CPT® Admission Codes For Initial Inpatient & Observation Hospital H&P.

Determining the correct group of CPT® admission codes during an initial hospital encounter can be a frustrating experience for doctors and other non-physician practitioners.  This lecture simplifies that complex process by having practitioners answer a series of specific questions necessary to define the correct group of care codes used in their initial hospital evaluation.   Physicians use Current Procedural Terminology (CPT®) codes, part of the Healthcare Common Procedure Coding System (HCPCS), to submit claims for reimbursement.  Evaluation and Management (E/M) codes are just one small portion of these codes.  E/M codes are often referred to as the nonprocedural codes.  These are the codes providers use to bill for such services as hospital, clinic and nursing home visits.

Once the correct group of codes has been determined, the level of service ("low, medium or high") can then be defined.  This lectures will focus on choosing the correct group of codes, not the right coding level within a chosen group.  For physicians and other non-physician practitioners (NPPs) who need help defining the correct level of service, I refer them to my complete collection of free and original CPT® coding lectures.  After studying this lecture, readers will understand the CPT® code groups that apply to hospital inpatient and observation admissions and the questions that must be answered based on their coding scenario.  I am a practicing hospitalist with over a decade of clinical experience at a large community hospital.  I have written dozens of medical billing and coding lectures over the years.  While some of these lectures are several years old, their information remains highly relevant today.

INITIAL HOSPITAL ADMISSION CARE CODE GROUPS

Listed below are all the groups of CPT® admission codes  that can be can be used during an initial hospital service encounter.  At first glance, some of these codes may seem out of place, but they aren't.  They can and should all be used under the correct circumstance.   By understanding the possible groups of codes, the questions that must be asked will make more sense.   Below this list, I walk the provider through a series of questions that will help them define the correct grouping of CPT® codes to choose from.  I approach the process by defining whether the provider is the attending physician or the consultant, as the choice of codes are quite variable between these two groups.  As you can see from the list below, there are 12 possible groups of CPT® admission codes with 40 specific E/M codes.

• Hospital inpatient initial care:  99221, 99222, 99223
• Hospital inpatient subsequent care:  99231, 99232, 99233
• Hospital observation initial care:  99218, 99219, 99220
• Hospital observation subsequent care:  99224, 99225, 99226
• Hospital inpatient initial consult care:  99251, 99252, 99253, 99254, 99255
• Hospital admit/discharge same date care:  99234, 99235, 99236
• Outpatient established office care 99211, 99212, 99213, 99214, 99215
• Outpatient, new to office care:  99201, 99202, 99203, 99204, 99205
• Outpatient consult care: 99241, 99242, 99253, 99244, 99245
• Critical care: 99291 and 99292.
• Hospital inpatient discharge codes:  99238, 99239 (rarely)
• Hospital observation discharge code:  99217 (rarely)

Once the provider understands how these codes are grouped together, picking the correct set of codes is simple if the right questions are asked.   These questions are detailed below.  Just below the questions,  I have created a flow chart decision tree analysis tool to help the reader visualize the pathway to the correct group of CPT® admission codes.  As you continue to read, refer to this flow chart for quick reference.    

1. Does my patient meet criteria for billing critical care?
2. Am I the attending physician or am I a consultant on the case?
3. Does my documentation support the code I am supposed to use?
4. Does the code I chose appropriately describe the level of service provided?
5. Did my  admission face-to-face encounter and discharge face-to-face encounter occur on the same date?
6. Was my discharge encounter more or less than eight hours after the original face-to-face encounter on the same date or did I only provide one face-to-face encounter for admission and discharge?
7. Did I provide one or two face-to-face encounters on the same date admit/discharge?
8. Have I seen the patient in the last three years?
9. Has anyone in my group of the same specialty seen the patient in the last three years?
10. Does the patient have Medicare or other insurance that does not recognize consultation codes?

Before I begin the discussion, I think it is important to define the difference between when the order for admission was written and when the physician or NPP provided their first face-to-face encounter.  The date of the admission order has no relevance on Medicare Part B physician billing.  What matters is when the physician provided the medically necessary and reasonable face-to-face encounter.  This is an important point of clarification when trying to define the appropriateness of using the same day admission and discharge codes 99234-99236 for inpatient or observation services.  Here is the exact wordage from a Medicare carrier provided during a Q&A session (see question #1 at this link).

"Medicare Part B adjudicates physician services based on the calendar date of the service. In the above situation, the physician would submit the combination hospital inpatient/discharge services (99234-99236). In the Medicare Part B environment, the time of an "admission" to the hospital is not a physician payment issue. The physician service begins when he/she actually see the patient and performs the work for which Medicare may make payment. The "admission" time and date are necessary for the hospital billing, but not for the physician billing."

Here is a direct link to the image below on Photobucket.  The original source file appears to be broken.  Make sure to click on the magnifying glass in the lower right hand corner of the image for the full size view. 

ATTENDING PHYSICIAN 

          INPATIENT

This section will walk the physician and NPP through the necessary questions to arrive at the correct inpatient CPT® admission code group.  The groups available for the attending physician are critical care codes (99291 and 99292), hospital inpatient initial care codes (99221-99223),  hospital inpatient subsequent care codes (99231-99233),  hospital admit and discharge same day codes (99234-99236) and very rarely the hospital discharge codes (99238 and 99239).  Refer to the decision tree flow diagram above for a big picture view of this section.

