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Medicare Regulation #Tweetorial time!
Determining status for Medicare patient undergoing elective surgery.
CMS is eliminating the inpatient only list over the next 3 years and started 1-1-21 with all orthopedic and most spine surgeries. So how do you determine status? 1/
Determining status for Medicare patient undergoing elective surgery.
CMS is eliminating the inpatient only list over the next 3 years and started 1-1-21 with all orthopedic and most spine surgeries. So how do you determine status? 1/
First, note this is Medicare FFS only. Every other payer, incl Medicare Advantage, gets to make their own rules.
Also, status affects hospital payment and not surgeon payment. But without money, hospital cannot buy new toys for surgeons to use in OR. 2/
Also, status affects hospital payment and not surgeon payment. But without money, hospital cannot buy new toys for surgeons to use in OR. 2/
Until list is gone, still need to refer to the list to see if surgery is inpatient only. https://www.ronaldhirsch.com/inpatient-only-lists.html If it is on the list, admit as inpatient no matter the length of stay, even if going home same day. 3/
If it's not on the list, need to apply the Two Midnight Rule and look at 4 factors-
1- Expected LOS
2- Actual LOS
3- Complexity of Surgery
4- Risk of Surgery from patient's medical conditions 4/
1- Expected LOS
2- Actual LOS
3- Complexity of Surgery
4- Risk of Surgery from patient's medical conditions 4/
Expected LOS- how many days will the patient need in hospital?
If going home same day, always outpt
If will not go home on POD#1 as standard of care for in-hospital recovery or due to patient factors, admit as inpt
(Docs cannot keep pt extra days just to get inpatient) 5/
If going home same day, always outpt
If will not go home on POD#1 as standard of care for in-hospital recovery or due to patient factors, admit as inpt
(Docs cannot keep pt extra days just to get inpatient) 5/
Joint replacements generally go home the same or next day but if the surgeon wants the patient to stay longer for specific reason like they have old CVA and wants to watch with therapy, or patient will need SNF, document and admit. 6/
If expected to go home on day of surgery or POD#1 but now too much pain/nausea/bleeding/lethargy, and needs to stay a second post-op day, document and admit as inpatient. 7/
If surgeon expects surgery to be more complex than the usual surgery, and documents that, admit as inpatient. for example, "Due to deformities, will be complex surgery." 8/
If patient's comorbid conditions increase risk of surgery, document that and admit as inpatient. Even if plan is to discharge the next day. "Due to diabetes and sleep apnea, patient at higher risk of complications." 9/
The preop evaluation is about assessing the risk and documenting that. Did you know a diabetic has a 4.5x risk of dying in hospital after joint replacement? That's a lot! https://www.ncbi.nlm.nih.gov/pubmed/28735804 10/
Please do not give @aoglasser nightmares by writing "clear for surgery" for any patient. Even if the problems are stable, they do increase perioperative risk and more monitoring will be done. 11/
I'll note here again that other insurers do not follow these rules. Many won't allow the diabetic to be inpatient unless they end up with DKA after surgery or the sleep apnea patient admitted until they require re-intubation. They want to see "risk realized." 12/
There is obviously a lot more to this and some controversy. I wrote an article about it that is pretty good (humble brag). https://www.racmonitor.com/the-demise-of-the-medicare-inpatient-only-list-the-myths-and-facts
And definitely talk to your physician advisor to get help. 13/
And definitely talk to your physician advisor to get help. 13/
I am grateful for all of you out there caring for patients and know that status for surgery patients is the least of your worries now, but CMS and the auditors are still watching and auditing and denying so we must follow the rules. @MedTweetorials @AmerCollPhyAdv end/
