Waiting for more than 30 minutes? We’ll send you to the … out this sample apology letter one organization uses to apologize for ED waits. p. 6 It’s time for discharge Read how

In thIs Issue

p. 3 I’m sorryCheck out this sample apology letter one organization uses to apologize for ED waits.

p. 6 It’s time for dischargeRead how a collaborative—and organized—approach can improve patient flow.

p. 8 You’re totally in denialSee how patient access and case management can team up to reduce denials.

p. 10 that’s a good questionOur expert provides answers to some of your toughest observation questions.

For years, Domino’s Pizza had a 30-minute guarantee:

Order a pizza to be delivered, and if it’s not at your door-

step in 30 minutes or less, the pizza’s on Domino’s.

No questions asked.

Sister hospitals St. Mary’s in Blue Springs, MO, and St.

Joseph in Kansas City, MO, have their own 30-minute

guarantee: If you’re a patient in the ED, and you’re not

seen by a doctor or nurse practitioner within 30 minutes

of the time you walk in, you get two free movie passes.

No questions asked.

The facilities one-up the national pizza chain when it

comes to customer service—if they fail, they send a letter

of apology to patients. The 143-bed St. Mary’s and 300-

bed St. Joseph offer acute care, outpatient, and extended

Waiting for more than 30 minutes? We’ll send you to the moviesKansas City, MO, medical center guarantees a short wait in ER, or it’s tickets on the house

care services. They implemented the 30-minute rule in

June with an aim to trim wait times for ED patients and

improve their satisfaction.

Wait times for patients have not only improved—in

some cases by 40 minutes on overall stay in the depart-

ment—but the program also boosts staff morale, from

the person who registers the patients to the doctor who

treats them.

“We started this program with the idea of increas-

ing patient satisfaction and improving the quality with

patients coming

into the ER,” says

Deborah White,

coordinator of

public relations for

Carondelet Health, a

Catholic-sponsored

healthcare system

that includes five

facilities, including

St. Mary’s and St. Joseph, in the Kansas City metropoli-

tan area. “Overall, the staff has responded very positively.

They’re seeing how it affects patient quality and how

patients are pleased. A lot of the patients say we don’t need

to give them movie tickets, but we say we want to recog-

nize [their] time, and that we know we made [them] wait.

I think the fact that we’re acknowledging their time and

acknowledging the fact that we made them wait helps.”

Identifying the problem

White says St. Mary’s modeled its program after

a similar one in the Emergency & Trauma Center at

Borgess Health System and the Borgess-Pipp ED in

Kalamazoo, MI. They are all members of Ascension

Health, the largest national Catholic healthcare facility

in the nation.

> continued on p. 2

november 2007 Vol. 4, no. 11

“A lot of the patients say

we don’t need to give

them movie tickets,

but we say we want to

recognize [their] time,

and that we know we

made [them] wait.”

—Deborah White

Patient Access AdvisorPage 2

© 2007 HCPro, Inc.

For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at www.copyright.com or 978/750-8400.

november 2007

In its Emergency & Trauma Center, Borgess, accord-

ing to its Web site, makes the 30-minute guarantee work

with the following:

Bedside registration for all patients

Addition of a second triage bay

Streamlined triage process

Reorganization and reduction of paperwork

That is the model St. Mary’s adapted when it began

rethinking its ED response to patients in August 2006.

“We started looking at ED performance because we

knew there were things we needed to do better,” says

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Debbie Gengler, RN, director of emergency services

for St. Mary’s. “Our initial plan was to get to the point

where patients would have a length of stay in the ER of

90 minutes. We started doing things to see if we could

get there.”

the process

St. Mary’s began in August with committee meetings

involving radiology, patient access representatives, and

staff nurses and doctors. They recorded times for patient

visits to the ED. They broke down the problems step by

step, from the time a patient parks to the time he or she

checks out and leaves the hospital.

➤ Parking. The first problem the team identified did

not begin with the registration process. It actually began

outside the hospital—in the parking lot.

“We did a patient-mapping process and went to the

parking lot,” says Gengler. “What are the obstacles?

One of them was we didn’t have designated emergency

patient parking areas. We had handicap spots and that

sort of thing, but we didn’t have a first-level tier for ER

patients. You would have visitors parking there, and it’s

sort of inconvenient for a person with an injured ankle

to have to hobble in to the emergency room.”

