Guest Post: A peck of PEPPER, Part 3

by Linda Renee Brown, RN, MA, CCDS, CCS, CDIP

If you’ve started using your PEPPER to help you identify potential issues at your hospital, good for you!  In this final entry, I’m going to suggest you take it a step further—identifying charts that may fail for lack of medical necessity.

I’m pretty sure that a RAC bounty hunter will jump at the chance to overturn your admissions due to not meeting criteria. Nobody’s expecting you to become a case manager, but it  behooves all of us to gain an understanding of what documentation may survive a medical necessity audit.

Quite a few of the PEPPER medical necessity target areas involve what might be considered questionable diagnoses—including our old favorites, chest pain, TIA, back pain, and syncope—and some others that you might not have thought of as questionable, such as DRG 314-316 and DRG 393-395, as well as short stays in renal failure, vascular surgery, and heart failure DRGs. If you are a high outlier, review your short stay patients, to see if their documentation supports an inpatient stay.

InterQual(TM) guidelines now include the condition-specific diagnoses of acute coronary syndrome (ACS), asthma, epilepsy, heart failure, pneumonia, and stroke/TIA, with plans to add many more. The new guidelines help you determine who qualifies for inpatient and who should stay in an observation status. If you don’t have access to admission and continued stay criteria, make friends with someone who does, or better yet, ask your manager to give you access and send you to class to learn the basics. (Some hospitals use Milliman (TM) guidelines, so your mileage may vary.)

Your impact will be on documentation that supports inpatient severity of illness.   The physician admitting a patient for acute onset chest pain or suspected MI needs to understand the importance of documenting a specific diagnosis such as acute MI supported by positive cardiac markers, or unstable angina, any EKG changes that support the diagnosis, and following specific treatment protocols.

It’s not enough for a physician to diagnose pneumonia in a stable patient—the treatment on day one is the same for both observation and acute inpatient status so the difference is in the presentation, and that means documentation. What is the oxygen saturation? Did the patient fail outpatient antibiotics? Is there evidence of abscess or empyema? Is the pneumonia multilobar? Are there additional clinical risk factors?

For your TIA patients, a TIA lasting longer than 60 minutes raises the likelihood of meeting inpatient criteria. Teach your physicians to assess and document the duration of TIA symptoms. “R/O stroke” won’t allow you to work around TIA, without documentation of specific physical findings consistent with a possible stroke, such as paresis or dysphagia, or confirmation of CVA by CT or MRI. For your stable heart failure patients, among the requirements for an acute inpatient admission is oxygen saturation below 89% or a sustained heart rate of 100-120 bpm within 24 hours of admission. Evidence of greater instability, such as hypotension, mental status changes, or heart rate > 120, with IV medications or increased oxygen requirements, may move the patient into an intermediate or critical care status.

In DRG 314 – 316, other circulatory system diagnoses, you might have patients who come back with a vascular complication such as an occluded central line.  Just having a complication is not enough to justify an inpatient stay—is there evidence of a decreased peripheral or femoral pulse? Did they qualify for an inpatient admission in some other way? Syncope, DRG 312, may meet inpatient criteria if it is attributed to a cardiovascular drug, reflects evidence of certain arrhythmias or pacemaker failure, or if the patient has known cardiac disease. Do you see a documentation opportunity there?

Look closely at your short-stay patients, regardless of DRG. Did they meet criteria because they underwent a procedure on the inpatient list? Or did the physician not really think about admission status when they wrote the order? Your PEPPER will list your top medical DRGs for one-day stays. Consider auditing the top DRGs, particularly if they are the non-specific DRGs such as chest pain and syncope, for medical necessity. Can the top DRGs be explained by a specific patient population your hospital services? Did the documentation support the status order? Did the patient leave before the case manager had a chance to review the case? Does your CM department just do a great job of moving patients through the system? What processes does your hospital have in place for reviewing short-stays, either concurrently or retroactively? What documentation improvement processes can you recommend and/or implement?

I was trying to think of some snappy way to join SALT with PEPPER, but all I came up with was the strategic arms limitation talks. So on that note, don’t try to force documentation to fit when it doesn’t. But the more you know, the more you can do.

Editor's note: Brown, at the time of the article's original response, was an independent CDI consultant based in Carrollton, GA. With experience in critical care, nursing education, disease management, case management, and long-term care, she has worked as a CDI specialist, educator, director, and consultant. She is a frequent writer on topics involving clinical documentation and published her own "The Case Manager's Quick Guide to Diagnostic Related Groups" in 2013.