1. Does my documentation meet the threshold for critical care?
1. YES:  Choose critical care codes 99291 and or 99292.   If your admission encounter meets the threshold for critical care, you have found your correct admission CPT® code group.  Critical care codes can be used on admission and on followup hospital care.  There is no limit to the number of times they can be used on any one patient in the hospital, but documentation should support their use.  Critical care codes can be used at any site of care.  Patients do not have to be in the ICU to use these codes.  Likewise, being in the ICU does not mean a patient qualifies for using critical care codes either. 
2. NO:  Go to question #2.
2. Does my documentation support use of hospital inpatient initial care codes (99221, 99222, 99223)?
1. YES:  Go to question #3.
2. NO:  Choose from the inpatient hospital subsequent care code group (99231, 99232, 99233).  These codes are used as initial care codes when documentation does not support the use of the initial care codes (99221-99223) or the admit/discharge same day codes (99234-99236).  This is allowable because the Centers For Medicare & Medicaid Services (CMS) says they are.  CMS has previously stated "in all cases, physicians will bill the available code that most appropriately describes the level of the services provided".  Another document supports this concept as well.   In a Q&A resource from one Medicare carrier, they answered:  "If the documentation for the initial visit does not support one of the initial inpatient procedure codes, CMS has instructed contractors to not find fault with the physician billing a subsequent care procedure instead." I often use subsequent care codes as my initial hospital service when evaluating routine post operative consults for medical management when an H&P has been provided by the primary care physician before surgery.  Technically, I could choose to provide a full H&P that would rise to the level of an initial inpatient procedure code, but I often choose not to spend the additional time required for initial care codes.   If documentation does not support use of these inpatient subsequent care codes, I recommend getting intense coding education as you will have provided your service for free.  There are no alternative codes to consider.  
3. Was my face-to-face discharge encounter date different than my face-to-face admission calendar date?
1. YES:  Choose from the inpatient hospital initial care codes 99221-99223.  These are the "H&P" codes.  This group of CPT® codes will be used for the majority of your admissions. 
2. NO, my admission and discharge face-to-face encounters or encounter (if the patient was seen just one time) occurred on the same calendar date. Go to question #4:  
4. Did I discharge the patient less than 8 hours from my first face-to-face encounter (or provide only one face-to-face encounter for admission and discharge)?  
1. YES:  Choose from the inpatient hospital initial care codes 99221-99223.   Some resources suggest the physician can instead choose the discharge code 99238 or 99239 if only one face-to-face encounter was provided and the service was consistent with a discharge encounter.  There is some discrepancy in resources from CMS and Medicare carriers in this scenario.    Regardless, physicians who admit and discharge patients less than  8 hours between their admission and discharge face-to-face encounter or if they only provided one face-to-face encounter should not submit same day admit and discharge codes 99234-99236.  Should they submit for the admission (99221-99223) or  the discharge (99238 or 99239) code?  Read the discussion below:
   
   • CMS discussed this in section 30.6.9.1 of of change request 6740 of transmittal 1875 from December 14th, 2009.   They say to use the initial encounter admission codes. 
   • "When the patient is admitted to inpatient hospital care for less than 8 hours on the same date, then Initial Hospital Care, from CPT code range 99221 – 99223, shall be reported by the physician. The Hospital Discharge Day Management service, CPT® codes 99238 or 99239, shall not be reported for this scenario."   That sounds pretty clear to me.
   • However, this Medicare carrier says you could consider billing for the discharge instead.   In question 2 at this Medicare carrier resource they say "The medical record documentation determines the appropriate procedure code. The physician could bill an initial inpatient visit or a discharge management summary based on the service documented. The combination admit and discharge procedures codes are not appropriate since the patient was an inpatient for less than 8 hours."
   • Discharge codes 99238 and 99239 are only supposed to be used on dates different than the date of admission.   It says so in the AMA definition of these CPT codes.  So there may be a discrepancy in how the AMA defines the code and what CMS allows.  This is not precedent.  It has happened before (such as the prolonged service codes).  There appears to be contradictory information between CMS documents and the Medicare carrier resource above.  Billing a 99238 or 99239 on the same date of the physician's first face-to-face encounter is contradictory to the AMA definition of these discharge codes. My recommendation is to provide an intensity of service that meets the criteria for  the inpatient admission codes if only one face face-to-face encounter or two face-to-face encounters were provided less than 8 hours apart on the same calendar date and bill 99221-99223 if documentation supports it.  If documentation does not support these codes, go to question #2.
   Answering question #4 is important when providing hand-offs from night shift hospitalist admissions to day shift hospitalists who may or may not discharge the patient.   Knowing how long the patient has spend in the hospital is important to prevent denial of payment.  Some physicians may choose to round last on these special situation patients if they think they will initiate discharge orders.
2. NO, my patient was discharged greater than 8 hour from admission on the same calendar date:  Go to question #5.
5. Did I or my partners in combination with me provide two face-to-face encounters at least eight hours apart on the same calendar date?
1. YES:  Choose from the hospital admit and discharge same day inpatient or observation care codes 99234-99236.  This is a bundled care code.  If two physicians from the same group and specialty each provide one of the face-to-face encounters, only one provider should submit the code from the care group 99234-99236.  Traditionally, the physician or other NPP who provided the admission encounter would get credit because of the higher intensity of service provided during the  initial admission H&P service.  I have provided a thorough  review of the admit and discharge same day CPT codes at this link.   If you don't have two documented face-to-face encounters separated by 8 hours, then go back to question #4.
2. NO, two face-to-face encounters were not provided:  Choose from the inpatient hospital initial care codes 99221-99223.  As I stated above, I do believe the discharge codes 99238 or 99239 apply.  These codes should  apply to discharge services on a date different from the admission face-to-face encounter. 

          OBSERVATION

This section will walk healthcare providers through the necessary questions to arrive at the correct observation CPT® admission code group.  The groups available for the attending physician are critical care codes (99291 and 99292), hospital observation initial care codes (99218-99220),  hospital observation subsequent care codes (99224-99226), the hospital admit and discharge same day codes (99234-99236) and the observation discharge code 99217.  Refer to the decision tree flow diagram above for a big picture view of this section.

1. Does my documentation meet the threshold for critical care?
1. YES:  Choose critical care codes 99291 and or 99292.  See the discussion above on question #1.
2. NO:  Go to question #2.
2. Does my documentation support use of hospital observation initial care codes (99218, 99219, 99220)?
1. YES:  Go to question #3.
2. NO:  Choose from the hospital observation subsequent care code group (99224, 99225, 99226).  See the discussion in question #2 above to understand why this group of codes is appropriate.
3. Was my face-to-face discharge encounter date different than my face-to-face admission calendar date?
1. YES:  Choose from the observation hospital initial care codes 99218-99220 . 
2. NO, my admission and discharge face-to-face encounters or encounter (if the patient was seen just one time) occurred on the same calendar date. 
4. Did I discharge the patient less than 8 hours from my first face-to-face encounter (or provide only one face-to-face encounter for admission and discharge)?
1. YES:  Choose from the observation hospital initial care codes 99218-99220.  Physicians who admit and discharge patients who spend less than 8 hours in the hospital should not submit same day admit discharge codes 99234-99236.  I discussed the use of the options for using the discharge code (99217 in this case) above in the attending section (under question #4).  I do not recommend it. See that discussion to better understand the reasoning. 
2. NO, my patient was discharged greater than 8 hours from the face-to-face admission encounter on the same calendar date:  Go to question #5.
5. Did I or my partners in combination with me provide two face-to-face encounters at least eight hours apart on the same calendar date?
1. YES:  Choose from the hospital admit and discharge same day inpatient or observation care codes 99234-99236.  See the discussion above at question #5.
2. NO,  two face-to-face encounters were not provided:  Choose from the observation hospital initial care codes 99218-99220.  Again, I do not recommend billing observation CPT discharge code 99217.  This code should only apply for discharge services on dates different than the admission face-to-face encounter.  

