When is a Patient Not a Patient?

“Admit as inpatient” are probably the most valuable words written or electronically entered by physicians. And to be honest, I think the Centers for Medicare & Medicaid Services (CMS) has a little too much psychological and physical dependence on these words.

Is a patient any less a patient because those three words are not on the chart? I don’t think so. Does it cost a hospital less to care for a patient if those three words are not on the chart? I know that’s not true. And does something magically happen to a patient when they leave the hospital if they had those three words on the chart, but they were not authenticated prior to discharge? They sure look the same when they leave. Yet this phrase is seems to be viewed by CMS as being even more important than anything else that happens to the patient.

This came up two weeks ago when a physician advisor asked how to status a patient who came into the emergency department with a heart attack. During cardiac catheterization the patient rapidly decompensated and required the placement of an intra-aortic balloon pump to maintain circulation – and actually, to keep them alive. The patient then was rapidly transferred to a larger hospital for specialized care.

But those silly doctors, in their rush to save a life, did not stop to consult addendum E of the Outpatient Prospective Payment System (OPPS) Final Rule and see that an intra-aortic balloon pump is an inpatient-only surgery – and therefore, an inpatient admission order should have been written prior to the patient’s discharge.

As a result, the hospital is unable to bill for an inpatient admission; it must bill an outpatient stay and get paid a much lower outpatient rate for saving that patient’s life. In fact, since the patient underwent a cardiac catheterization and the balloon pump procedure, by outpatient bundling rules (only one SI = J1 procedure is paid), the hospital will get no money beyond the payment for the catheterization.

But can’t the hospital explain that the patient was dying, and patient care should come first? Well, that sounds good, but the example CMS gives for the extremely rare situation when billing with a missing or defective order is a patient who has emergent open-heart surgery and spends several days at the hospital – not the patient who never even gets to an inpatient bed, but underwent an inpatient-only surgery.

One case management director recently stated that his hospital’s write-offs of inpatient-only surgeries without admission orders is a constant problem, since the surgery booked by the surgeon and the actual surgery performed often differ just slightly and result in a new code and a different required status. And if that status was inpatient, the hospital is out of luck and gets no payment.

And why the requirement to authenticate a verbal admission order prior to discharge? That also has no logical explanation. The patient was formally admitted as inpatient, received inpatient care, and was discharged. Yet the lack of a simple signature potentially costs the hospital tens of thousands of dollars.

I can’t explain why these three words mean so much. I know it is outlined in the Social Security Act and federal regulations, and but it just feels good to be able to go on Monitor Mondays and suggest to CMS and Congress that they just get beyond it.


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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