Q&A: How can we ensure the right documentation for a level of care recommendation?

Q: As part of an integrated access management program, what medical documents are needed to perform a medical necessity review so that the access care coordinator (ACC) can offer a level of care recommendation to the physician?

A: The 2016 Outpatient Prospective Payment System rule states:

"The physician’s decision should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.” 

But another important consideration should be whether the patient requires hospital-level care.

This is the crux of the review. For example, a patient may have an exacerbation of a chronic illness, but the ACC or case manager then needs to ask whether hospitalization is required to resolve the problem. If this is a new illness, does it require hospitalization to find out the source? (Auditors inevitably deny so-called work up hospitalizations if the testing could be performed on an outpatient basis.) Finally, the ACC or case manager must see medical documentation that states that the care the patient requires is expected to exceed two midnights, which CDI specialists should pay attention to.

Reviewers should consider the history of present illness, the severity of the signs and symptoms of the patient’s current medical condition, and the expectation of a two midnight stay, in addition to:

• The patient’s age
• Disease processes
• The medical predictability an adverse event

Also look at admitting orders. What are the patient’s current needs that require hospital-level care? What is the risk of not admitting the patient? I call this the “because clause”—if the patient is not admitted, given his history of pre-existing condition, he may be at risk for complication. During a CDI specialist’s regular record review he/she may note some indicators or clinical factors that could help the ACC or case management team. If so, there should be a process in place to help both teams facilitate open communication.

Editor’s Note: This question was answered by Stefani Daniels, RN, MSNA, CMAC, ACM, founder and managing partner of Phoenix Medical Management, Inc., in Pompano Beach, Florida. It was originally published in Case Management Insider.