RACs focus on details, admission orders
Focus on level-of-care orders
During the Recovery Audit Contractor (RAC) demonstration project, the auditors were extremely focused on the level-of-care orders to the point of denying admissions that did not have a clear admission order such as "admit to inpatient." That is not likely to change as the permanent RAC program begins, says Deborah Hale, CCS, president of Administrative Consultant Services LLC, a health care consulting firm based in Shawnee, OK.
In one instance, a patient presented to the emergency department in acute respiratory failure. She was intubated and the physician wrote the order to admit her to the critical care unit. The patient died three days later. When the RAC reviewed the case, the auditors denied the claim, saying the physician didn't specify the level of care, Hale says.
In the RAC demonstration project, the physician order took precedence over everything else when auditors reviewed the files, and the RACs recouped a lot of money for inadequate or incomplete admission orders, Hale points out.
If there is not a specific order to admit a patient to a specific level of care and the chart is reviewed, the RACs are likely to deny the claim and recoup the money, Hale says.
"No matter how critical the patient's condition was, if the order for the level of care was not accurate when the patient was admitted, the claim was denied and the money was recouped during the demonstration project. When you are looking at medical necessity of an admission, so much hinges on the date and time of the admission order," she says.
Case managers should ensure that all patients who are admitted have an admission order signed by a physician in order to meet the requirements of the Centers for Medicare & Medicaid Services (CMS). The order should clearly state the level of care the patient requires, and the time and date must be recorded, Hale says.
"An admission order signed by a physician is critical for an inpatient stay, and the patient is not considered an inpatient until the physician issues the written order. The order must clearly define and state the level of care the patient requires. Having an admission order that is fully documented is critical to so many issues," she explains
The admission date and time determine the principal diagnosis because they reflect the patient's condition at the time the order was written.
The date and time of the admission order also are important now that hospitals have to document what conditions are present on admission, she says.
In addition, the timing of the order can affect the three-day stay that qualifies patients for a skilled nursing facility.
The order cannot be backdated, Hale adds.
"You can't go back and clarify an order after the fact. If the order isn't clear, it has to be clarified immediately, and not after discharge," she explains.
Ensure physicians follow guidelines
Case managers often report that it is difficult to get physicians to fully document the admission order.
But CMS asserts that it is the hospital's responsibility to educate the physicians and ensure that they follow the Medicare guidelines, Hale adds.
If your hospital has an electronic order entry system, develop standardized admission orders that prevent the physician from ordering anything until the admission and the level of care is documented, she suggests.
If you're still using paper orders, develop standardized order sets for various diagnoses and include checkboxes for inpatient, outpatient, or observation, she adds.
Make the nursing staff aware that all admissions need an order for level of care.
"Nurses need to be aware that if they do not have a level-of-care order, they should clarify it with the physician immediately, just as they would a medication order. You're not asking the nurse to make a level-of-care determination but to ensure that the physician does so," Hale says.
During the Recovery Audit Contractor (RAC) demonstration project, the auditors were extremely focused on the level-of-care orders to the point of denying admissions that did not have a clear admission order such as "admit to inpatient."You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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