, CMS assigned Medicare administrative contractors to conduct pre-payment status probe and educational reviews for the short stays.[2] However, two years later, this task was shifted to a post-payment review under the Beneficiary and Family Centered Care Quality Improvement Organizations. Less than a year later, in May 2016, CMS temporarily paused the reviews to promote a more consistent approach toward medical review of short-stay admissions. A few months were taken to retrain the Beneficiary and Family Centered Care Quality Improvement Organizations and short-stay audits were resumed in September 2016. Three years later, in May 2019, CMS again paused the reviews with the intention of having one organization conduct the audits nationwide. In November 2020, the OIG again expressed concerns regarding overpayment of millions of dollars for short inpatient stay claims as well as its intent to audit the short inpatient stay claims.[3] More recently in April 2021, Livanta was announced as the national Medicare claim review contractor with plans to resume short-stay admission audits in the near future.[4]
Step-by-step guide to an electronic short-stay review process
A proactive approach toward conducting internal short-stay admission reviews can help identify and correct any errors prior to claim submission. In 2016, ChristianaCare transitioned from a manual to an electronic review process. Below is the framework of our current electronic short-stay review process, which incorporates various departments within the revenue cycle team.
The two-midnight rule alert
The entire process is initiated when a discharge order is entered by a clinical provider on a Medicare beneficiary in inpatient status who has not crossed a second midnight. The two-midnight rule alert is received by the clinical provider at the time of discharge. In addition to educating the provider about the two-midnight rule, it directs the discharging provider to the appropriate action. If it is a true short stay, it guides the provider to another screen where free text information can be entered indicating clinical rationale for early discharge for a short inpatient stay. Alternatively, it leads the provider to ensure appropriate discharge location is selected when applicable toward one of the CMS’s exceptions for short inpatient stays, including departure against medical advice, unexpected death, selection of hospice care, or transfer to another acute hospital.[5] More importantly, unnecessary alerts are suppressed if the encounter meets one of the CMS exceptions for short-stay admissions during the hospitalization.
Identification of short-stay cases
A daily report is reviewed by the utilization management (UM) manager for any patients stays where the two-midnight rule alert was fired. Additional reports are designed for patients with a change in status, resulting in fewer than two midnights in the inpatient status. Any patients changed from observation/outpatient to inpatient status are identified for possible occurrence span code 72. Patients changed from inpatient to observation/outpatient without UM committee member are also flagged for a potential condition code W2.
Initiation of UM retrospective review documentation form
A new form is created for each short-stay admission encounter with the most appropriate review type, short stay or occurrence span code 72 being the most common options. For a patient with an elective surgery, the form is sent electronically to the coding team for potential inpatient-only (IPO) procedure. If an IPO is identified, the form is sent directly to the finance auditor for appropriate claim submission. If the procedure is determined to be not IPO, the form is sent electronically to the physician advisor for medical necessity review under the two-midnight rule regulations.
Physician advisor review
Upon receipt of the form in the message center, the physician advisor can access the complete medical record by one click as the form itself is attached to that specific admission encounter being reviewed. The physician advisor must review the case for medical necessity and document a summary supporting the status determination. If the physician advisor disagrees with the discharging status, the case is sent to a second physician advisor for additional review. After the physician advisors have recorded their final status determination, the form is sent electronically for completion to the finance auditor, a member of the ChristianaCare’s Medicare finance team.
Finance auditor review
The final document review outcome is reconciled by the finance auditor based on the input from the coding team and/or physician advisors, as applicable. Most importantly, all short-stay cases are automatically put on a bill hold built into the institution’s billing system as a safety net. This helps the finance auditor ensure all short-stay encounters are reviewed appropriately through the various steps of the short-stay review process prior to the final claim submission.
Continuous improvement: Four process improvement opportunities identified
All encounters discovered through the bill hold process with suppressed two-midnight rule alerts were investigated retrospectively to detect any gaps in the process. Over the past few years, we identified several opportunities that have led to improvement in various processes throughout the healthcare system.
Insurance verification
A few cases were identified with a short stay over the weekend where updated insurance information was not entered into the electronic medical record. Since enlisting of Medicare as primary insurance is one of the requirements for the two-midnight rule alert to fire, missing payer information resulted in missed alert at the time of discharge. While the chart was identified later when the payer was updated, we identified a gap in the payer verification process during off hours. A simple communication with the admitting director and enhanced collaboration with our emergency department registration team helped us bridge those gaps and improve payer verification process for all our patients.
Ventilation orders
CMS has listed initiation of mechanical ventilation during hospital stay as one of the exceptions to the two-midnight rule where Part A payment is generally appropriate. Therefore, to prevent unnecessary alerts, ventilation orders were added as an exclusion criterion for the alert. A reconciliation of all ventilation orders was performed to ensure patients with noninvasive ventilation orders are being reviewed appropriately after a case with a missed initial alert was caught by our safety net mechanism.
Types of discharge orders
One of the charts caught through our safety net process had a unique discharge order. Due to an extra character in the discharge order, the electronic system did not recognize the discharge order, resulting in a missed alert. As a result, a reconciliation of all available discharge orders was performed to create standardization of discharge from acute hospital level of care.
Manual changes to orders
As a large healthcare system and a teaching hospital, we have several mid-level providers, including residents and advance practice providers. To ensure compliance with CMS’s requirements for authenticated inpatient orders, we have additional alerts in place that stop a provider from discharging a patient without a valid cosigned inpatient order, if applicable. A few cases were caught by our safety net process as a user had manually discontinued the original inpatient order to bypass both the cosignature alert as well as the two-midnight rule alert upon placing the discharge order. These scenarios have presented as one-on-one educational opportunities to improve our processes by reaching out to those providers.
Over the years, these process improvement opportunities have helped us enhance our capture rate to ensure all short stays have been reviewed through the process. In 2020, more than 97% of all short-stay inpatient discharges had the utilization management retrospective document review outcome form present. Periodic analysis of document review outcomes can help bridge any gaps in the process to ensure a 100% capture rate. Furthermore, this proactive approach promotes confidence for compliance professionals to ensure all short-stay claims are reviewed appropriately prior to the final claim submission to CMS.
Retrospective data analysis
Using power forms for electronic review of short stays has the added benefit of easy data extrapolation for retrospective analysis. Power forms have discrete data fields that can be readily collected to create interactive dashboards for rapid data analysis. In addition to Program for Evaluating Payment Patterns Electronic Report as a resource for review of short-stay trends, dashboards created using data extrapolated from these power forms have helped us identify opportunities to improve our short-stay trends.
Over the past few years, several musculoskeletal procedures were taken off the IPO list.[6] We have successfully used this information to conduct data-driven discussions with the orthopedic department, resulting in a marked improvement in appropriate initial postings for non-IPO elective surgeries. In the wake of the CMS announcement to eliminate the IPO list by CY 2024, all elective procedures will now be reviewed under the two-midnight rule, resulting in a potential increase in short-stay volume. Therefore, creating an internal audit process for close monitoring of short stays with added capability of rapid data analysis is crucial for compliance professionals and utilization management departments nationwide.
Takeaways
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Understand the history of how Centers for Medicare & Medicaid Services has approached short-stay reviews.
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Create a process within provider workflow to ensure appropriate initial status with supporting documentation.
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Build an internal proactive utilization management auditing process with retrospective physician advisor review of all inpatient short stays.
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Improve short-stay compliance rates by ensuring claims are reviewed prior to submission for reimbursement.
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Develop interactive dashboards with actionable data for providers, revenue cycle team, and senior leadership to help improve short-stay trends.