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September 26, 2011

May I See Your Order?
By Judy Sturgeon, CCS
For The Record
Vol. 23 No. 17 P. 6

When I first learned to code, we typically completed four or five inpatient admissions per hour. On days featuring plenty of obstetric and newborn charts, that number could increase to around seven to 10 charts per hour. We didn’t touch an admission until all documentation was in the chart. There were no queries to send or review, and we rarely saw—much less spoke to—a physician.

No one ever mentioned data quality or core measures reporting at meetings. No one had heard of data reporting for risk of mortality. There was no pressure to add codes for present on admission, severity of illness, or intensity of service. The only “SCIP” we did was out the door at 4:30 or to the pay window on alternate Fridays.

Each addition of a new coding and reporting responsibility detracts from productivity. Despite the gnashing of teeth by people whose budgets are subsequently affected, the responsible coding department is likely to shoulder each new burden to better serve the needs of the facility and its patients.

But let’s look at an old documentation issue. Does your inpatient coding team review the doctor’s admission order as a matter of course on each case? Typical responses often include the following:

• “It isn’t our responsibility.”

• “We already have to clean up everybody’s messes and misses.”

• “We can’t babysit everything.”

• “Isn’t that the doctor’s job?”

• “Isn’t that the case manager’s job?”

• “We can’t possibly do one more chore and still manage to code even one chart per hour.”

• “Hey, if it’s an admission when it gets to us, we code it as an admission. End of story.”

Did any—or all—of those responses come immediately to mind? Not many people would argue with any of them, but if your staff members aren’t already looking at physician admission orders, there are plenty of external and internal reasons why they should be.

Principal Diagnosis
The admission order may include documentation of the symptoms or even the definitive diagnosis for which the physician is requesting inpatient status. Should the diagnosis be further defined after study, this order can still help validate present-on-admission criteria for both principal and secondary diagnoses. The order may not always be the defining document for assigning the principal diagnosis, but it can contribute significantly to the final determination.

The date and time of the admission order can affect which diagnoses may be considered for principal diagnosis and diagnosis-related group (DRG) assignment. If the status changes to inpatient after a planned outpatient procedure or after a new condition develops that requires a higher level of care, the chief complaint or the reason for surgery may no longer be in the running for principal diagnosis. In its place, the coder will need to identify the complication or new problem that required the change from outpatient to inpatient status.

How the Chart Is Coded
Patient status affects codes and the rules that govern them. Outpatient cases will need CPT codes for procedures while inpatient cases will use ICD-9-CM for procedure codes. The criteria for selecting diagnosis codes can vary between outpatient and inpatient charts. For example, the former can use diagnoses from pathology and radiology tests for coding but cannot use “possible/probable” diagnoses, while the opposite is true for the latter.

Work Assignment
Some hospitals have staff dedicated to coding outpatient cases and separate coders to handle inpatient/DRG charts. Checking the order to validate inpatient vs. observation status prior to beginning coding can save both time and money because the chart won’t have to be redirected and recoded if an error is found after coding is completed.

Room rates for an inpatient stay tend to be significantly higher than those on the outpatient side. Remember that anything affecting charges also influences the facility’s cost-to-charge ratio, which in turn affects the overall rate paid by Medicare and Medicaid for the entire reporting period.

Bill Types
For DRG payers, the value of an inpatient payment can be more lucrative than if the same case were billed as an observation or emergency patient status. This applies not only to Medicare and Medicaid but also to the typical commercial payer.

Facility and Individual Risk
Anything that affects payment will eventually ping someone’s radar. If a facility isn’t requiring and monitoring physicians’ admission orders, then denial and recoupment are likely to be swift as well as deserved. Medicaid performs large and regular audits for medical necessity at its provider hospitals, and one of the many documents it reviews is the admit order. Auditors for commercial insurance payers are no exception.

All four of the nation’s recovery audit contractors (RACs) have posted an unnerving target: inpatient admissions without a physician’s inpatient admit order. The issue includes the reminder that “Admissions to the inpatient setting require a physician’s order in order to qualify and be paid as an inpatient stay.”

Connolly Healthcare, the RAC for region C, even includes handy references. Additional information can be found in the following manuals/publications: the November 27, 2006, Federal Register 42 CFR Part 482, page 2 requires authentication of orders for the care of the patient by a physician/ provider; the Medicare Benefit Policy Manual chapter 1 section 10; and the Medicare Claims Processing Manual chapter 3 sections 10 and 40.2.2

If the order is missing or does not match the status for which the patient is billed, the full payment will be recouped. What if the order was not made in a timely manner and the patient’s condition improved, or the treatment that justified inpatient status was already completed? The facility might be allowed to bill only for outpatient services or perhaps the full payment will be recouped.

And woe to the hospital that decides to change an erroneous Medicare inpatient status order to an observation order after the fact. There are myriad rules that must be followed and utilization review committees and physicians to consult. Additional documentation and patient notifications explaining copay and deductible changes are also required.

To make matters more complicated, Medicaid is beginning to institute a few similar restrictions on order status changes.

If a pattern of error is found on audit and determined to be due to ignorance, disregard, or malicious intent, the consequences increase exponentially. At risk are not only repayment directives, but also the possibility of triple indemnity fines, years of mandatory federal compliance oversight, loss of Medicare/Medicaid participation privileges, and even civil and criminal prosecution for the individuals involved.

Conscientious coders need to review a physician’s order for admission as part of determining the correct principal diagnosis. However, their responsibilities shouldn’t stop there. If there is no order, if the status is inpatient but the order is for observation (or vice versa), if the admit order is timed 10 minutes before the discharge order or is dated retroactively, the case needs to be reviewed by the appropriate department prior to billing whenever possible.

Be certain that the coding staff knows to refer any chart with one or more of these issues to a designated manager for review. Case management and/or the admitting department will need to be informed; they might wish to consider internal process improvement or increased physician education. The hospital billing department must be notified if the status is changed in case a claim is in process or has already been submitted. It will also need to have the corrected codes and the new DRG if those have been affected.

As one of the gatekeepers of medical documentation, the coding staff plays a major role in helping ensure clean processes, compliant billing, and fiscal security. If the same problems reoccur and if the source departments and/or the affected departments do not respond, coders must raise the issue with hospital administration.

After all, compliance is everyone’s responsibility.

— Judy Sturgeon, CCS, is the clinical coding/reimbursement compliance manager at Harris County Hospital District in Houston and a contributing editor at For The Record. While her initial education was in medical technology, she has been in hospital coding and compliance for 21 years.