News You Need to Know in the Auditing World

From LOS to CC 44 and the Pepper Report, important news, and updates.

Last week was (thankfully) a boring regulation week. So instead of working to interpret new rules, I was able to do some real work. These last few weeks I have been working on the third edition of my book that I am co-authoring with Stefani Daniels on Hospital Utilization Review. Some of you may know Stefani- she has been working in case management for a very long time. She has helped many hospitals redesign their case management program over the years. To tell you Stefani’s devotion to her work, she first told me in 2017 that she is retiring yet here we are in 2021 collaborating. One of the other reasons I like Stefani is that she agrees with me that length of stay is a terrible metric. Anyways, as I was writing sections, I got to the condition code 44 section. The bulk of the section required no edits since the Medicare condition code 44 process has not changed since 2004 and I was going to move on but then I recalled the RACmonitor article by Dr Juliet Ugarte Hopkins on condition code 44. Reading that article was a huge “aha” moment for me. That article made me realize that condition code 44 was just a number and not a process and we had all been misinterpreting it. So the book now has an in-depth explanation of condition code 44 as it applies non-Medicare payers.  Now if you don’t recall reading that article on RACmonitor news, look it up and read it or even better wait until fall and buy a copy of the third edition of the Hospital Guide to Contemporary Utilization Review.  

Last week I did a review of a health system’s latest PEPPER. This system had several measures where they were a low outlier. Now being a low outlier is good in that no auditor will waste their time with you, but you must decide if maybe you are too conservative and leaving money on the table. Are you doctors documenting thoroughly or do you need to call Dr. Erica Remer for a chart audit and education? The concern was that this system had an academic medical center and really sick patients. On the call, the physician advisor asked a very interesting question. What if they were doing everything right but many other hospitals were ignoring the rules? How profound. And other data in the PEPPER may support that. The PEPPER data shows that about 20 percent of hospitals in the nation did all their Medicare total knee arthroplasties as inpatient from 2018 to 2020 when it was no longer inpatient only. Do all their patients require a stay over two days or are they all at high risk or were they admitting all as inpatient because no one was auditing?

There are over 5,000 hospitals in the country. There are hundreds of compliance areas where hospitals can stretch the rules or even totally ignore them.  And when they do that, the hospitals that are following the rules have their data look like they are underperforming. This goes back to what I said at the beginning- that length of stay is a terrible measure. Likewise, I dislike the term “benchmark rate.” Whose benchmark? Whose data contributed to that benchmark? If the benchmark consists of those hospitals that are flaunting the regulations, is that really the goal you want to attain?

Programming Note: Listen to Dr. Ronald Hirsch conduct his Monday rounds during Monitor Mondays, 10 Eastern, sponsored by R1 RCM.