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Chapter 2 - Observation Medicine – Key Concepts: How to Start (and Maintain) an Observation Unit: What You Need to Know

Administrative Issues

from Part I - Administration: Key Concepts of Observation Medicine, and Developing and Maintaining an Observation Unit

Published online by Cambridge University Press:  31 March 2017

By
Sharon E. Mace
Edited by
Sharon E. Mace
Sharon E. Mace
Affiliation:
Department of Emergency Medicine, Cleveland Clinic, Ohio
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Type
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Information
Observation Medicine
Principles and Protocols
 , pp. 11 - 22
Publisher: Cambridge University Press
Print publication year: 2017

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References

References: Overview

Medicare Payment Advisory Commission. A Data Book: Health Care Spending and the Medicare Program. June 2012. Section 7. www.medpac.gov/documents/Jun12dataBookEntireReport.pdf (Accessed March 2016)Google Scholar
Feng, Z, Wright, B, Mor, V. Sharp rise in Medicare enrollees being held in hospitals for observation raises concerns about causes and consequences. Health Aff (Millwood) 2012; 31(6): 1251–1259.CrossRefGoogle ScholarPubMed
MedPAC report to Congress: hospital inpatient and outpatient services. www.medpac.gov/documents/mar14_EntireReport.pdfchapters (Accessed March 2016)Google Scholar
MedPAC report to Congress: hospital inpatient and outpatient services. www.medpac.gov/chaptersMar13_Ch03.pdf (Accessed March 2016)Google Scholar

References: Two-Midnight Rule

Centers for Medicare and Medicaid Services inpatient prospective payment system 1599-F. Fiscal year 2014 Final rule. www.gpo.gov/fdsys/pkg/FR-2013-08-19/pdf/2013-18956.pdf (Accessed March 2016)Google Scholar
Sheehy, AM, Caponi, B, Gangireddy, S, et al. Observation and inpatient status: clinical impact of the 2-midnight rule. Journal of Hospital Medicine 2014; 9(4): 203–209.CrossRefGoogle ScholarPubMed
www.healthcapital.com/hcc/newsletter/01_14/2-Midnight%20Rule.pdf (Accessed March 2016)Google Scholar
Society of Hospital Medicine Public Policy Committee. The Observation Status Problem. Impact and Recommendations for Change. Society of Hospital Medicine Whitepaper, July 2014. Available at www.hospital medicine.org/advocacy (Accessed March 2016)Google Scholar
www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30-4.html (Accessed March 2016)Google Scholar