CONSULTING PHYSICIAN

          INPATIENT

This section will walk the physician and NPP through the necessary questions to arrive at the correct inpatient CPT® admission code group.  The inpatient CPT® code groups available for the consulting physician are critical care codes (99291 and 99292), hospital inpatient initial care codes (99221-99223),  hospital inpatient subsequent care codes (99231-99233),  and the hospital inpatient consult codes (99251-99255).  Same day admission and discharge codes are reserved for the attending physician or NPP only.  Remember  that the inpatient hospital consultation codes have not been  recognized by CMS since 2010, but may be recognized by other third party payers.  Refer to the decision tree flow diagram above for a big picture view of this section.  

1. Does my documentation meet the threshold for critical care?
1. YES:  Choose critical care codes 99291 and or 99292.
2. NO:  Go to question #2.
2. Does my patient have Medicare?
1. YES:  Go to question #3.  Medicare no longer recognizes hospital inpatient consultation codes.
2. NO: Go to question #4.
3. Does my documentation support use of hospital inpatient initial care codes (99221, 99223, 99223)?
1. YES:  Choose from the inpatient hospital initial care codes 99221-99223.
2. NO:  Choose from the inpatient hospital subsequent care codes 99231-99233.  These codes are used as initial care codes when documentation does not support the use of the initial care codes (99221-99223).  I have provided reference to CMS opinion of this situation in question #2 in the  inpatient attending discussion.   
4. Does my patient's non-Medicare insurance recognize the inpatient CPT consult code group 99251-99255?
1. YES:  Go to question #5.
2. NO:  Go to question #3.
3. I DON'T KNOW:  Find out.  When you find out, choose yes or no in question #4.  
5. Does my documentation support the use of hospital inpatient consult care codes 99251-99255?
1. YES:  Choose from the inpatient hospital consult care codes 99251-99255.
2. NO:  Choose from the inpatient hospital subsequent care codes 99231-99233.  This is the only alternative group of codes from which to choose from.  As stated above,  the physician should bill the code that most appropriately describes the level of service provided.  If the documentation does not support the inpatient hospital consult codes, then the subsequent care codes should be used instead.  If documentation does not support the use of the subsequent care codes, I recommend the physician seek intensive coding education as no other codes are available.  That means they provided their service here for free.

          OBSERVATION

This section will walk providers through the necessary questions to arrive at the correct observation CPT® admission code group.  Being a consultant on an observation case is the most difficult of the coding scenarios I have detailed above.  The observation  CPT® code groups available for the consulting physician are critical care codes (99291 and 99292), new patient office or other outpatient visit care codes (99201-99205),  established patient office or other outpatient visit care codes (99211-99215),  and the office or other outpatient consultation codes (99241-99245).  Remember, office or outpatient consultation codes are no longer recognized by CMS but may be recognized by other third party payers.  Refer to the decision tree flow diagram above for a big picture view of this section.

1. Does my documentation meet the threshold for critical care?
1. YES:  Choose critical care codes 99291 and or 99292.
2. NO:  Go to question #2.
2. Does my patient have Medicare?
1. YES:  Go to question #3.  Medicare no longer recognizes outpatient and office consult codes.
2. NO:  Go to question #7.
3. Have I seen the patient at any time in the last three years?
1. YES:  Go to question #5.
2. NO:  Go to question #4. 
4. Have any of my partners in my same group and same specialty seen the patient at anytime in the last three years?
1. YES:  Go to question #5.
2. NO:  Go to question #6.
5. Does my documentation support the use of  established patient office or other outpatient visit care codes 99211-99215?
1. YES:  Choose from the established patient office or other outpatient visit codes 99211-99215.
2. NO:  Nothing can be billed.  I recommend the physician or other NPP obtain help with their coding skills.  You just saw the patient for free.
6. Does my documentation support the use of the new patient office or other outpatient visit care codes 99201-99205?
1. YES:  Choose from the new patient office or other outpatient visit care codes (99201-99205).
2. NO:  Go to question #5.
7. Does my patient's non-Medicare insurance recognize the office or other outpatient consultation codes 99241-99245?
1. YES:  Go to question #8.
2. NO:  Go to question #3.
3. I DON'T KNOW:  Find out.  Once you find out, choose yes or no in this question.
8. Does my documentation support the use of the office or other outpatient consultation codes 99241-99245?
1. YES:  Choose from the office or other outpatient consultation codes 99241-99245.
2. NO:  Go to question #5.

In this lecture, I have touched on the majority of situations the attending or consulting physician will find themselves in when trying to decide which CPT® admission code group to utilize.  I have provided a walk through series of questions based on whether the physician or NPP is filling the role of attending or consultant in the inpatient or observation hospital setting.  It is my hope readers bookmark this lecture for quick reference when they have questions about which admission code to choose on their initial evaluation.  Of course, there are other issues to consider as well, such as seeing patients with non-billing resident or billing and non-billing NPPs.    I do not currently have any resources on billing shared services in the academic environment using shared services with residents.  I do, however, have a detailed review of coding in shared services situations when patients are seen in conjunction with  non-physician practitioners (billing and non-billing).  I cover numerous scenarios for inpatient and observation situations that involve care before and after the midnight hour.

And finally, here is a Happy Hospitalist original flow diagram detailing all the actual thought processes that go into deciding which CPT® admission codes are correct for the initial hospital H&P encounter. I think it accurately details the quirks, irritations and internal emotional distress many providers experience during the process.  This diagram is copy write protected by The Happy Hospitalist.  If you wish to forward it on to your colleagues, I ask that you provide reference back to this lecture post.   This is the  mother of all CPT® admission decision diagrams.  I have framed the image due to its very large size.  You can also view it directly at the full screen view here.  Make sure to click the magnifying glass image in the bottom right corner of the image to expand the view on Photobucket.  The original source file site appears to be broken, so use this Photobucket link to view.  

If you've decided you don't want to click through to view the diagram, here's a screen shot below that might change your mind.  It's funny people.   Trust me.

Once you've determined the correct group of CPT® admission codes, The Happy Hospitalist has laminated hospital and clinic bedside pocket E/M reference cards available to help the clinician determine the correct level of service within the code group.  All purchase proceeds are donated to charity to help make this world a better place.  Click on your desired option below and stay compliant with all your daily E/M coding adventures.

