Published in the March 2011 issue of Today’s Hospitalist
A LOT OF WATER has passed under the proverbial bridge since “hospitalist” was first coined by Robert Wachter, MD, and Lee Goldman, MD, in a now famous piece in the Aug. 15, 1996, New England Journal of Medicine. Amid all the rah-rah, self-congratulatory, “fastest-growing- specialty-in-the-history-of-medicine” fanfare, we’ve actually had some major accomplishments: forming a specialty society, delineating core competencies and achieving board recognition in the form of focused practice. It seems that we’ve come a long way, baby.
But what do we really know about inpatients? Sure, we know a lot about various diseases, medications and surgeries. But could you pick out an inpatient in a police line-up? Could you pass a test worth 0.01 hours of CME credit that has this one question: What is an inpatient?
Looking for help in all the wrong places
You could hit the library or your iPad for the answer, but neither would be much help. The Society of Hospital Medicine’s “Core Competencies in Hospital Medicine” addresses clinical conditions, procedures and health care systems, but nowhere defines who or what an inpatient actually is. Ditto for hospital medicine textbooks. Nor will you find breakout sessions on the topic at national conferences.
You’d think something this basic would be covered on your first day of residency or at least in the hospital medicine specialty literature. But you’d have to turn instead to third-party payers who, not surprisingly, have a thought or two on the subject.
In a nod to how much confusion there is among hospitals as to what constitutes a bona fide admission, the Centers for Medicare and Medicaid Services recently issued some guidance. And Chapter 1 of the “Medicare Benefit Policy Manual,” which consists of 45 pages of scintillating reading, presents several important definitions, including this one:
“An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight.”
The manual further states: “Physicians should use a 24- hour period as a benchmark, i.e., they should order admission for patients who are expected to need hospital care for 24 hours or more, and treat other patients on an outpatient basis.”
So far, so good; an inpatient is someone who needs at least 24 hours of inpatient services. But how do you decide who gets to sleep at the hospital?
The Centers for Medicare and Medicaid Services (CMS) acknowledges that “the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors.” Here are some factors the CMS includes:
- the severity of a patient’s signs and symptoms;
- the probability of something going wrong with the patient or of his or her condition deteriorating;
- the need for diagnostic studies that may ordinarily be administered in the outpatient setting but are required to help assess whether the patient should be admitted; and
- the availability of diagnostic procedures when the patient presents.But does any of this really matter? Or is it simply pedantry on the part of CMS lawyers “or from some guy in Minnesota who needs to churn out a column?Broken record
Hospitals “and, by extension, hospitalists “are being closely scrutinized by third-party payers for care delivered. Don’t consider anything to be self-evident. While it may be obvious why critically ill patients need to be hospitalized, third-party payers tend to quibble much more about generic acute care patients, so think about how to better document garden-variety presentations of common illnesses.In my health care system, order sets begin with an admitting order and some friendly reminders:
- admit to inpatient “please document reason for admission in chart;
- interventions requiring inpatient services;
- high risk of deterioration due to comorbidities; and
- high risk of deterioration due to nature of admitting diagnosis.Make it explicit
Which brings up a recurring theme in these columns: better, more explicit documentation of medical decision-making. Maybe some of you are at the same point I was when I started out in hospital medicine and included nothing “zero! “in terms of documentation to support an admission.Now, however, I have become a big fan of highly structured, very literal dictations, and I attack it head-on. In fact, I’d suggest getting in the habit of crafting an entire paragraph devoted to “Justification for Inpatient Status.” (See “What to write,” below.) Many of us think we’re too busy to spend time making that case. But the pressure to produce ends up costing you time when you’re being chased down by utilization review people “or when payment for your services has been denied.There’s nothing hard about this once you add it to your mental script. I guarantee that your coding, compliance and utilization review people will love it. And learning to document a compelling case for each admission will keep third-party payers off your back.Yes, we’ve come a long way since the term “hospitalist” was first suggested. But we’re even further away from the days when “because I’m a doctor, and I said so” was all the justification you needed for an admission.
David Frenz, MD, is a hospitalist for HealthEast Care System in St. Paul, Minn., and is board certified in both family medicine and addiction medicine. He serves as system medical director for addiction medicine and can be reached at firstname.lastname@example.org.
NO, YOU DON’T NEED TO DICTATE an entire medical history. But you do need to make a strong case for why a patient needs to be admitted. Here are some wording examples to try:
COPD flare: Patient has a long history of COPD requiring multiple hospitalizations. Inpatient status is required secondary to hypoxemia, for which supplemental oxygen is needed, aggressive bronchodilator therapy and the risk of rapid deterioration.
Elderly woman with dizziness: Patient presents with a vague episode of dizziness in the community that has since resolved. Although her physical examination and initial studies are reassuring, history is significant for heart disease. Inpatient status is required secondary to the need for continuous cardiac telemetry, serial laboratory studies and cardiology and neurology consultations.
Nephrolithiasis: Patient presents with a known history of nephrolithiasis, vomiting and debilitating pain. Inpatient status is required secondary to the need for intravenous fluid therapy, parenteral pain control and a urology consultation for consideration of facilitated stone passage.