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Medical Medical Necessity & Necessity &

Charting GuidelinesCharting Guidelines

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In most cases we are told the rules upIn most cases we are told the rules upfront - or will be told if we askfront - or will be told if we ask

Like most games, the one who knows theLike most games, the one who knows therules the bestrules the best

WINSWINS

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Nationally RecognizedNationally RecognizedIndustry Guidelines for determination Industry Guidelines for determination

of Medical Necessity used by payor of Medical Necessity used by payor sources: sources:

MillimanMilliman®®InterQualInterQual®®

Payors will approve day/s for patient Payors will approve day/s for patient stay based on these guidelines.stay based on these guidelines.

Hospital and physicians have signed Hospital and physicians have signed contract to use these guidelinescontract to use these guidelines

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InterQual Guidelines forInterQual Guidelines for Medical Necessity Medical Necessity

Utilized for Medicare patientUtilized for Medicare patientAcute Care inpatient or Observation Acute Care inpatient or Observation –– Severity of Illness (SI)Severity of Illness (SI)–– Intensity of Service (IS)Intensity of Service (IS)Used for Adult and Pediatric ServicesUsed for Adult and Pediatric ServicesOffers Discharge ScreensOffers Discharge ScreensCriteria are specific forCriteria are specific for–– Body Systems: Neuro, Cardiac, etc.Body Systems: Neuro, Cardiac, etc.–– Care Units: ICU, Intermediate, Medical, Care Units: ICU, Intermediate, Medical,

Monitored bedMonitored bed

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InterQual Guidelines forInterQual Guidelines for Medical NecessityMedical Necessity

Criteria for Alternative Level Of Criteria for Alternative Level Of Care (ALOC)Care (ALOC)–– Long Term acute Care Long Term acute Care –– RehabRehab–– SNF: Skilled Nursing facilitySNF: Skilled Nursing facility–– Hospice: Hospice: Not limited to cancer Not limited to cancer

patientpatient–– Home HealthHome HealthReference copy in LibraryReference copy in Library

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Severity of Illness (SI)Severity of Illness (SI)

What brought the patient to What brought the patient to the hospital?the hospital?Does the patientDoes the patient’’s condition s condition require stay in ACUTE CARE require stay in ACUTE CARE settings? WHY?settings? WHY?Has the patient FAILED Has the patient FAILED outpatient treatment?outpatient treatment?

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Intensity of Service (IS)Intensity of Service (IS)

What are we doing for the What are we doing for the patient that requires an patient that requires an ACUTE CARE setting?ACUTE CARE setting?Can treatment safely be Can treatment safely be performed in an Alternate performed in an Alternate Level Of Care (ALOC)?Level Of Care (ALOC)?

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Discharge Screens Discharge Screens ––Examples Examples of Next Level of Careof Next Level of Care

Pain Controlled with PO MedsPain Controlled with PO MedsHeart Rate 50Heart Rate 50--100100PO Fluids ToleratedPO Fluids ToleratedTemperature ResolvingTemperature ResolvingAnemia ResolvingAnemia ResolvingWounds HealingWounds Healing

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InterQualInterQual®® -- Alternate Alternate Level Of Care (ALOC)Level Of Care (ALOC)

Long Term Acute care (Kindred)Long Term Acute care (Kindred)Acute Rehabilitation (Siskin, Acute Rehabilitation (Siskin, HEALTHSOUTH)HEALTHSOUTH)Subacute Rehabilitation (Siskin)Subacute Rehabilitation (Siskin)Skilled Nursing Facilities (SNF)Skilled Nursing Facilities (SNF)Intermediate Care Facilities (ICF) Intermediate Care Facilities (ICF) ––Nursing HomeNursing HomeHome Health Care (HHC)Home Health Care (HHC)OutpatientOutpatient

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ALOC DeterminationALOC Determination

Determine, with the Determine, with the assistance of the Case assistance of the Case Manager, the Level of Care Manager, the Level of Care required based uponrequired based upon–– Stability of PatientStability of Patient–– Proposed ServicesProposed Services–– Safety IssuesSafety Issues–– Family SupportFamily Support

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DOCUMENTATIONDOCUMENTATIONIt is very important document and It is very important document and communicate with other care givers communicate with other care givers about what you are planning to do, about what you are planning to do, reasons for admission to acute care reasons for admission to acute care as inpatient or as an observation, as inpatient or as an observation, treatment plan (plan of care), reasons treatment plan (plan of care), reasons for continued stay and discharge plan.for continued stay and discharge plan.Review examples shown in next few Review examples shown in next few slidesslides

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Charting Medical NecessityCharting Medical Necessity–– Patient Status (Admit, Obs, Outpatient)Patient Status (Admit, Obs, Outpatient)–– Time and Date (both required)Time and Date (both required)–– Legible Orders (reduce errors and Legible Orders (reduce errors and

interruptions)interruptions)–– Legible SignatureLegible Signature–– Pager NumberPager Number–– Severity of Illness (SI) Severity of Illness (SI) -- Condition, H&PCondition, H&P–– Intensity of Service (IS) Intensity of Service (IS) –– OrdersOrdersNote Note –– Intent to admit should be Intent to admit should be

documenteddocumented with appropriate medical with appropriate medical necessitynecessity

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Charting GuidelinesCharting GuidelinesIf a patient is to be placed in an If a patient is to be placed in an inpatient status write inpatient status write ””Admit to Admit to inpatientinpatient””If a patient is to be in observation If a patient is to be in observation status write status write ““Place (or hold) in Place (or hold) in observationobservation”” avoid writing avoid writing ““Admit to Admit to 23 hour observation.23 hour observation.”” Follow up in Follow up in timely manner to determine the timely manner to determine the patientpatient’’s progress and continued stay s progress and continued stay need to admit or discharge the need to admit or discharge the patient.patient.