LINK TO HOSPITALIST POCKET CODING CARD POST EM Pocket Reference Cards Using Marshfield Clinic Point Audit One Hospital: (Admit/Consult) One Side, Follow-Up On Other Side $10.00 One Clinic: (New/Consult) One Side, Established On Other Side $10.00 Two Hospital Cards $16.00 Two Clinic Cards $16.00 One Hospital Card + One Clinic Card $16.00 Two Hospital Cards + Two Clinic Cards $29.00 Click image for high definition view

Dementia Quotes, Sayings and Stories That Will Make You Laugh!

Over the years I've had some pretty fascinating, interesting and humorous conversations with dementia patients. Behind all that agitation and confusion that can make hospitalization for demented people so complicated and full of risk is the innocence of dementia itself. Dementia is a child like state of innocence that separates the patient's reality from ours.  It is that skewed reality that drives both the pain and humor of dementia.

Take for example the demented old lady with multiple medical problems. She's brushing her teeth with the help of staff. She's laughing and giggling and then blurts out from nowhere, "I don't know what I'm doing, but if I spit on you it's going to kill you!"   The innocence of it all.  I asked my facebook readers to share their funny stories and experiences they have had with their demented patients and they didn't disappoint.  Dementia can be sad and sweet at the same time.  By definition, dementia robs one of their ability to understand and comprehend the world around them.  They live in their own reality.  Some demented people become angry.  Some become paranoid.  Some become sweet and funny.    Below is a collection of quotes, stories and sayings my readers have experienced from patients with dementia.  Feel free to add your own.  In addition, make sure to "Like" my facebook page for The Happy Hospitalist if you want to experience a whole lot of humor and occasionally crappy serious stuff too.  Over 3,500 followers agree.  Without further delay, here is some good old fashion dementia humor!

• "The nurses are trying to poison me and the rats here are huge." My response: "No sir, they're trying to poison the guy down the hall and I just got off the phone with the exterminator. He'll be here soon with a rat trap. Now, do you think you can take the medication this nurse has here in sealed packaging? Your blood pressure is too high."
• I once helped an alcoholic going through withdrawal feed the "kitten under his bed" milk. Got a small dish of milk, put it under the bed. He said the meowing stopped and he could lay down. If you can't beat crazy, join them.
• I was wearing a yellow isolation gown... Heard from the room, "Hey you.  Yeah you.  Big bird"
• One of my first days as a new nurse on an Alzheimer's unit we were in the dining room and an elderly gentleman walked up to a table of female patients, says "Hello ladies" and proceeds to whip out his penis and urinate all over the table.
• A patient told the dayshift that nightshift was making beer at the foot of his bed.  We were emptying his Foley!
• The most common one was the patient from down the hall in an angry indignant voice, "What kind of hotel IS this!" We felt compelled to come up with something amusing to share.
• This patient kept coming out of his room and wondering in the hall.   We placed a square of tape on the floor and told him he could not go past this area and he would come out of his room, staying inside that square and lean out over the tape on the floor to look around. He never went past it. That was cute.
• After shuffling an old lady to the bedside commode she says, "It's been a long time since I had a young man take my pants down."
• ""Are you Jewish, because I only want a Jewish doctor". As luck would have it there were no Jewish doctors around.  I know, right? And in NEW YORK of all places! We sent in the Korean ER doc and she never knew the difference!
• I'm a speech pathologist and I was trying so hard to get a little old guy to eat. He grabbed my hand to stop me and said, "Can't you see I'm trying to die here?" He actually did pass away a couple of days later.
• Old man lying in bed looking out the window at night said, "I'm waiting for them to come and take me to my home planet".   He died that night so maybe it wasn't dementia. Another patient shared the super secret code to all of the nuclear weapons in the world: zero-zero-zero.
• "Call 911! This bitch is trying to kill me!"  I was doing a neuro check:  Q2 hrs as ordered by a completely clueless resident.
• An elderly female patient with dementia was going to MRI and got agitated when transportation arrived. She refused to go and kept asking for Dr. Bright Eyes. When I figured out who she was talking about, one of our doctors with the prettiest eyes, I asked him to see her and she calmed right down and was able to get the MRI. The nickname stuck with me. 
• I had a 91yo WWII Vet at the VA tell me that he was going to "take me to fist city" because he was unhappy with the quality of his breakfast.
• Little man sitting at bedside with towel folded square on top of head. When I asked why, he stated it was to keep the kangaroos away. I asked how it was working and he said he hadn't seen one yet. We're in Georgia. There's no high population of kangaroos at our facility to begin with.
• I suddenly hear someone on the intercom saying, "Bob, Bob, Why won't you talk to me........" The conversation was one-sided and she became more angry and was clearly confused. It seems our confused patient dialed the hospital three number password for the hospital intercom and thought her son was on the other end.   Eight floors and about a ten minute search we found her and shut her phone off.  Im sure everyone in the building thought it was funny.
• Kept asking who that man was.  When we said her husband she said, "No ma'am, my husband is a good looking guy. That old man ain't my husband."
• "Somebody needs to get out there and feed that owl.  He's gonna starve out there!"  Regarding the plastic owl on the roofline to keep the pigeons away. We kept telling him it was not real.  He was not convinced!
• My dear grandmother was a bit of a terror at times with her dementia, but once she said so sweetly, "I don't know who you are but thank you for coming to visit me."
• The old lady that told her family that the night shift nurses tortured and killed puppies. The family believed her enough to ask staff about it.
• One who screamed we were going to drown her in the river every time we would transfer her from bed to chair, took one look at me and said, "Dirty squaw".  I'm Mi'kmaq first nations. Most of my colleagues didn't even know.   Or the one who would wave at the lady in the mirror every time and then tell me she was such a lovely lady, that one.
• I've been known to park an imaginary goat for a guy to keep him happy and in bed and was tipped with coins made of poop.
• "I don't know who you are but you sure are pretty!"  Elderly guy, slightly demented but you can tell he was a ladies man and is still a charmer. My moms patient "With boobs like that who am I to argue with you!"  Good point man. Now do your therapy.
• While suctioning a lady she spit at me and said "Scram, skunk!" But I guess I would do the same with someone shoving something down my nose.
• I had a resident walk up to me in nothing but pantyhose and ask, "Excuse me, do I seem overwhelming queer to you?"
• A CNA called me to help get a demented patient off the toilet. She refused to move. I said, "You can't just stay here all night." She shot right back, "I most certainly can." Gotta admit, she had a point. Started to wonder which one of us was the confused one. I told her technically she was right, but it wouldn't be optimal for her to stay there all night. She pondered the word "optimal," decided I must be right, got up and got into bed.
• My aunt remembered me as a five year old, did not understand I was an adult. She also thought she was running the nursing home where she lived.
• A man once took out his tray from his bedside table and shit in it. The same man also gave everyone spy names and codes. He was bat shit crazy! Each day with him you cried and laughed.
• In the middle of the night, call bell rang.  When CNA answered, the man said "Come quick, and bring a big banana!"
• I was doing a home health setup on an elderly man. I was talking to a family member when the patient comes in and puts on a Sinatra record, strips completely naked and starts dancing with the DME tech who was about 350 lbs. The family was horrified, but I wish I had a camera for that.
• "I don't know about that. I've got a Pap smear machine." He said in response to the nurse asking if he wore a CPAP for his apnea.
• I had a 92 year old patient flip me off with both hands with such a flourish she would have won an Oscar!
• As I was wheeling past her room for the 100th time that day she told me there hay girl goes with that lawn mower again.  She said those to the CNA which happened to be my sister, Sheri.    Earlier in the day the patient was getting mad at me while I was trying to assess her.  Sheri ce in and the woman looked at her badge and said "you better listen to her she is the sheriff" needless to say the name stuck with her throughout nursing school.
• Me: Mrs. Dementia, how are you feeling today? Mrs. Dementia: I'm feeling like I wanna kick your ass! Nurse: Now Mrs. Dementia, you shouldn't say that her, she's pregnant. Mrs. Dementia: Shame on you!
• Patient admitted with respiratory issues also seeing spiders and bugs all over his room. When RT walked into the room for the breathing treatment he shouted "Oh good, the exterminators are here!" Yeah it was quite a time trying to convince him the updraft was not bug spray!
• My dad had a sweet dementia. He was engaged to every female caretaker. He also spoke to our deceased mother on a regular basis and told us what it was like where she is!
• Little lady in restraints turned her mantra of "Please help me, please help me!" into a nursery rhyme ditty that continued for most of my 12-hr shift.
• I was talking to the family member of a patient with dementia who was on a stretcher in the ER lying nearly flat under a bunch of blankets. I talk with my hands and as I was making an open hand gesture, something came through the air in an arc from the vicinity of the patients head and landed in my hand. I knew right away what it was and started to laugh as I ran to the sink. The horrified family member who also had an inkling of what is was asked, "Momma what did you just do?" A voice came from somewhere in the blankets, " I spit."
• I got told the CT surgeon and I would make a cute couple. She was way demented!
• The one who refused to go to sleep because I was trying to get my filthy hands on her husband. She kept calling 911 until the phone service was ahem, removed, from her bedside.
• "I have diverticulitis in my toes"
• I measure how long my patient has been demented by their answer to the question: "Who's the president?" One patient answered "Richard Nixon". You know instantly he's not demented....he's schizophrenic.
• "Will you come home with me?"