➤ Registration. When a patient comes in the door at

St. Mary’s, he or she is immediately greeted at the front

desk. Before, Gengler says, the center had the front desk

covered only 12 hours; now, it’s 24.

At St. Joseph, patient access representatives are

usually the first to see the patients. The representative

creates what the center calls a “short form” registra-

tion, just enough to create an account—name, birth

date, and reason why the patient is there. From there,

the information is logged in the ED’s FirstNet Tracking

system, a computerized monitoring program that uses

icons to track patient status. It informs the triage nurse

that someone needs to be seen. “It’s not even a minute

to do the short form,” says Denise Ashby-Cohen,

Wait time < continued from p. 1

> continued on p. 5

editorial Advisory Board Patient Access Advisor

Group Publisher: Lauren McLeod

Executive Editor: Lori Levans

Senior Managing Editor: Dom nicastro

[email protected]

Rose t. Dunn, RhIA, CPA, FAChe, FhFMA Chief operating officer, First Class Solutions, Inc., St. Louis, MO

Donna K. GilleyDirector of revenue cycle and regulatory compliance, LBMC Healthcare Group, Brentwood, TN

Amy harttVice president, VHA Southwest, Plano, TX

Diane Jepsky Healthcare consultant, Seattle, WA

steven OrvisSenior consultant, Sinaiko Healthcare Consulting, Los Angeles, CA

Joyce sourbeck, Ms, RnAssistant vice president for patient financial services, Washington Hospital Center, Washington, DC

David s. szabo Nutter, McClennen & Fish, LLP, Boston, MA

sandra J. Wolfskill, FhFMA President, Wolfskill & Associates, Inc., Chardon, OH

Joe Zebrowitz, MDExecutive vice president/senior medical director, Executive Health Resources, Newtown Square, PA

Patient Access Advisor (ISSN 1933-3307) is published monthly by HCPro, Inc., 200 Hoods Lane, Marblehead, MA 01945. Subscription rate: $399/year; back issues are available at $25 each. • Postmaster: Send address changes to Patient Access Advisor, P.O. Box 1168, Marblehead, MA 01945. • Copyright 2007 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at 978/750-8400. Please notify us immediately if you have received an unauthorized copy. • For editorial comments or questions, call 781/639-1872 or fax 781/639-2982. For new subscriptions, renewals, change of address, back issues. billing questions, or permission to reproduce any part of PAA, call customer service at 800/650-6787, fax 800/639-8511, or e-mail: [email protected]. • Visit our Web site at www.hcpro.com. • Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the Marketing Department at the address above. • Opinions expressed are not necessarily those of PAA. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions.

Patient Access Advisor is one of the resources from the Patient Access Resource Center from HCPro, Inc. For information, call 800/650-6787 or go to www.accessresourcecenter.com.

Patient Access Advisor Page 3

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november 2007

FormThis Month’s

➤ Download this entire form in the Patient Access Advisor section of www.accessresourcecenter.com.

sample customer service apology letter

The following is a sample apology letter St. Joseph Medical Center sends to patients if it does not keep its promise of a

30-minute wait time in the ED.

Dear Patient:

Thank you for choosing St. Joseph Medical Center’s emergency department. We hope your recent experience was positive, and

that you are well on the road to recovery.

At St. Joseph, our objective is to provide the highest level of quality care and treatment as quickly as possible. At the same time,

we must provide care based on the needs of all patients who are present. Patients in critical or serious condition must be seen

and stabilized first. For that reason, there are circumstances in which providing care to these patients makes it necessary for

other patients to wait longer than normal.

We regret that your visit to the emergency department coincided with one of these rare situations and that we were unable to

meet our promise of having you seen by a physician within 30 minutes. As a token of our understanding of the fact that you

were inconvenienced, enclosed are two movie tickets. We will continue to provide our 30-minute guarantee and expect to be

able to meet it nearly all of the time.

While you continue to recover, please remember that you are always welcome to contact us with any questions or concerns;

just call 816/943-2713 at any time.

Thank you once again for choosing St. Joseph. We look forward to providing you high-quality, timely care whenever you might

need it in the future.

Sincerely,

Karen Lee, MSN, RN, CNAA

Vice President, Nursing

Carondelet Health

Source: St. Joseph Medical Center, Kansas City, MO. Reprinted with permission.