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Charting GuidelinesCharting Guidelines

When charting concerning the patientWhen charting concerning the patient’’s s condition, condition, chart chart ““patient improvingpatient improving””not not ““patient stablepatient stable””. . ““StableStable”” denotes that the patient is in good denotes that the patient is in good enough condition to be discharged and the enough condition to be discharged and the hospital day will be disallowed due to hospital day will be disallowed due to ““lack lack of severity of illnessof severity of illness””. Write why the . Write why the patient has to remain in the hospitalpatient has to remain in the hospital----what what acute care services are being provided or acute care services are being provided or the severity of the patientthe severity of the patient’’s condition.s condition.

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Charting GuidelinesCharting Guidelines

Avoid charting Avoid charting ““awaiting IMCU bed awaiting IMCU bed transfertransfer””. Rather, chart . Rather, chart ““patient to patient to IMCU soonIMCU soon””. The first entry will . The first entry will qualify as a nonqualify as a non--acute ICU bed day. acute ICU bed day. Avoid charting Avoid charting ““patient doing well, patient doing well, will discharge in a.m.will discharge in a.m.”” This denotes This denotes that the patient no longer meets that the patient no longer meets ““severity of illnessseverity of illness”” criteria to criteria to warrant his/her stay in an acute care warrant his/her stay in an acute care facility.facility.

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Charting GuidelinesCharting Guidelines

Avoid charting Avoid charting ““will observe, will observe, and discharge in 1 or 2 daysand discharge in 1 or 2 days””. . Again, this denotes Again, this denotes ““lack of lack of severity of illnessseverity of illness”” and and ““intensity of service.intensity of service.””

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Do Chart Do Chart ……

Why the patient remains in the Why the patient remains in the hospital in terms of Severity of hospital in terms of Severity of Illness (SI) and Intensity of Illness (SI) and Intensity of Service (IS):Service (IS):–– What is his/her What is his/her conditioncondition that can that can

only only be treated in an acute care be treated in an acute care facility?facility?

–– What What treatmenttreatment is being provided is being provided that can only be performed in an that can only be performed in an acute care facility?acute care facility?

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Do ChartDo Chart……

CoCo--morbidities, complications, morbidities, complications, and contributing factors (CCand contributing factors (CC’’s)s)PatientPatient’’s History and Physical s History and Physical (H&P)(H&P)Treatment received prior to Treatment received prior to being placed in a bedbeing placed in a bed

––MD Office, ED, other MD Office, ED, other treatment facilitytreatment facility

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Charting GuidelinesCharting Guidelines

Do chart in the admit note the Do chart in the admit note the initial hospital treatment plan.initial hospital treatment plan.Discharge summary should Discharge summary should include all diagnosis, coinclude all diagnosis, co--morbiditymorbidity’’s and hospital course. s and hospital course. Be very specific, i.e., identify the Be very specific, i.e., identify the type of pneumonia, location, and type of pneumonia, location, and organism. organism.

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Charting GuidelinesCharting GuidelinesIM and PO medications without IM and PO medications without documentation of strong severity of illness documentation of strong severity of illness does not meet criteria for continued stay.does not meet criteria for continued stay.

A patient admitted on Friday or Saturday A patient admitted on Friday or Saturday must meet must meet ““severity of illnessseverity of illness”” and and ““intensity of serviceintensity of service”” and have supporting and have supporting documentation for the entire weekend to be documentation for the entire weekend to be determined determined ““medically necessary.medically necessary.”” If the If the patient is stable and outpatient treatment is patient is stable and outpatient treatment is appropriate then evaluate patient for appropriate then evaluate patient for outpatient procedure and consider outpatient procedure and consider discharging the patientdischarging the patient..

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Timely Follow UpTimely Follow UpIf you are part of the admitting team If you are part of the admitting team and write and write ““OK to discharge if OK with OK to discharge if OK with surgery,surgery,”” then then followfollow--up laterup later in the in the day for the discharge order.day for the discharge order.If a patient is almost ready to be If a patient is almost ready to be discharged except for his diet discharged except for his diet tolerance then you may write the tolerance then you may write the order order ““May be discharged if eating May be discharged if eating OK.OK.”” Follow upFollow up and write the and write the discharge order.discharge order.

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Charting GuidelinesCharting Guidelines

Attending physicians must write Attending physicians must write a progress note daily on a a progress note daily on a patientpatient’’s chart s chart ---- not just conot just co--sign sign a residenta resident’’s note.s note.–– Please note that the these are suggestions based Please note that the these are suggestions based

on InterQual criteria and Milliman criteria used by on InterQual criteria and Milliman criteria used by Medicare, Medicare, TennCareTennCare and most of the major and most of the major payers. If you have any questions, you may payers. If you have any questions, you may contact Resource Management staff at 2520 for contact Resource Management staff at 2520 for Erlanger or call 6296 for questions at TCTCH. Erlanger or call 6296 for questions at TCTCH.