Quality Improvement Organizations’ Short-Stay Audits Dig Deep

Hospitals caught off guard

When quality improvement organizations (QIOs) took over the role of education and enforcement for the two-midnight rule on October 1, 2015, many anticipated that the reviews would only look at records from that date forward. But some hospitals have reported QIO records requests zeroing in on cases as far back as May 2015, according to a report from HealthLeaders Media.

“It caught everybody off guard. No one expected them to audit any [records] earlier than October 1,” said Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group for AccretivePAS in Chicago. “But audits are starting hot and heavy, and it’s important for organizations to understand that it’s permitted and that the QIOs can request charts going back six months.”

In another unexpected turn, QIOs are requesting charts for inpatient-only surgeries.

Auditors are supposed to look at the ICD codes on a case and translate them to figure out if it’s inpatient-only, Hirsch said. If it is, the auditors know not to request the chart. But that doesn’t appear to be happening. Auditors aren’t translating the codes and instead are just requesting charts, which makes a lot more work for the hospital, Hirsch said.

Currently, only two QIOs serve the entire country: KEPRO and Livanta. The short-stay reviews that the QIOs took jurisdiction over in October 2015 will use the current two-midnight policy until January 1, 2016, when the companies will switch to the version of the rule outlined in the 2016 Outpatient Prospective Payment System (OPPS) final rule.

With reviews already under way, it’s too late for hospitals to do anything about it, Hirsch said. “If hospitals knew that they were in an audit period, they may have been more diligent about looking at short-stay admissions,” he remarked.

Hirsch recommends that organizations review every short-stay admission — those between zero and one day in duration — prior to billing. Case managers should also look to see that every patient’s status is appropriate up front, he said.

The physician advisor (PA) also needs to step in to ensure compliance. “The regulations are changing constantly,” said Hirsch. The PA needs to ensure that the case managers and the physicians are educated about these changes and know how to comply.

If a current case doesn’t comply with the two-midnight rule, a PA should be involved to make sure that it meets one of the exceptions under the rule. Cases that don’t qualify for an exception should be changed prior to discharge using condition code 44.

Source: HealthLeaders Media; January 20, 2016.

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