© 2007 HCPro, Inc.


november 2007

FormThis Month’s

➤ Download this entire form in the Patient Access Advisor section of www.accessresourcecenter.com.

st. Joseph/st. Mary’s ‘short form’ registration in eD

Patient ___________________________________________________________________

Name __________________________ Birth date ______________ Age ___________ Sex ________________________

Maiden and/or Unit # _________________________

other names _______________________________

Mother’s Name ____________________________ Demo recall ____________________

Last discharge __________________

Prim care phys ________________________________________________________________

ER physician ___________________________________________________________________

Family physician _______________________________________________________________

Other provider _________________________________________________________________

Admin priority _________________________________________________________________

Reason for visit _________________________________________________________________

Visit diagnosis 1 _______________________________________________________________

2 _______________________________________________________________

Arrived by ____________________________________________________________________

Location ___________________________ Service date _____________________________ Service time ______________

Comments _________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Notes on page 1, from Denise Ashby-Cohen, regional director of patient access at St. Joseph and St. Mary’s:

We would enter information in the “Maiden and/or other names” field if a patient told us he or she has been a patient at our

facility in the past but we are not finding his or her name in the Master Patient Index. If the patient has been at our facility in

the past, the Unit # will automatically fill in and “Last discharge” or “Demo recall” will have a date.

FormThis Month’s

Patient Access Advisor Page �

© 2007 HCPro, Inc.


november 2007

regional director of patient access at St. Joseph and St.

Mary’s, who manages a staff of 55. “It could be saving

five minutes of time or it could be saving 15 minutes of

time. If a patient has never been in the system, we have

to type in a lot of information.”

Once the short form is done, a patient access repre-

sentative marks a little key icon on the tracking board so

a triage nurse knows it’s that patient’s turn. The entire

registration is completed after the patient is treated—usu-

ally at bedside. “If we’ve completed registration but need

to get an ER copay, we’ll put a stop sign icon on there,”

says Ashby-Cohen, “so nurses can see that and stop [the

patient] before [he or she] leave[s].”

Gengler says the 30-minute program helps patient

access representatives strive for a goal and not forget

about the current patient. “Being aware and having a

goal to work toward has helped, whereas before if you

were working on something else, you would finish that

and then go to the current patient,” she says.

➤ On-site radiologist. St. Mary’s has a radiologist

technician dedicated to the ER who tracks patient flow

and anticipates the need for imaging. “If [he] see[s] a

patient come in with a broken arm, [he] say[s], ‘I’m

going to get an x-ray ready,’ instead of waiting for them

to come to radiology,” says White. “He’s keeping tabs on

what’s going on and anticipating any need for imaging

services.”

➤ Quick cleaning. Rooms are getting cleaned faster

now, ensuring a smooth transition for new patients.

Employees are also clearing out rooms on the inpatient

side faster for a quicker transition from the ER.

➤ Staff incentives. The facilities recognize staff work

on the 30-minute initiative. They give coupons for free

meals and other perks. “So if you have a day when you

hit 99 or 100%, we say, ‘Thanks for all your hard work,’ ”

says Gengler.

In all, the changes have helped decrease overall wait

times in the ER by 40 minutes in some cases, Gengler

says. As for ensuring the program works, White says the

center is always revisiting response times and tracking

patient response through telephone surveys.

Three months into the program, officials say it’s a win-

win for the ED—and for its patients, whose preference is

most likely quality, efficient care rather than a free pass

to the movies. “The concept is we understand their time

is valuable,” says Gengler. n

Wait time < continued from p. 2

st. Joseph/st. Mary’s ‘short form’ registration in eD (cont.)

The main fields we fill in are:

Name

Birth date

Age and sex

Family physician (if the patient has one)

“E” for emergency for the “Admin priority”

Reason for visit

Arrived by (car, ambulance, air ambulance)

Source: St. Joseph’s Medical Center, Kansas City, MO. Reprinted with permission.

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november 2007

Discharge appointments: Remedies for poor patient flowMost new front-end directors spend their first

couple of days on the job introducing themselves

to staff members and patients, touring the hospital,

and organizing their desks. This was not the case for

Jackie Connor, RN, MS, CCS, director of case man-

agement at St. Joseph’s Medical Center (SJMC) in

Townsend, MD.

Before she could even set up her office, Connor was

immediately assigned the duty of revamping SJMC’s

discharge system. “Literally the day I started, the exec-

utive team wanted me to assemble a task force to study

and explore new ways to improve hospital discharges,”

says Connor.