References: Background

Centers for Medicaid and Medicare Services. CMS finalizes FY 2014 policy and payments changes for inpatient stays in acute-care and long-term care hospitals. www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-Sheets-Items/2013-08-02–2.html (Accessed March 2016)Google Scholar
Ross, MA, Hockenberry, JM, Barrett, M, et al. Protocol driven emergency department observation units offer savings, shorter stays and reduced admissions. Health Affairs 2013; 32(12): 2149–2156.CrossRefGoogle ScholarPubMed
Baugh, CW, Schur, JD. Observation care – high-value care or a cost-shifting loophole? New Engl J Med 2013; 369(4): 302–305.CrossRefGoogle ScholarPubMed
Baugh, CW, Venkatesh, AK, Hilton, JA, et al. Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year. Health Affairs 2012; 31(10): 2314–2322.CrossRefGoogle ScholarPubMed
Mace, SE, Graff, L, Mikhail, M, et al. A national survey of observation units in the United States. Am J Emerg Med 2003; 21: 529–533.CrossRefGoogle ScholarPubMed
Mace, SE, Shah, J. Observation medicine in emergency medicine residency programs. Acad Emerg Med 2002; 9:169–171.CrossRefGoogle ScholarPubMed
Graff, LG. Observation Medicine: The Healthcare System’s Tincture of Time. American College of Emergency Physicians Web site: www.acep.org/WorkArea?Download/Asset.aspx?id=45885 (Accessed March 2016)Google Scholar
Venkatesh, AK, Geisler, P, Gibson Chambers, JJ, et al. Use of observation care in US emergency departments, 2001 to 2008. PLos ONE 2011; 6(9):1–10 (e24326).CrossRefGoogle ScholarPubMed
Baugh, CW, Venkatesh, AK, Bohan, JS. Emergency department observation units: a clinical and financial benefit for hospitals. Health Care Manage Rev 2011; 36(1): 28–37.CrossRefGoogle ScholarPubMed
Osborne, A, Weston, J, Wheatley, M, et al. Characteristics of hospital observation services: A Society of Cardiovascular Patient Care survey. Critical Pathways in Cardiology 2013; 12(2): 45–49.CrossRefGoogle ScholarPubMed
Department of Health and Human Services (DHHS) Centers for Medicare and Medicaid Services (CMS). CMS Manual System Pub. 100-02 Medicare Benefit Policy. Transmittal 42. Date: December 16, 2005. Available at www.cms.gov/Regulations-and-Guidance/Transmittals/downloads/R42BP.pdf (Accessed March 2016)Google Scholar
Sheehy, AM, Caponi, B, Ganigreddy, S, et al. Observation and inpatient status: clinical impact of the 2-midnight rule. J Hosp Med 2014; 9(4): 203–209.CrossRefGoogle ScholarPubMed
Centers for Medicare and Medicaid Services Hospital inpatient prospective payment system 1599-F. Fiscal year 2014 Final rule. Federal register/Vol. 78, No.160/Monday, August 19, 2013/Rules and Regulations. www.gpo.gov/fdsys/pkg/FR-2013-18956.pdf (Accessed March 2016)Google Scholar
Don’t ignore the two-midnight rule. It’s still in effect. Hosp Case Manag 2014; 22(5): 57–66.Google Scholar
CMS announces delay in two-midnight rule enforcement. Hosp Peer Rev 2014; 39(4): 37–38.Google Scholar
www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html) (Accessed March 2016)Google Scholar
Carlson, J. Auditing inpatient stays. “Two-midnight” rule may still prove costly. Mod Healthc 2013 September 9; 43(36):9–10.Google ScholarPubMed
Is the two-midnight rule much ado about nothing? Hosp Case Manag 2013 December; 21(12): 161–164.Google Scholar
Egusquiza, D. 8 critical steps for 2-midnight compliance. Healthc Financ Manage 2014 February; 68(2): 54–57.Google ScholarPubMed
Edelberg, C. A. closer look at the two-midnight rule, what it means for ED providers. ED Manag 2013 December; 25(12): 142–143.Google Scholar
Cesta, T. Case management insider. The 2-midnight rule – a game changer for case management. Hosp Case Manag 2014 April; 22(4): 47–50.Google Scholar
www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls- and-Events.html (Accessed March 2016)Google Scholar

References: PEPPER Report

PEPPER can help you focus on likely RAC targets. Hospital Case Management; 2010 December; 18(12): 181–182.Google Scholar
PEPPER can identify areas where denials may occur. Hospital Case Management; 2005 June; 13(6): 84–86.Google Scholar
http://store.relearning.com/by-topic/pepper-1/pepper.html (Accessed March 2016)Google Scholar
Wiedemann, LA. Seasoning your compliance plan with PEPPER. How to read PEPPER data on payment errors; 2007 January; 78(1): 44–49.Google ScholarPubMed
www.hcpro.com/print/HOM-218293–5750/What-is-PEPPER-data-and-how-can -it-help-prepare-for-a-RAC-audit? (Accessed March 2016)Google Scholar
TMF Health Quality Institute http://pepperresourcs.org/PEPPER/SecurePEPPERAccess.aspx ( Accessed March 2016)Google Scholar
Kulus, J. PEPPER gives corporate compliance guidelines. Provider: Long Term & Post-Acute Care. 2013 March; www.providermagazine.com/archives/2014_Archives/Pages/0314 (Accessed March 2016)Google Scholar
TMF health Quality Institute http://hospitals.tmf.org/PEPPERResources/tabid/1115/Default.aspx (Accessed March 2016)Google Scholar
www.hcpro.com/HIM-245049–865/Use-PEPPER-reports-to-stay-on-top-of-common-coding-errors (Accessed March 2016)Google Scholar
Corrati, RR. Report data identify risk areas for improper payments. Healthcare Financial Management 2011 October; 65(10): 88–92.Google Scholar
Report on Medicare Compliance: PEPPER compliance tool is revised for two-midnight rule in time for June release. Atlantic Information Services, Inc. 2014 May; 23(16). Available online at www.AIShealth.com (Accessed March 2016)Google Scholar
Centers for Medicare and Medicaid Services. www.cms.gov/Medicare/medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY2014-IPPS-FinalRule (Accessed March 2016)Google Scholar

