Are You Leaving Compliant Revenue on the Floor in the OR?

As you may recall, last week I critiqued a webinar on the two midnight rule. As you will recall it was not pretty. Today I want to talk a little about another presentation I watched online. And just in case you are concerned about my computer time, I also watch television. And if you have not started watching The Pitt on HBO (I refuse to call if Max, just as I refuse to call the Sears Tower the Willis Tower or call Marshall Field’s Macy’s- you must stand for your principal!), you should. It is an amazingly accurate portrayal of hospital medicine today. And I was delighted when they bashed Press Ganey scores.

But I digress. The presentation I watched was the American College of Physician Advisors Town Hall on Observation. And it was great, addressing both medical and surgical observation. But the issue that really caught my eye was a case presentation of an 80+ year old patient, insured by Medicare.

The patient has diabetes and End Stage Renal Disease (ESRD) and was having a scheduled knee replacement. The discussion centered on the patient’s delayed recovery which did warrant an order for observation services.

My comment in the Q&A, which moderator Tiffany Ferguson properly ignored since it was off topic, was that this patient could have been admitted as inpatient preoperatively for their surgery based on the Medicare case-by-case exception. While we were not provided details about the state of their diabetes, and I am sure the clinical documentation integrity staff will be all over that doctor to be more specific in their documentation, I cannot imagine that anyone would try to suggest that a patient with ESRD on dialysis is not at high risk for any surgery.

Remember, the case-by-case exception for high-risk patients is not limited to medical patients or only emergent surgery; it can be applied whenever the patient is at higher risk due to the severity of their signs and symptoms, or the increased risk of an adverse event. Now of course you need documentation to support that decision; since the physician is making the determination based on that individual case, the notes must support the decision to admit as inpatient.

Now the other question is whether it is worth the effort to irritate the doctor to assess that risk and add that documentation and that’s a decision for you to make. I am sure the Medicare Trust Fund would be happy to pay you the lower rate, as would Medicare Advantage plans who are also bound by this rule. But I bet there are lots of times when such a patient needed to go to a nursing home after surgery for rehabilitation and you wished you had that inpatient order on the day of surgery instead of the second or third day.

And of course the money is a factor. I will be doing a brief tutorial on how to figure out what you get paid by Medicare in my upcoming RACmonitor webinar. And it can be interesting with payment differentials between inpatient and outpatient from $400 to almost $12,000. I don’t know the threshold for what makes asking a doctor for help worth it but these days it seems any extra compliant revenue should be sought.

Do the analysis and then build a process into your pre-operative process. These surgeries are elective and scheduled weeks in advance, so you have plenty of time to make it work. Your CFO will thank you.

Programming note:

Listen live to Dr. Ronald Hirsch every Monday morning on Monitor Mondays, sponsored by R1-Physcian Advisory Services, with Chuck Buck at 10 Eastern.