Like many hospitals, SJMC had a universal discharge

time system in place with a goal of getting all patients

discharged by 11 a.m.

After collecting and tracking data, Connor and the

new discharge task force—a team consisting of nurses,

physicians, social workers, and ancillary staff mem-

bers—decided that overall patient flow could be bet-

ter leveraged by pushing the discharge time back an

hour—to noon.

But midway through crafting her first policy change

and making the case for a later universal discharge

time, Connor had an epiphany: A noontime discharge

goal would only slightly improve patient flow and not

bring about the type of change the executive team

wanted to see.

“After looking at our ED visits, surgeries, OR sched-

ule, and population, we realized that a universal dis-

charge time—whether at 11 a.m. or noon—would still

create bolus discharges and bolus admissions later in

the day,” says Connor. “There would still be an uneven

workload throughout the day.”

After further dissecting the policy of universal dis-

charge times at SJMC, Connor and her team identified

the following flaws in its system:

The reality of discharging 70–80 patients at a desig-

nated time always created a chaotic scramble of ser-

vices and demands on the entire staff

No matter how hard case managers tried, it was

always an uphill battle to get all physicians to round

at certain times in the morning

Certain patients require more tests or special instruc-

tions, and addressing all of these issues within a few

hours in the morning was not realistic

After identifying the major roadblocks of the univer-

sal discharge time system, the discharge task force at

SJMC decided it was necessary to move in a completely

different direction and try something new. In an effort

to even patient flow and create balanced scheduling

throughout the day, Connor and her team abolished

universal discharge times and switched to a discharge-

by-appointment system.

how it works

SJMC case managers, along with members of the

discharge task force, now make daily rounds to identify

patients who are almost ready to be discharged. Once

a patient has been identified, a case manager or nurse

contacts the physician to get his or her approval, and a

scheduled discharge is made 24–48 hours in advance.

Discharge appointments are made throughout the

day—mornings, afternoons, and early evenings—based

on patient, family, and physician needs.

“After an appointment has been made, it goes into

the computer system, and the physician is reminded,

and the ancillary departments are notified so they can

prepare necessary labs and tests ahead of time instead

of having to scramble at the end,” says Connor. “This

structure allows doctors and ancillary staff time to pre-

pare and eliminates some of the surprise factors that

come along with patient discharges.”

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© 2007 HCPro, Inc.


november 2007

Under a scheduled system, if a physician wants to

see a final chest x-ray or a blood test, the ancillary staff

is alerted ahead of time and can prepare to have these

exams ready, adds Connor. The ancillary department’s

goal is to have all requested tests three hours before

a patient’s scheduled discharge time. This way, says

Connor, if anything unexpected arises, the department

has time to review and preplan.

“I’ve never done [discharge by appointment] at any

of the other facilities I’ve worked for, but it immediately

made sense,” says Connor. “The more predictable we can

make our work, the more we can manage our patient’s

expectations and, ultimately, their overall satisfaction.”

Implementation

Discharge by appointment at SJMC began on the

surgical unit and with interventional cardiology patients

and has recently expanded to include all hospitalists.

“We started piloting discharge by appointment on

the cardiac floor because it’s our largest practice and we

have more of a captive audience with these patients,”

says Connor. “And we expanded to our hospitalists first

because they’re generally more flexible and open to

ideas than the private physicians.”

After deciding where to pilot the new program and

who would be involved, the task force next had to

decide how to identify patients for discharge. “At first,

our goal was to attempt to predict a patient’s discharge

time and plan upon admission,” says Connor. “But

what we found was there were too many unknowns

during a patient’s first 24–48 hours. For example, a

cardiac patient would not even have a clear diagnosis

or course of treatment, which makes it very difficult to

schedule a discharge ahead of time.”

In light of this, the decision was made to schedule

discharges the day before they occur, says Connor.

“Every day, the case managers and nurses do rounds

to identify patients we believe are most likely to be dis-

charged the next day.”

“Some of the processes are automated,” Connor

adds. “In order for the scheduled discharge appoint-

ment to be recognized by the physician and the ancil-

lary departments, we have to communicate that time.

Before the date and time can be put into the system to

alert the physicians and the ancillaries, there has to be

an agreement between the case manager or nurse and

the physician.”

time saved, satisfaction gained

Discharging by appointment has drastically im-

proved communication between case managers and

physicians and also saves case managers a lot of time,

says Andrea Cottrell, MS, RN, case manager on the

cardiology floor at SJMC.