If you happen to think of your own dementia quotes or stories, feel free to leave them in the comments below for others to enjoy.

2-Midnight Rule: Medicare's New 2013 Inpatient Hospital Payment Policy Explained (CMS 1599-P).

Hospitalists have risen to the challenge of only providing medically reasonable and necessary inpatient hospital care under the rules of three-midnight medicine.  They have refused to delay patient discharges just so patients could enjoy  high quality care in the nursing home of their choice that is paid for by our Medicare National Bank.  They are willing to accept discharge to home and face the music of bad patient satisfaction survey scores filled out by angry family members who are upset their hospitalist wouldn't commit Medicare fraud to get grandma to a Medicare paid nursing home for the next 100 days so she could avoid selling her assets and enter Medicaid without a fight.  Nope.  Hospitalists everywhere are taking the ethical road and accepting their bad scores in defeat, knowing their ethics matter more than Medicare rules and regulations.

 I tip my hat to all my fellow hospitalists who refuse to commit Medicare fraud in the interest of patient satisfaction. It just doesn't happen, ever.  We are an honest breed.   I know all my fellow brethren follow this wholesome practice style and have never even considered holding on to a patient just-one-more-day to qualify them for their three midnight stay in the hospital.  And for that, we are going to be rewarded by Medicare.    Hold on to your seats.  Medicare just gave us a bombshell that promises to change how we practice medicine forever.  They're calling it the 2-midnight rule (and 1-midnight rule too).  The 2-midnight rule changes everything and we owe it to ourselves to get educated.  We need to understand the importance  of chart documentation requirements we will be asked to comply with starting October 1st, 2013. Read this whole article and then read it again and pass it on to all your hospitalist friends so they too can increase their value to hospitals.  As hospital funding takes us on a race to the bottom, we must learn  how to maximize our calorie intake at ObamaCare's Budget Buffet or we too will end up in the hospital as an  observation admission for acute exacerbation of too-angry-for-discharge.

I have now been a hospitalist for ten years.  A consistently frustrating job in my role as physician is my requirement to determine whether a patient should be admitted as inpatient or observation status.  If you are a Medicare patient or a family member of a Medicare patient admitted to the hospital,  you should always ask during your admission evaluation whether the order is being written for inpatient or observation. Don't ever assume that being admitted into the hospital means you are inpatient.   If you have no idea what inpatient vs observation status means, you're not alone, but you owe it to yourself to understand.  Medicare has an  excellent patient resource to help explain all the important financial implications.  I encourage all Medicare patients and their family to click this link and save the pdf file for quick review.

Medicare Part A rules apply if the physician writes an order for inpatient but Medicare Part B rules apply if the physician writes an order for observation.  Observation is considered outpatient.  That means all the copays, deductibles and coverage inclusions or exclusions are determined by what order the physician has written.  Patients without supplemental insurance will get a bill for 20% of all charges incurred during an observation hospital stay because Medicare Part B only covers 80% of allowed outpatient Medicare charges.  Patients without Medicare Part B will get a bill for full price. This mostly affects veterans who have Medicare Part A coverage but choose not to pay for Medicare Part B coverage due to their VA benefits.   Most of these folks say they want to stay in their local hospital because they say, "I have Medicare".  Most have no idea that not paying for Medicare Part B means they aren't covered for observation stays at their local hospital unless the VA is willing to pay for that care.   I wouldn't count on that.  

Most patients pay for Medicare Part B.  Most patients have a supplemental policy too, so the issue is a  non issue, except for payment of home medications administered in the hospital. The biggest problem occurs when physicians write an order for observation status and don't tell patients their routine self administered home medications will not be paid for by their Medicare insurance if the hospital provides these pills for them.  Patients  also have an obligation to educate themselves about the rules of their plan.  Because Medicare will not pay, neither will a patient's supplemental policy.   That means the hospital will send their patient a very large bill for the $25 dollar Tylenol given for their observation stay for headache,  thus causing them another trip to the ER and observation admission for chest pain when they get their $2,000 bill three weeks after discharge.   Since this $25 Tylenol is not covered under insurance, the patient gets no benefit of the insurance discount.   In addition, I would not always count on Medicare Part D picking up the tab.  They may, under certain circumstances, but I wouldn't consider that option reliable.    Grandma gets to pay full price for that $25 pain pill.  Oops, sorry about that, right?

