ABQAURP News
Don’t Let Confusion About ‘Admission Criteria’ Stop You From Admitting
Some hospitals use McKesson’s InterQual admission criteria; some use MCG (formerly Milliman). Some managed care plans use InterQual, and some use MCG. The Centers for Medicare & Medicaid Services (CMS) has said it and its contractors may refer to either InterQual or MCG, but they don’t recognize either as the deciding factor in establishing payment. And of course there’s the two-midnight rule for Medicare. Some managed care plans have said they use both InterQual and the two-midnight rule, as did the recent announcement by the Quality Improvement Organizations (QIOs) that will be doing admission reviews, but they have not explained how they can be used in conjunction. And then there are the arbitrary payment decisions arising from managed care plans that don’t seem to follow any guidance except what’s best for the plan.
Amidst all this confusion, physicians are expected to apply their clinical judgment, document the decision-making process, and accurately determine billing status. No wonder they roll their eyes, raise their hands, and tell the utilization nurse, “Tell me what to write.” Aye, but there’s the rub: the landscape is so confusing that even when they know the proper status, it’s nearly impossible for them to explain it to physicians in the little time they have with their attention.
Using InterQual and MCG, the initial admission decision is based on meeting fairly rigid clinical criteria. If a plan accepts these criteria, which would be unusual, the decision is clear when criteria are met. But since published criteria can’t take into account the clinical complexities of real patients, they allow a secondary review by a trained physician to override the criteria and allow admission. But this is a subjective process and subject to retrospective review by health plans and Medicare auditors who may disagree with the physician’s decision and deny payment, hence the breakdown of a hopelessly overburdened Medicare appeal mechanism.
The Two-Midnight Rule
Complying with the two-midnight rule sounds simple. There are two criteria: 1. Does the patient require hospital care? and 2. Does the physician expect the care to require at least two nights (midnights) in the hospital? But whether that determination was justified and whether the thought process behind it was adequately documented leads to a whole new reason for denials when a patient goes home before reaching the second midnight benchmark.
To top it off, using both published criteria and the two-midnight rule together is an oxymoron. A patient could meet InterQual inpatient criteria but not have an anticipated two-midnight stay. Now what does the physician do? We have a pretty good idea what auditors will do, and that’s deny based on whichever criteria aren’t met. Unfortunately, unless CMS decides to scrap the current confusion and adopt simpler admission regulations, we are stuck with this chaos.
But what about admission of patients who have had a night in observation and aren’t going to be stable for release prior to the second midnight? CMS made this decision a lot easier when, under the two-midnight rule, it said that a patient should not spend two midnights of necessary hospital care as an outpatient. As long as the second midnight of hospital care is medically necessary (not needed due to delays in care or convenience factors), the patient should be admitted. That’s the case even if the physician’s plan is to send the patient home the next morning after completing the work up or treatment. And if for some reason the patient remains in the hospital past the second night without being admitted, CMS even allows an admission order any time prior to discharge. (The inpatient stay begins when the admission order is entered in the record and it must be authenticated prior to discharge.)
Confusion occurs all too often when case managers or utilization review nurses try to apply InterQual admission criteria to determine whether a patient should be admitted from observation. There are two things to keep in mind: 1. Observation is a short period of time that allows the physician to determine whether a patient needs to be admitted or can be sent home, and 2. Admission criteria only apply to the initial decision. If you are doing admission reviews, do not use admission criteria after a patient has spent a night in observation. Based on principle 1 above, if the patient isn’t ready to be released after a period of observation (you can use 24 hours as a guideline in the InterQual world, and it would be up to two midnights to Medicare), then the decision to admit is appropriate. And since according to 2, admission criteria are only for the initial admission decision, there’s no reason to refer to them for admission from observation. The decision to admit under InterQual, MCG, and the two-midnight rule is the same: As long as a patient requires continued care in the hospital after the appropriate period of observation, the patient should be admitted. CMS uses the second midnight as the cut off period. This is not the case for InterQual and MCG, but the principle is exactly the same.
So if you want to know whether a patient can be admitted from observation, put away your InterQual and MCG criteria and as the witching hour approaches, ask the physician one question: Can the observation patient be safely discharged? If the answer is no, have the physician document the reason the patient requires continued hospital care and write an admission order. Now you’re ready to bill for inpatient care and fight the auditors (and win) if they deny payment.
Quality Under the Affordable Care Act: Keys to Success!
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Health Care Quality and Management (HCQM) Certification
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