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Understanding nuances of patient status and therapeutic services

Learning objective

At the completion of this educational activity, the learner will be able to:

• Identify strategies to comply with condition code 44 and the Medicare Outpatient Observation Notice (MOON), and understand rules related to some aspects of therapeutic services.

Assigning the correct patient status is a constant challenge for hospitals and the case managers who are charged with ensuring these decisions are accurate. CMM often gets questions from readers on related topics and we forward them to our experts to get the answers. This month’s questions were answered by Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at Accretive Health in Chicago. 

Q: If a Medicare patient is downgraded from inpatient to observation is it expected that the patient will be issued the MOON and condition code 44 will be used on the claim? 

A: First, it must be noted that all patients who are downgraded using the condition code 44 process are being downgraded from inpatient status to outpatient status. If the patient then needs continuing hospital care (i.e., is not ready to be discharged), then observation can also be ordered. If observation is needed and is ordered, the MOON will be required only if the patient receives observation for 24 or more hours from the time of this order for observation services.  

Q: I have a question about how to interpret the CMS Standard Operating Procedures. If a requisition/order for physical therapy treatment is received at a hospital facility and is not authenticated (e.g., signed, timed, dated) by a community physician who is not credentialed at the hospital, is it true that facility can begin treatment but the order must be authenticated when it will be filed in the record?

A: Therapy services (e.g., physical, occupational, speech-language pathology) are unique in that an actual order from a physician or non-physician practitioner is not required (see the Medicare Benefit Policy Manual, Chapter 15, Section 220.1, at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf). The following is required:

• The patient must be under the care of a physician
• The therapy must be provided under a plan of care
• The physician must certify that plan of care by way of signature and date

In this case, the therapy provider may develop a plan of care and forward it to the physician for certification. Treatment may begin while awaiting the return of the signed plan of care. But the organization staff should do their best to get the signed certification returned within 30 days of start of therapy services.

Because the physician is not on the medical staff, the therapy provider may want to confirm that the physician is enrolled with Medicare and therefore eligible to order and certify services on Medicare recipients.

Got a question on any case management topic that you’d like to ask our experts? Email it to Kelly Bilodeau at [email protected].

Bonus question

Q: What do you do with a patient who does not have a safe discharge plan, but does not meet inpatient criteria and has been in observation status for 48 hours?

A: The original instruction from CMS that still stands is that we give the patient an advance beneficiary notice that says his or her care in the hospital setting is no longer medically necessary and is not being billed to Medicare and that he or she will be financially responsible.

Sample form: Boost documentation improvement efforts as a team

Case management and clinical documentation improvement (CDI) specialists share a common goal: improving documentation, which is critical to quality care.

But all too often the two groups are working separately to achieve it. "Everyone is operating in a silo," says Glenn Krauss Glenn Krauss, BBA, RHIA, CCS, CCS-P, PCS, FCS, CPUR, C-CDI, CCDS, director of enterprise solutions at ZirMed in Chicago. To help the two groups work together more effectively, Krauss decided to develop a quick and easy reference guide that can be used to help foster collaboration.

"I put this form together based on my experience with denials and from reviewing denials for medical necessity," he says. "My goal was to create a document that educates CDI and case management so they can work together, collaboratively."

Working together as a team, CDI and case management can ensure that the patient moves along the continuum of care smoothly and is treated in the right setting at the right time for the right reasons. They can also ensure the proper terminology is in the report to ensure accurate payment.

The form below describes some of the most common documentation lapses, so CDI and case management can work together to address them.

"If you don’t have good processes in place to work together you may have the best value-based care in the hospital, but there is no real value if you don’t get paid," says Krauss.

HCPro.com – Case Management Monthly