“Discharge times are now on a physician’s roster in

the morning, which helps them prioritize what patients

they need to see first,” says Cottrell. “So as a case man-

ager, I’m spending a lot less time on the phone tracking

down doctors and asking them for dictation, instruc-

tions, and what time they may or may not be able to

discharge a patient.”

Cottrell admits there are a few challenges to sched-

uling discharges by appointment, such as knowing

each physician’s rounding preferences and making sure

patients don’t slow down the process on their end by

not being prepared, but she says the benefits far out-

weigh these challenges.

“Case managers and nurses love this new system

because it helps us plan our day and we know exactly

what we have to do to get a patient discharged,” says

Cottrell. “Since getting rid of universal discharge times,

I’ve never felt more organized.” n

Contact senior Managing editor Dom nicastro

E-mail [email protected]

Questions? Comments? Ideas?

Patient Access AdvisorPage �

© 2007 HCPro, Inc.


november 2007

Like many hospitals, West Virginia University Hospital

(WVUH) in Morgantown had a way of tracking and man-

aging details that resembled a game of scavenger hunt.

A denial would come in from an insurance company or

Medicare and often sit on someone’s desk or in-box for

days or weeks. The denial notice would then get passed

around and sometimes make it to the proper person or

department, and sometimes not. Once the notice found

its proper home, a mad scramble would ensue to reverse

the denial, but without a formal plan intact, WVUH was

successful only about half the time.

“Our denials were falling through the cracks,” says

Christy Whetsell, BSB, RN, MBA, director of care

management at WVUH. “Nobody really knew what to do

because we lacked a protocol and didn’t have a solid sys-

tem in place.”

To help streamline denials and organize an official

policy, a multidisciplinary team consisting of directors

from case management, patient access, finance, and the

executive suite got together and mapped out an entirely

new denial management protocol. The first plan of action

was to designate centralized headquarters for all denials

coming through the system, says Whetsell.

Because case management already worked as a liaison

between so many departments and followed patients

across the continuum of care, the team voted unani-

mously to make it the gatekeeper of denials.

However, being the gatekeeper didn’t mean that case

management would take responsibility for all denials, just

help direct them, says Whetsell.

“The next crucial step we took was to help define all

the different types of denials and assign who would be

responsible for each type,” says Whetsell.

For example, case management would oversee inpa-

tient denials while patient access would handle all preop-

eration denials.

“Assigning responsibility was huge, because before

everybody was essentially responsible, which meant

nobody was responsible,” says Whetsell.

Once WVUH’s denial infrastructure was in place, the

multidisciplinary team focused on the communications

component—getting the word out to payers. Whetsell

sent out letters to all the different insurance companies

explaining that all denial notices should be sent to the

case management department.

“We had to get everyone on the same page, both inter-

nally and externally,” says Whetsell. “Insurance compa-

nies would send notices to physician’s offices, to different

departments, and they would get lost in the maze. We

spent a lot of time reaching out to payers to get them to

understand our new system.”

To help get the word out, Whetsell began her public

relations campaign by:

Developing individualized relationships with pay-

ers through phone calls, e-mail, and scheduled

teleconferences

Using associations with patient access and patient

financial services to communicate to payers using

template language about how denials were to be

delivered to the hospital

Attending regularly scheduled payer update meetings

After establishing key contacts with each of the payers

and adequately getting the message out about how and

where to send denial notices, the next step for Whetsell

and the interdisciplinary team was to focus on the inter-

nal steps of denial management.

enter technology

Even though case management was elected headquar-

ters of denials, a centralized electronic database was creat-

ed, allowing anyone involved in the denials process access

➤

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Case study

Denial management: Collaboration between front-end departments can result in significant improvement

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november 2007

to information about any denial, any time. “Anyone can

access the database and submit information about a deni-

al, and the program will automatically send the denial to

the appropriate person or department responsible,” says

Whetsell. “This way, everybody knows we have a denial

out there and knows who’s handling it.”

Case management checks the database daily, moni-

tors start and end dates, and tracks the response activity

between the hospital and payers.

“Centralizing our denials has improved the speed in

which we submit and track denials and has enhanced

everybody’s awareness about their part in denial man-

agement,” says Whetsell.

tag-team effort

The final and perhaps most important step in WVUH’s

new denial management program is the ongoing dia-

logue and collaboration among case management, patient

access, and physicians, says Whetsell.

