Return to LYNX Lines Table of Contents

Admit status from the Emergency Department: Getting it right the first time

According to the Agency for Healthcare Research and Quality, more than 55% of hospital inpatient admissions originate in the Emergency Department (ED), which means timely and accurate patient disposition decisions have a significant impact on quality and revenue. Unfortunately, while most ED physicians are adept at documenting clinical decision making and risk management, their documentation is often insufficient to support timely and accurate disposition decisions. All too frequently these physicians are not familiar with the criteria for admission that must be documented to support the medical necessity for inpatient admission. Due to the 24/7 nature of the ED, there is often little or no guidance from case management for the ED physicians to identify which patients do not meet criteria. Each patient placed into incorrect status has financial, quality, and resource ramifications to the hospital.

Minnesota Medicine, February 2007, reported that incorrectly coding admission status for one patient per day could cost a hospital more than $1.9 million a year in lost revenues and put a hospital out of compliance with Medicare regulations.

The current process in the majority of settings involves case managers evaluating admissions from the ED for criteria after the patient has been admitted to the hospital. ED physicians rely heavily upon the inpatient Care Management team to identify and correct admit status when necessary. CMS's policies (outlined below) related to changing Medicare beneficiary status to outpatient when inpatient admissions are determined not to be medically necessary are laborious to say the least. In addition, off hours, weekends and holidays create even larger windows for patients to go all the way through to discharge in the wrong status.

The Hospital Condition of Participation (CoP,) requires all hospitals to have a utilization review (UR) plan. A hospital must ensure that all the UR requirements of 42 CFR 482.30 are fulfilled. The hospital is responsible to ensure that all the UR activities, including the review of medical necessity of hospital admission and continued stay is fulfilled as described in 42 CFR 482.30. Specifically:

• A UR committee consisting of two or more practitioners must carry out the UR function. At least two members of a hospital's UR committee must be doctors of medicine or osteopathy, and the other members may be any of the other types of practitioners specified in regulation.
• The determination that an admission or continued stay is not medically necessary must either by made by one member of the UR committee if the practitioner(s) responsible for the care of the patient either concurs with the determination or fails to present their views when afforded the opportunity, or by two members of the UR committee in all other cases.
• The UR committee must consult with the practitioner(s) responsible for the care of the patient and allow them to present their views before making the determination.
• If the UR committee determines that the admission is not medically necessary, the committee must give written notification, no later than 2 days after the determination, to the hospital, the patient, and the practitioner responsible for the care of the patient.

In some instances, a beneficiary may be admitted to an inpatient bed by the physician, but upon later review, determination is made that an inpatient level of care does not meet the hospital's admission criteria. The National Uniform Billing Committee (NUBC) issued Condition Code 44 effective April 1, 2004 to identify cases where such inpatient admissions were changed to outpatient:

For use on outpatient claims only, when the physician ordered inpatient services, but upon internal UR performed before the claim was initially submitted, the hospital determined the services did not meet its inpatient criteria.

In cases where status is changed from inpatient to outpatient following UR determination that criteria had not been met, the hospital can submit an outpatient claim to receive payment under the outpatient prospective payment system for medically necessary Medicare Part B services that were furnished to the patient provided the following conditions are met:

• The change in patient status from inpatient to outpatient is made prior to discharge or release from the hospital;
• The hospital has not submitted a claim to Medicare for the inpatient admission;
• A physician concurs with the utilization review committee's decision; and
• The physician's concurrence is documented in the patient medical record.

Upon review of these Medicare payment policies, it is clear that ensuring criteria are met and that the patient is placed into the correct status at the time of admission are key factors. Reallocating resources to the point of entry into the hospital (the ED) and providing tools to the staff to get it right the first time will save time, resources, and money.