I have a personal rule to notify every patient I admit observation status into the hospital of this hole in their Medicare coverage so I can give them the opportunity to either provide their home medications for my hospital  to verify and administer  by the nurse or to hold all their routine home medications until their expected less than 48 hour observation stay has been completed.  Sometimes doctors may even  look the other way while recommending patients take  their own pills without telling anyone.  Universally, patients are grateful for my discussion.  Unfortunately, this uncompensated time isn't paid for and doesn't affect patient satisfaction scores.  That only applies to inpatients.  It is a freebie for my time out of respect for my patient's sanity. Unfortunately, I am the exception to the rule.  Nobody explains this rule to patients so they can understand the implications to their financial health.  I have stopped counting how many times I have heard angry patients describe their bills for several thousand dollars they received three weeks after a 24 hour stay in the hospital.  It's a good thing their anger doesn't count for patient satisfaction scores.  Maybe that's why nobody takes the time to care.  

Determining inpatient or observation status is complex.  Medicare says  physicians must write an inpatient order for hospitals to get paid for inpatient care (Medicare Part A rules), but having a physician write the order does not guarantee Medicare will pay.  Medicare wants it both ways.  They require the order but refuse to accept the order as law.  So my question becomes, why require a physician order if the order has no teeth?  Why not develop a different process that provides experts with the opportunity make the decision.  I have no idea why physician input is even relevent.   Physicians aren't trained to know this stuff.  We are guessing 100% of the time.  That's right folks, physicians are not trained to know all the details required for Medicare to pay or deny an inpatient stay.   So we guess, every time.  All of us.  It's irrational, I know.  Most hospitals have utilization review experts that scour the patient chart for information to determine whether my order for inpatient or observation status was correct, but this rarely happens in real time.  If I get it right, nothing happens.  If I get it wrong, I am often asked to consider writing an order to change the status, which may affect patient coverage for self administered medications already provided.  Oops, sorry about that, right?  It's a shameful way to treat patients.

What are physicians thinking about on admission?  In addition to evaluation and stabilization, the medical plan from the start often revolves around methods to quickly and safely get the patient discharged to the next appropriate level of care.   That may mean physicians provide an intensity of service much higher than would be expected for  the patient's number-of-wrinkles/age ratio.   That may mean an aggressively documented thought process to include one-in-a-million-doc types of conditions that would make any residency director put on their pimping caps with an excitement only a morning report can provide.  This process defines skilled nursing facility (SNF) driven medicine  all across this country.  EMTALA is the leaky faucet and "sniffs" are the plumber.  The moment patients are admitted to a hospital, the astute hospitalist is already formulating a plan to get free front row tickets in the too-weak-to-pee-on-my-own  section of the the three-midnight-road-rally paid for by the Medicare National Bank.

Hospitalists are writing orders and aggressively documenting their grave concerns about acute exacerbation of too-old-to-answer-a-question-without-telling-a-story as a reason to meet inpatient criteria and writing essays about why inpatient status is required to qualify for a three midnight hospitel stay and early disposition to the land of skilled nurses in a nursing home.   It happens everywhere in this country, except on my service and in my hospital.  Trust me.  I refuse to play that atrocious game.  My patients whom I admit with acute exacerbation of  too-old-to-go-home and life threatening cases of upset-son-is-demanding-admission only get exactly what they need and not a thing more.   They don't get medically reasonable and necessary intravenous fluids running  at 150 cc/hour for 72 hours because their baseline creatinine is 1.223.  They do not get medically reasonable and necessary every 4 hour neuro checks for 72 hours because they're pinky toe is numb without explanation after being stepped on  by a farm animal.   They won't get that MRI on day three, making sure to wait until agressive hydration has been achieved and they definitely won't get the blood cultures that require inpatient monitoring to rule out sepsis as a contribution to their three year battle with perma-supine syndrome.   No.  Sir.  Ree.  My patients don't get any of that medically reasonable and necessary care to get them qualified for their three midnight stay and a golden ticket to the palace in the Sniffdom of their choice provided for under medically  reasonable and necessary Medicare benefits paid for by IOUs to the Canadian, British and Chinese governments.

Are you confused yet?    Well, things are about to change, again.  Many Medicare carriers determine appropriateness of inpatient status by using a combination of diagnosis and intensity of service to determine whether inpatient criteria has been met. For example, diagnoses such as back pain, chest pain, pain in my ass, weakness, syncope and abdominal pain won't get you qualified for inpatient status unless you have a really good hospitalist with extra fellowship training treating exacerbation of needthreemidnightitis as a Medicare approved major complication and comorbidity.     When I write the wrong order, lots of paper work must happen for the hospital to get paid.  Even I  have to retroactively change my billing to match the hospital status  or my physician claims will get denied.  Most doctors aren't trained on any of this stuff. 

UPDATED May 31st, 2013 with new page references  to the appropriate files detailed below.  The original source file is no longer active.

On April 26th, 2013, the Centers for Medicare & Medicaid Services (CMS) issued an assortment of  proposed rule changes to update 2014 Medicare payment under the Inpatient Prospective Payment System (IPPS) to be applied to discharges on or after October 1st, 2013.      Comments on these proposed rule changes will be accepted through June 25th, 2013 with a final ruling to be issued August 1st, 2013.  The proposed rule change (CMS-1599-P, RIN 0938-AR53 ) was published in the Federal Registrar on May 10th, 2013.   I have focused on the proposed rules changes detailed on pages 27644-27648 of the Federal Registrar document  (page 160-164 of the pdf file).   It's a fascinating look into the mind of Medicare madness.  It has huge implications on how we practice medicine as a hospitalist and what we will be asked to document in the chart.  It adds another layer of complexity to our role as documenteurs.   This CMS fact sheet gives a summary of the proposed rules change.  The bolded words are stressed by me.  

Admission and Medical Review Criteria for Inpatient Services.
 In the proposed rule, CMS clarifies its longstanding policy on how Medicare contractors review inpatient admissions for payment purposes. Under this proposed rule, CMS is proposing that hospital inpatient admissions spanning at least two midnights (that is, at least more than one Medicare utilization day), will presumptively qualify as appropriate for payment under Medicare Part A. Conversely, hospital inpatient admissions spanning less than two midnights (that is, less than one Medicare utilization day) will presumptively be inappropriate for payment under Medicare Part A.  