References: Criteria for Inpatient Admission or Observation

www.ngsmedicare.com/ngs/portal/ngsmedicare (Accessed March 2016)Google Scholar
www.careguidelines.com (Accessed 2016)Google Scholar
www.mckesson.com/about-mckesson/our-company/businesses/mckesson-health-solutions/interqual-evidence-based-clinical-content (Accessed 2016)Google Scholar
Mitus, AJ. The birth of interqual. Professional Case Management 2008; 13(4): 228–233.CrossRefGoogle ScholarPubMed
www.acep.org/Clinical–Practice-Management/Utilization-Review-FAQ (Accessed March 2016)Google Scholar
McKendry, MJ, Van Horn, J. Tips, tools and techniques. Case Management 2004; 9(2): 61–71.Google Scholar
Wang, H, Robinson, RD, Coppola, M, et al. The accuracy of interqual criteria in determining the need for observation versus hospitalization in emergency department patients with chronic heart failure. Critical Pathways in Cardiology 2013; 12(4): 192–196.CrossRefGoogle ScholarPubMed
Irwin, CB, Nigl, J, Lowe, RA. Accuracy of interqual criteria in determining the hospitalization need in medicare patients with gastrointestinal bleeding. Acad Emerg Med 2000; 7:552–553 (abstract).Google Scholar
Irvin, CB, Monfette, K, Lowe, R. Retrospective evaluation of potential Medicare admission denials using interqual and Milliman Roberts admission criteria. Acad Emerg Med 2000; 7:543 (abstract).Google Scholar
Rutledge, R. An analysis of 25 Milliman & Robertson guidelines for surgery: data driven versus consensus-derived clinical practice guidelines. Ann Surg 1998; 228(4): 579–585.CrossRefGoogle ScholarPubMed
www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R299CP.pdf (Accessed March 2016)Google Scholar
www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0622.pdf (Accessed 2016)Google Scholar
Confusion ahead as CMS changes inpatient criteria. Hospital Case Management 2013 October; 21(10): 133–136.Google Scholar

References: Inpatient Prospective Payment System (IPPS)

www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/index.html (Accessed March 2016)Google Scholar
www.cdc.gov/nchs/icd/icd9.htm (Accessed March 2016)Google Scholar
http://cms.gov/Medicare/Coding/ICD10/index.html (Accessed March 2016)Google Scholar
www.cdc.gov/nchs/icd/icd10cm.htm (Accessed March 2016)Google Scholar
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ICD-10-CM. Official Guidelines for Coding and Reporting –Fy 2015. Department of Health and Human Services, 2015. ,Google Scholar
Gabber, W, Kachur, KH, Canter, KV. Current Procedural Coding Expert: CPT Codes with Medicare Essentials Enhanced for Accuracy. American Medical Association, 2011.Google Scholar
www.medicare.gov/what-medicare-covers/part-a/what-part-a-covers.html (Accessed March 2016)Google Scholar
www.medicare.gov/what-medicare-covers/part-b/what-medicare-part-b-covers.html (Accessed march 2016)Google Scholar
www.acep.org/Clinical–Practice-Management/Utilization-Review-FAQ (Accessed March 2016)Google Scholar

References: Medicare’s Hospital Payment Monitoring Program (HPMP)

www.cms.gov/apps/er_report/preview_er_report.asp?from=public&which=long&reportid=7&tab=3/ (Accessed March 2016)Google Scholar
www.pepperresources.org (Accessed March 2016)Google Scholar
www.primaris.org/sites/default/files/resources/HPMP/hpmp%20info%20sheet.pdf (Accessed March 2016)Google Scholar
www.acep.org/Clinical–Practice-Management/Utilization-Review-FAQ (Accessed March 2016)Google Scholar

References: Observation Medicine Billing: The Controversy

Sheely, AM, Graf, B, Gangireddy, S, et al. Characteristics of patients with “observation status” at an academic medical center. JAMA Intern Med 2013; 173(21): 1991–1998.Google Scholar
Centers for Medicare and Medicaid Services. Are you a hospital inpatient or outpatient? www.medicare.gov/publications/pubs/pdf/11435.pdf (Accessed March 2016)Google Scholar
Centers for Medicare Advocacy Inc. Observation status. www.medicareadvocacy.org/medicare-info/observation-status#definition (Accessed March 2016)Google Scholar
Medicare Benefit Policy Manual. Chapter 6: Hospital Services Covered Under Part B. 20.5 –Outpatient Observation Services. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf (Accessed March 2016)Google Scholar
Baugh, CW, Schuur, JD. Observation care – high-value care or a cost-shifting loophole? N Engl J Med 2013; 369(4): 302–305.CrossRefGoogle ScholarPubMed
Society of Hospital Medicine Public Policy Committee. The Observation Status Problem. Impact and Recommendations for Change. Society of Hospital Medicine Whitepaper, July 2014. Available at www.hospital medicine.org/advocacy (Accessed March 2016)Google Scholar

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