Determining the Third Day of a Hospital Stay and Patient Steering 

As I discussed recently, we have a go-live date for the Medicare Change of Status Notice of Feb. 14. Before reading on, stop and take a deep breath. There is no need for panic.

Despite what you may have read or heard, I must stress that not every Medicare patient having their status changed from inpatient to outpatient gets this notice. It is only for two limited groups of patients whose status has changed via the Condition Code 44 process: those with Part A and not Part B, and those who have their status changed and then stay at least three days.

Stop and think about that. How often do you make Condition Code 44 changes? Now take that number and multiply it by 0.08, representing the approximate percentage of Medicare patients who have Part A and not Part B. Then think about the number of Condition Code 44 changes you have where the patient then remains for three more days. That’s how many times you will need to provide this new notice.

The Centers for Medicare & Medicaid Services (CMS) has published the updates to the manual, but as often happens, there are several points that are ambiguous. First, the manual states that for the second group, “the notice must be delivered as soon as possible after the hospital reclassifies the beneficiary from inpatient to outpatient receiving observation services and the third day in the hospital is reached.” But that’s not correct; it is not the third day. It is actually the fourth day after the date of the inpatient admission order.

To quote CMS, from a personal correspondence, “it is to be counted such that if a beneficiary would win an appeal to the QIO (Quality Improvement Organization) and have their status revert to inpatient, they could be eligible for Medicare covered SNF (Skilled Nursing Facility) services.”  And since the patient can appeal even after discharge, which could be the day you deliver the notice, they must have three days starting on the day of the admission order, not counting the day of discharge.

Confused? You are not alone.

Moving on, I want to read to you a question posed by a case manager on a case manager user group. This person, who posted anonymously, asked, “what would you do if a provider (in this case, a physician assistant) sent you an email (stating) that all of their patients had to be sent to a specific home health agency, and your department director told you to follow that?”

Now, I was relieved to see that not one single respondent supported the provider or the director, with most referencing the Conditions of Participation requirement to offer choice regardless of the provider’s preference. Many pointed out that it is acceptable to inform the patient of their provider’s preference and even why, such as better outcomes for their patients, but full choice must be offered.

And of course, many suggested reporting this to compliance. Personally, I am not surprised that a provider would suggest such a thing, as their job is to provide the best care possible to the patient, which in their mind might include using that agency, and most doctors don’t read the Conditions of Participation, but for a case manager director to support this is inexcusable.

That director should have explained why this could not be done, and explained the compliant alternatives.

As I have noted in the past, we cannot hold others accountable for violating the rules when we violate some ourselves.

Let’s all do better.