When Discharge Orders No Longer Signify Patient Discharge

As with many other physicians of a certain age, I have 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 (CDI), 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 of 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 (DRG) 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, it 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 (EHRs) 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 prevention of 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 in which the patient no longer requires hospital care, but transfer to an Inpatient Rehabilitation Facility (IRF) or other Skilled Nursing Facility (SNF); however, there is 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 their 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 that 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 actually leave the hospital building, a discharge order is placed.

Review of the applicable Centers for Medicare & Medicaid Services (CMS) rule uncovers other points that 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 (bold emphasis 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 (IMM) 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 (bold emphasis 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 IMM 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 IMM itself (bold emphasis 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.

Programming note:

Listen to Dr. Ugarte Hopkins report this story live today on Talk Ten Tuesday with Chuck Buck and Angela Comfort, 10 Eastern.