The three departments now have monthly meetings

to discuss denials, and directors at every level are more

involved.

Whetsell says her new role at these meetings is that

of translator because she’s able to talk numbers with the

finance people and clinical-speak with the physicians and

anyone else involved in medicine.

“I translate what the other person needs to hear,

because finance does not understand the clinical

complications that may be preventing a patient from

going home, and the clinicians don’t understand lan-

guage such as ‘your LOS is up,’ ” says Whetsell. “I help

bridge the perspectives, and this helps with fighting

denials.”

A strong new foundation combined with contin-

ued collaboration has paid off in a big way for WVUH.

Since overhauling its entire denials management pro-

gram two years ago, the hospital has seen the following

improvements:

Physicians now seeking information related to their

denials and actively participating in the appeal process,

which leads to stronger appeal letters

A decreased turnaround time with appeal submissions

and financial resolutions

Overall denial awareness from every healthcare pro-

fessional involved in patient care

The biggest mark of success, however, is in the hospi-

tal’s bottom line.

In 2005, before revamping its denials management

program, WVUH had a denial reversal rate of 50%, com-

pared to 2007 when 80% of all denials were reversed in

the hospital’s favor.

“We’ve improved because of our tracking methods,

interdisciplinary collaboration, and relationships with

payers,” says Whetsell. “If we didn’t make these changes,

we’d be in the same boat.” n

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november 2007

Editor’s note: Check out some of the questions your peers

asked during HCPro’s September audioconference “Inpatient

vs. Observation Status: Managing levels of care to ensure com-

pliance and reimbursement.”

The following responses are informational only and should

not be taken as official answers to the services described in the

clinical scenarios below. Our audioconference speaker Deborah

K. Hale, CCS, has provided her guidance in an attempt to help

hospitals sort through a number of observation status issues,

but each hospital should determine how to overcome its own

individual challenges. If you should need further clarification

or if you disagree with a response, we urge you to request guid-

ance from the appropriate healthcare professionals or regula-

tory agencies.

If a patient is in observation status for three days and

then converts to inpatient on day four, can the hospital

bill for observation status and the inpatient hospitalization?

For a Medicare patient, all diagnostic services pro-

vided within 72 hours (three calendar days) of the

inpatient admission order are rolled into the inpatient

account paid by DRG. The time in observation is not

separately paid, and the days don’t count toward the

acute care length of stay. This becomes a problem when

the patient requires skilled nursing facility care and does

not have enough inpatient days to achieve the three-day

qualifying stay. The observation days don’t count.

We are a small critical access hospital in rural

Wisconsin that does not have a 24-hour, seven-

day-a-week pharmacy in our town. We have analyzed

the numbers, and it’s just not cost-effective to have a

drug-dispensing machine at our facility. I’ve heard that

some hospitals just do not bill for drugs given out dur-

ing certain off-peak times, but I thought we had to bill

all Medicare patients the same. Could you clarify this?

Would you treat self-administered drugs and take-home

drugs the same?

Take-home drugs are to be billed with revenue code

253 (take-home drugs) and should be billed to the

patient, or the payment may be collected at the time of

service. Medicare does not cover these drugs for home

use, and the hospital must implement a process to iden-

tify take-home drugs. Self-administered drugs are those

drugs that can usually be self-administered by the patient

and are not integral to the treatment or procedure in the

outpatient setting. CMS clarified this in the 2003 OPPS

final rule and gave examples. This is also stated in CMS

Transmittal A-02-129.

If a patient is admitted to observation for chest

pain with negative enzymes, no EKG changes, and

has been in the hospital for 24 hours, and the physi-

cian decides to do a heart cath prior to discharge on the

second day, should this patient be changed to inpatient

after 24 hours? Additionally, if an outpatient cath patient

is kept in the hospital overnight for monitoring, should

he or she be changed to inpatient? Are there any specific

references/guidelines in the CMS manuals to cover these

types of situations, or anything related to chest pain

observation, heart caths, stents, etc.?