This presumption may be overcome by documentation in the medical record supporting the admitting physician’s expectation that the beneficiary would need care spanning at least two midnights and an unforeseen circumstance results in a shorter beneficiary stay than the physician’s expectation. Physicians must support their expectation, and accordingly their order for admission, through clear and complete medical documentation. This proposed policy would address longstanding concerns from hospitals that they need more guidance on when a patient is appropriately treated and paid by Medicare as an inpatient.  At the same time the proposed change would help beneficiaries who in recent years have been having longer stays as outpatients because of hospital uncertainties about payment if they admit the patient to the hospital.

Let me give you a little background about why Medicare is making some changes.  Medicare is bankrupt. As a result, they have a program in place to retroactively take back money paid to hospitals for services they may determine not to be medically necessary and appropriate.  Much of the recovery has focused on inpatient hospital stays of short duration.  Hospitals responded by approaching physicians with recommendations to admit patients as observation status instead of inpatient status or apply observation status to patients already admitted as inpatient in an effort to avoid denial of payment from Medicare.  Hospitals want to get paid.  Medicare doesn't want to pay.  Do you see the problem here?

As a result, many Medicare beneficiaries have experienced longer and more expensive stays in the hospital with higher Medicare Part B financial obligations during observation stays.    Since 2006, the number of cases of Medicare beneficiaries experiencing greater than 48 hours of observation has increased from 3% in 2006 to 8% in 2011.  This proposed rule is an attempt to help doctors and hospitals write inpatient orders, with a confidence that they will not be denied, if documentation continues to support physician expectations of greater than 2 days in the hospital providing medically reasonable and necessary care.  Of course, even by their own admission, abuse potential is great  and will be monitored.  I have reviewed the proposed rule change, as it currently resides, on pages 27644-27648 of the registrar document.  If you've gotten this far, you are obviously interested in this stuff so I encourage you to review it for yourself as well.  It has a great potential to change how we practice and document as hospitalists for the simple fact that great hospitalists with additional fellowship training in documenting-smoke-and-mirrors can make anything look medically reasonable and necessary.  The abuse potential  they fear is going to hit Medicare financing straight in the noggin. Just look at the three midnight rule.  Patients who are alive, but not really, get shipped off everyday to skilled nursing facilities after their 3-midnight hospital stay for acute exacerbation of frozen body syndrome because they can.  Let's take a look at the proposed changes, shall we?

For the first time, as far as I can tell, CMS is telling hospitals and physicians that length of treatment will determine whether patients qualify for inpatient or observation status.  The proposed rule is directing carriers to presume hospital inpatient admissions are reasonable and necessary if they cross two midnights and the hospital services are medically necessary and appropriate.  Page 27644 of the Federal Registrar details the proposed rule change, with the following statement:

Policy Proposal on Admission and Medical Review Criteria for Hospital Inpatient Services under Medicare Part A 

Before this proposed rule change,  the only requirements for inpatient status were a physician (or other qualified practitioner) order and medical necessity.  On page 27645 (bottom left paragraph) of this document, stakeholders recommended redefining the parameters to include a beneficiary's length of stay at the hospital.  This section below is detailed from the bottom left to the top right of page 27645.  Pay special attention to section between the blue arrows I have highlighted at the end:

There you have it folks.  For the first time, Medicare is going to define length of a hospital stay as reasonable and necessary based on how long patients are in the hospital or are even just expected to be in the hospital.   How is this proposed rule change going to be applied in real life?  Fast forward to bottom right paragraph on page 27645 to the top left of page 27646 and the proposed rules change gets even juicier.  It describes how Medicare's external review contractors  will be required to act:

I think this single paragraph on the proposed rule change is going to transform how hospitalists document in the chart.  Medicare has defined for us exactly what is reasonable and necessary for inpatient care.  The answer is two midnights.  The way I see it, the 2-midnight rule is now our value mandate as a practicing specialty.  We have been given the two-midnight rule and I guarantee to all that is true in this world, this is going to be the Bible for hospitalist medicine.  Hospitalists that can document a  yellow brick road straight to the top of Two Midnight Mountain are going to see their value to administrators explode as diagnosis related groups (DRGs) are the drug of choice for hospitals addicted to Medicare dollars.

External review contractors are now required to presume the threshold of reasonable and necessary for 2-midnight stays.  Experienced hospitalists have an amazing ability to provide documentation supporting medically necessary care to anything that barely breaths, barely moves or barely speaks in our chronically alive, but not really patients admitted for medically necessary and reasonable nursing home care.  Everything great hospitalists do is medically necessary because their documentation says so. Great hospitalists are worth their weight in gold for this very reason.  External review contractors will never be able to show abuse of the 2-midnight presumption by  hospitalist groups with great documentations skills.  This. Is What. Hospitalists. Do. For. A. Living.  Hospitalists are documentation experts.  They play that game better than anyone.  Hospital systems aren't going to  subsidize hospitalists $140,000 per year per hospitalist for nothing.   For all intents and purposes, hospitalists are documentation whores and hospitals are their pimps.

How do hospital inpatient payments currently get denied?  The middle left column of page 27647 to top middle column of the same page provides a nice summary detailed below.  In a nutshell, payments made in error by CMS are more frequently associated with short stay procedural  inpatient claims that should have been provided on a hospital outpatient basis, which I believe is the driving force  behind this proposed rule change:

How bad have the errors been?  Continuing on with the middle column on page 27647:

In Medicare's eyes, the errors are due to procedures, not little old grandpa admitted with acute exacerbation of too-unsteady-to-ballroom-dance and have nothing to do with hospitalist patients  who also get three inpatient midnights for a primary diagnosis of too-wrinkled-to-smile.   As a hospitalist, I am not admitting observation patients who just had an EGD or heart catheterization.  I am admitting my 98 year old grandmothers who's family can't take care of them anymore so they drop them off at the emergency room for us to handle instead of  placing them in a nursing home because they refuse to sell off her assets to qualify for Medicaid instead of planning for the future and purchasing long term care insurance policies.

These are patients where hospitalists with exceptional documentation skills can make anything medically reasonable and necessary and show value under the 2-midnight rule where no value previously existed.  This documentation is important because Medicare clearly says part way down from the top right column on page 27647 that a physician order for inpatient shall not by itself make a patient qualified.  The medical necessity review rule continues as follows:

In other words, just because the physician writes an order for inpatient, it doesn't mean the inpatient status is automatically correct.  This gets me back to my original issue.  If the physician order isn't the law, then why have the requirement in the first place.  Why not bypass the physician and have a process in place that allows people trained in the determination of inpatient vs outpatient make the determination.  Why not allow hospital utilization review experts to make determinations on a retrospective basis and get rid of all the errors we have to deal with under this process.  I would love to write an order for "Hospital bed:  status per utilization review team" and have Medicare pay for all charges up to that moment in time  regardless of the status of the patient.  That would make patients happy.

