In a few months, Medicare will begin denying reimbursement for certain conditions if they’re acquired in the hospital. Hospitalist groups are working against the clock to refine their screening methods to better document when those conditions exist on admission.
Hospitalist groups are also implementing more vigilant checks on admitted patients to make sure those complications—such as bed sores and line infections—are less likely to develop.
The new rules for the In-patient Prospective Payment System (IPPS) name eight conditions, from injuries during a fall to an object left in a surgical patient, that Medicare no longer will pay for. More conditions will be added the following year. The changes also establish 745 new Medicare severity-adjusted diagnosis-related groups (MSDRGs), replacing the current 538.
The changes, ordered by the Centers for Medicare and Medicaid Services (CMS), won’t restrict payment until Oct. 1; coding changes went into effect in October 2007. Coding not only affects payment but also allows for public reporting of hospital performance.
What They’re Doing
“Hospitalists are in an extraordinarily crucial position to help their facilities prepare and manage the new MSDRGs and pay-for-performance models that are being rolled out,” says James S. Kennedy, MD. He is a director with FTI Healthcare in Atlanta and author of the book Severity DRGs and Reimbursement: An MS-DRG Primer, published by the American Health Information Management Association.
Hospitalists “have a tremendous amount of in-patient hospital volume and they can better standardize their approaches,” clearing the way for other medical workers, he says.
He suggests designating one hospitalist per group to develop a working knowledge of ICD-9-CM codes and DRGs and serve as a physician adviser to the coding department.
“It has to be clear to the coder whether or not every condition that was documented by a physician was present on admission or not,” Dr. Kennedy points out.
It makes sense that CMS would order these changes in reimbursement, says Patrick Torcson, MD, chairman of SHM’s Performance and Standards Committee, and medical director for the hospitalist program St. Tammany Parish Hospital in Covington, La.
“With preventable conditions acquired in the hospital, there’s this perverse incentive that hospitals can get more money when complications occur,” Dr. Torcson says.
How are hospitalist groups preparing for these changes? At St. Tammany, there’s a new emphasis on educating hospitalists on documentation to note those present-on-admission indicators (POAIs). Dictation templates now include reminders to note that data. Also, multidisciplinary rounding that’s been effective in the intensive-care unit is being extended to general medical floors.
“There might be the tendency to just order more tests at the time of hospital admission,” Dr. Torcson points out. “Our group is going to avoid going down the track of ordering a urinalysis on every patient admitted, for example, just to rule out a urinary tract infection. We’re going to emphasize clinical judgment on a case-by-case basis.”
For hospital groups with high-risk populations, more testing may be exactly what’s needed. Randy Ferrance, DC, MD, a hospitalist at Riverside Tappahannock Hospital in Virginia, says the average age of his patients is about 70.
“We are doing a lot more screening and urinalysis than we used to do,” Dr. Ferrance says. “Nearly everyone is getting urinalysis, if they have any risk factors at all.”
The group of about four full-time hospitalists also relies more on nurses to note in patients’ charts any skin abnormalities so they can be prevented from developing into sores. The nurses are also “developing criteria for who we consider to be a high risk for decubitus ulcers,” Dr. Ferrance says. “We’re lowering the threshold for what we consider to be high risk.”