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Defined output from Admission order Sets Improves Compliance with Federalbilling Standards

All hospitals are under a mandate to accurately distinguish between patients who are being admitted for the purpose of observation or intensive testing to determine the need for ongoing admission as opposed to an admission to the hospital for an extended period. The Center for Medicare Services reimburses differently based on these two statuses. In many hospitals, even if physicians understand the difference between the statuses, their wording in orders may not be accurately understood by coders. To address this issue, the University of California, San Diego Medical Center, embarked on an experiment to see if altering the word output for an order to admit as inpatient to the hospital vs admit to outpatient observation would result in fewer one day inpatient admissions and improve the correct coding of outpatient observation stays. Using prospective time series analyses, we observed all inpatient stays and tracked the number of one day inpatient stays as a percent of all admissions, with particular focus on one day inpatient stays among Medicare patients. Using our already implemented physician order entry product (Siemens Invision, Siemens Medical, Malvern PA), we constructed a protocol so that if the provider ordered inpatient status a “level of care” order would be inserted into the record reflecting level of care as Inpatient as opposed to an outpatient observation order in which the level of care was flagged as Observation. This level of care order, and its specific date/time was used by coders to determine the compliance with CMS standards. Prior to the intervention, providers were still asked about observation but a yes answer would only instruct the nurse to but on observation flag on the admission and did not result in a level of care order in the electronic record. In the period one month prior to the intervention, among 2,070 total stays and 398 Medicare stays there were 86 Medicare (21.6% of total Medicare) one day inpatient admissions. One month after the introduction of the coded outputs based on the physician order, among 2075 total admissions and 437 Medicare stays there were only 51 Medicare (11.7% of total Medicare with p < .01) one day inpatient admissions. This study is limited by it being a time series analysis but it is promising in that the use of existing order entry applications can be fine tuned with respect to specific coded outputs to assist hospital in meeting federal billing compliance guidelines.