It is difficult to determine the appropriate steps

without reviewing the medical record. If all markers

continue to be negative and the patient is pain free and

has no other indicators for admission, most likely the

patient should remain as an observation patient. Please

understand that my response is not medical advice, and

only a physician should make a determination regard-

ing medical necessity of admission. See Medicare Benefit

Policy Manual, Chapter 1. In a PPS hospital (not critical

access), hospitals do not receive a separate observation

payment for chest pain if a status T procedure is provided

during the visit. Cardiac cath is a status T procedure. The

patient would continue to be considered an outpatient

if the continued stay and scheduling of the cath was for

the convenience of the physician, patient, or patient’s

Answers to your toughest observation inquiries


© 2007 HCPro, Inc.


november 2007

family. If there are risk factors that would make it unsafe

to send the patient home without performance of the

cath, and those factors are well documented in the medi-

cal record along with a timely inpatient admission order,

a physician reviewer might be convinced to approve the

inpatient stay.

We are a hospital that has a hemodialysis unit within

our organization. The certification of need for this

unit states that it is an inpatient facility and we cannot bill

for outpatient hemodialysis. We run into the following

scenario frequently: A patient comes to the facility with a

malfunctioning graft of some sort, and it is repaired as an

outpatient procedure. However, before the patient is dis-

charged, the physician would like to use the site to ensure

that there are no complications, or it is the patient’s

dialysis day and the physician wants the patient to receive

services before he or she leaves the hospital. If a patient

has been placed in observation status, is it appropriate to

change the status to inpatient because we are not allowed

to bill outpatient dialysis? Does this billing rule supercede

the observation status rule?

Several concerns come to mind. If the patient is an

outpatient surgery patient, observation would not be

appropriate for the routine recovery associated with this

procedure. If the patient develops a complication that

requires more than 4–6 hours of additional care, obser-

vation could be ordered for this additional time with

good documentation of the physician’s rationale. During

this recovery time, the patient’s need for dialysis may be

covered by billing HCPCS code G0257.

If an order to admit a patient is written by the attend-

ing physician and a locum tenens writes the discharge

orders to include “discharge patient and change patient

status to observation,” how should we bill the claim and

would additional documentation be required?

The initial order to admit as inpatient stands, and

the case is billed as an inpatient admission unless the

hospital’s utilization review committee has deemed the

admission unnecessary, and the appropriate procedure

is followed for billing as Condition Code 44 (if reviewed

and decided before discharge) or 121 (if determination is

made after discharge).

Education for locum tenentes, hospitalists, etc., is criti-

cal to comply with Medicare regulations.

We are having a hard time getting stop times docu-

mented. With IV fluid infusion—both intravenous

piggyback and longer maintenance fluids—if the volume,

start time, and infusion rate are clearly documented, is this

sufficient to calculate infusion time? Keep in mind we have

a policy of charting by exception if there is a problem.

Adequate documentation would include the begin-

ning and ending times of all infusion therapy, includ-

ing infusion hydration.

There are Medicare fiscal intermediaries that are per-

forming probe reviews on drug administration services,

such as Trailblazers, and they are stating that if the start

and end times are not documented for an infusion thera-

py, then it is not billable.

We recommend that facilities use a drug administra-

tion documentation form, which will prompt nursing

staff for all required documentation for injections and

infusion therapy. This form should be used in all out-

patient settings where drug administration is performed

(e.g., ED, observation, treatment room, chemotherapy,

and wound clinic).

If an on-call doctor admits a patient from the ER to

observation, and the attending doc comes in the

next day and changes the status to inpatient, should the

bill be separate for observation and inpatient, or will the

ER and observation be included in the inpatient bill?

All diagnostic services provided within 72 hours

(three calendar days) are rolled into the inpatient

admission and paid by DRG. (Exception: critical access

hospitals.) n


© 2007 HCPro, Inc.


november 2007

The following are FAQs CMS posted on its Web site

in regard to its July implementation of the “Important

Message from Medicare” requirement. You can read the

FAQs in their entirety at www.cms.hhs.gov/BNI/Downloads/

WeichardtFrequentlyAskedQuestionsJuly2007.pdf.

Representatives

When a patient is not competent, the representa-

tive cannot be located, and/or there is no current

phone number or address, what process meets CMS

requirements?

We recognize that any type of notice delivery

requirement, particularly in the acute care set-

ting, raises questions about authorized representatives.

However, the need to identify appropriate individuals

to deal with in these situations is not new or limited to

these notices.

Thus, hospitals should have processes in place for

identifying an individual who can act on behalf of an

incompetent patient. In some cases, state law addresses

cases where hospitals, nursing home administrators, or

the like can act as representatives or guardians for pur-

poses of making these decisions.

A representative cannot be reached by phone,

e-mail, or fax. For contact by certified letter, must

a hospital keep the patient until it gets the signed card

back by U.S. mail?

