Determining the Proper Patient Status in the ED

Assigning status to likely terminal patients.

I received a great question last week and thought I’d share it with you, our readers.

This case management manager wanted to know how to determine status for a patient who came into the ED and was deemed unlikely to live past 24 hours. She raised several valid considerations: the cost to the family, the burden of the Medicare required notification and the effect on mortality measures. Let me address each one.

As far as cost, she was concerned that since this patient had a prior admission within the last month, observation would impose costs that would not be incurred with inpatient admission. She’s right; since the prior inpatient admission took place within 60 days, there is no Part A deductible. But can we use the cost to the beneficiary as a factor when determining which status to choose? Absolutely not! Even if the status you choose results in a lower payment to the hospital, that is still not allowed.

Second, she was concerned that if the observation was chosen, they would have to provide the Medicare Outpatient Observation Notice (MOON), which centers on copayments and nursing home eligibility (and that would certainly have been an uncomfortable conversation). But remember, the MOON is not required to be issued until 24 hours of observation has passed, so they could temporarily withhold it, waiting to see if the patient lived 24 hours. She should also remember that every inpatient needs to get the Important Message from Medicare (IMM). That does not require an oral explanation, but what if the family asks questions about what they are signing? It will be equally awkward to tell them that the form gives them information on appealing if they feel their loved one’s discharge is premature.

The third concern, again, is the mortality. If the patient is admitted as an inpatient and dies, it gets reported as in-hospital death, whereas the death of an observation patient is not counted. We all hate hospital-acquired complications and deaths, but you really should hate those affecting observation patients that result in an inpatient admission a little less, since those get reported as “present on admission” (POA). And POA diagnoses are not considered to be hospital-acquired. That means if an inpatient falls and breaks a hip, it’s your fault, but if an observation patient breaks a hip, it’s not your fault.

But remember that mortality measures are not based on an absolute rate. It is based on expected versus observed. So the patient who comes into the hospital and is likely to die will probably score out as an expected death, not influencing your mortality score.

So with all that, how should she have determined the status of this patient? Well, that depends on the treatment plan. If the plan is comfort care while they transition the patient to hospice care, then observation is correct. There is no two-midnight expectation. But if the family wants active treatment and the doctors order it, then inpatient admission is warranted. The treatment is being ordered in that case with the expectation that it will work, and get the patient past the second midnight.

So once again, the answer is to follow the rules, and don’t worry about the fallout. Doing anything else just creates mayhem.


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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