Providers have the flexibility to select a means of

delivery that is most appropriate for their opera-

tions (e.g., U.S. mail, FedEx, UPS, or a phone/faxed

response). If a representative is to be contacted using

certified U.S. mail, hospitals should initiate the process in

a timely fashion that will allow return of the card before

discharge. If the card indicates a refusal to sign or that

the notice is undeliverable, the hospital may proceed

accordingly. (Please refer to the Manual Instructions in

Chapter 30, Section 200.3.1, “Delivery of the Important

Message from Medicare,” subsection “Notice Delivery to

Representatives,” of the Medicare Claims Processing Manual.)

Documentation of the IM follow-up copy

If hospitals use a new blank IM for the follow-up copy

and obtain a signature on the form, do they keep

that form in the medical record (permanent) or do they

just give it to the patient?

You may either make a copy of the new signed IM

and put the copy in the patient record, or keep the

signed page 1 for the medical record and give page 2 to

the patient.

Inpatient to inpatient transfers

Two hospitals have different Medicare ID (provider)

numbers. Patients are transferred from one facility

to the other for other inpatient care. Sometimes patients

are returned to the initiating facility, whereas other times

they remain at the second facility to later be discharged

or moved to a lower level of care. Does the sending hos-

pital need to issue a follow-up copy of the IM? Does the

receiving facility need to issue a new IM?

Regardless of the hospital affiliation, the receiv-

ing hospital would provide a new IM if the transfer

involves different Medicare ID (provider) numbers.

However, no follow-up copy is needed prior to leaving

the sending hospital/unit if the transfer is an inpatient to

inpatient hospital level of care. The hospital ultimately

responsible for discharging the patient (i.e., releasing or

lowering the level of care) would provide the follow-up

copy if more than two days have passed since the last IM

was delivered.

Whenever the sending and receiving units have the

same provider number, no follow-up copy and no new

IM is required. The hospitals would operate as if it is

continual inpatient care from the same facility. n

CMs: ‘Important Message from Medicare’ FAQs

Emergency department scripting

A supplement to Patient Access Advisor November 2007

CP—Care personnel (i.e., nurse, nurse’s aide, licensed practical nurse)

PT—Patient

PSR—Patient service representative

CP (escorting): “Please let me escort you to our checkout area.”

PT: “Okay, thank you.”

CP (directing): “Please let me give you directions to our checkout area. They are printed here (handing the

patient written directions), but I will also review them with you before sending you on your way.”

PT: “Okay, thank you.”

If patient/guarantor asks what will happen at the checkout area . . .

CP: “Our checkout area is where we will verify all of the information we have recorded. We want to be sure that

we file your insurance claim quickly and correctly.”

If the patient/guarantor states that there is no insurance coverage . . .

CP: “Thank you. I understand. However, our checkout area will still need to verify the information you have pro-

vided for our billing records.”

If the patient/guarantor expresses concern about proceeding to the checkout area . . .

CP: “I’m sure when we/you arrive at the checkout area, they will be able to answer any questions you have.”

CP has successfully escorted/directed the patient/guarantor to the checkout area . . .

PSR : “Good morning/afternoon [applicable title and name[. Thank you, ______________ [name of CP if escorted

to PSR]. My name is ______________ and I am a patient service representative here at [name of hospital].

I’m sorry an emergency brought you here today, and I hope things are better now. Let me explain quickly

what we will be doing. Is that okay?”

PT: “Yes” or “no.”

PSR (if “no”): “What may I help you with before we go on?”

Note: Based on the response, it may be necessary to reconnect with the CP or allow the PT time to take care of

some immediate need (i.e., going to the restroom, getting a beverage, handing off a child, etc.).

Training ToolTraining Tool

Emergency department scripting (cont.)

PSR (if “yes”): “I just need to review some of the information you have provided. We want to be sure we have

complete and accurate information to file a claim with your insurance company. Let’s go over this quickly,

and please feel free to interrupt me if you don’t understand something or if we have recorded something

incorrectly. Does that sound alright to you?”

PT: “Yes” or “no.”

Source: Scripting developed by The Cleveland Clinic Health System and provided by Southwest General Healthcare Patient Access; 2004. Reprinted with permission from Wolfskill & Associates, Chardon, OH, www.wolfskill.com.

November 2007 A supplement to Patient Access Advisor

Documents

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