In addition to the physician order, medical necessity reviews will continue as described in the medical review criteria for all hospital services and the inpatient hospital admission guidelines.  The first paragraph at the top of page 27648 starts this discussion below.  I believe this entire page is vitally important and every hospitalist should read them and learn them.  The rules detailed on this page are going to transform how we document our social admits who are too-old-to-breath-in-the-upright-position so they can get qualified for three midnights under a diagnosis of  need-two-on-the-way-to-three-midnightitis :

It's all about documentation people.  Clear as day, Medicare is going to focus on patients who are being billed inpatient who do not stay more than 2 midnights.  They may continue to audit the rest,  but they are not going to focus their energies on that population unless they find an attempt to game the system (as if somehow the 3-midnight SNF rule is not being gamed).  Great hospitalists could get any patient who is admitted with a diagnosis of patient-becomes-invisible-due-to malnutrition-and-old-age-when-they-turn-sideways-but-they-have-no-other-medical-problems qualified for a ten day hospital stay with reasonable and necessary medical care.  I hate to tell Medicare the bad news, but from where I'm sitting in the peanut gallery, the entire country is gaming the Medicare system.  It's-All-One-Giant-Game.  The 3 midnight rule is already a farce.  We now have the 2-midnight rule too!  Hurray! Oh, and the 1-midnight-rule too!  Yeah!

Medicare's rule change has just given hospitalists the social admit green light to write inpatient orders on all their patients with acute exacerbations of too-demented-to-care-about-paying-for-a-nursing-home-but-the-daughter-wants-the-farmland.  Why do I say this?  Because Medicare clearly states they are going to use physician documentation of the "reasonable basis for the expectation of a stay crossing 2-midnights" that will justify the medical necessity of the inpatient admission.  If this isn't an entry into the Inpatient Social Admit Marathon, then you're not reading what I'm reading.  Social admits ALWAYS take longer than two midnights to disposition out of the hospital.  If a hospitalist states on admission that they think their admission for too-slothy-to-support-themselves  is going to be in the hospital longer than two midnights, all they need to do is document their supporting reasons. They state that clear as day:

"The judgement of the physician and the physician's order for inpatient admission 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."

Every social admit a hospitalist is asked to admit  into the hospital could qualify for inpatient based on the expectation of the process taking longer than two midnights to provide an appropriate discharge to the community (especially at really crappy hospitals) and documenting their judgement of  risk for an adverse event if they are not discharged to a nursing facility.  They way I see it, Medicare is telling me I can qualify my 98 year old patient who is too-weak-to-hyperventilate as inpatient status by simply writing the following statement:

It is my medical judgement that Mrs Smith presents as a great danger to herself if not continuously monitored in a 24 hour care setting.   Due to   ___________________ (write anything reasonable that doesn't seem related to patient or family convenience) I do not expect Mrs Smith to be discharged in less than two midnights. 

What are the reasons social admits always take longer than two midnights to discharge? Just off the top of my head, here are some reasons:

• It's the weekend and everyone knows nursing homes don't accept new SNF patients on the weekend.
• It's a holiday.  See above.
• The patient is homeless and can't find their Medicare card.
• The patient is drunk.  It takes two days to safely get them sober.
• The patient refuses to be discharged and files an appeal.  You get two midnights right there.
• It takes two midnights to get the psychiatrist to see the patient to tell you they can't make their own decisions.
• Any patient admitted after 6 pm by the night hospitalist isn't going to get discharged before 6 pm the next day.  That's because they'll be done rounding at 9 am and all the tests won't get done until the afternoon and that means another midnight waiting for test results.  
• The powers of attorney won't return your phone calls.
• It takes two midnights for families to choose a nursing home.
• Families demand 12 consultants to prove grandma is just old and weak.
• There is no access to clinic records on weekends. 
• Home medications can't be verified until after the patient is already discharged.  
• Physical therapists are too busy to see them on day one.  Bam!  You got another midnight.
• The powers of attorney is crazy themselves.  
• The patient won't talk to you or You won't talk to them because they are too hard of hearing. 

How can hospitalists encourage compliance with the 2-midnight inpatient rule that is really nothing more than a gateway to 3-midnight Heaven ?  Try these methods:

• Tell families to go home and don't answer their cell phone for two midnights.  Don't call me.  I'll call you.
• Tell families to tell the hospitalist grandpa was hallucinating this morning, although nobody saw it.  Make sure to refuse the CT of the head your hospitalist will order.  Delirium will buy you a midnight, maybe two.
• Order a cardiac stress test after the patient has has their morning coffee.  Oops.  Sorry about that. I guess they'll have to wait another midnight to get their test.
• Place them on telemetry.  Note the one beat run of VT, but forget to call for a cardiology consult until late in the day on a Friday night.  
•  If you admit  a patient on Friday, just forget to request clinic records until Saturday.  That buys you the weekend while you wait for their clinic to open on Monday.  It's not safe to discharge the patient without a complete picture of their health.  
• Order lots of lab tests. Don't follow up on them until the next day.  Regardless of what the labs show, order an advanced imaging test, but don't follow up on the results until the next day.  Bam.  Two midnights.
• Just order a bone marrow biopsy on a weekend to prove grandma doesn't have a case of disseminated it-just-doesn't-matter.  Nobody does bone marrow biopsies on weekends.  Cancel the bone marrow biopsy on Monday after confirming the patient's case of it-just-doesn't-matter.  

I'm fascinated by this proposed rule on several levels.  All those patients who are too weak to go home have just found themselves a  way into the golden palace of a skilled nursing facility (SNF) paid for by Medicare, otherwise known as a free nursing home.  As I interpret this proposed ruling, hospitalists can write an order for inpatient status and document their expectation of longer than 2-midnights in the hospital by documenting their on going concerns to rule out stroke, rule out sepsis and rule out acute exacerbation of old age, regardless of their intensity of service, and support that documentation with further concerns about adverse events, comorbid conditions and severity of signs and symptoms and their patient qualifies for inpatient status because CMS will presume them to qualify as appropriate.

Just wait until the general public gets a hold of this change.  No longer do they need to worry about caring for grandma at home.  Just bring them to the adult humane society (aka the ER), get them their two midnights  on the way to the mandatory three SNF midnights and it's a Friday night SNF party at the fancy nursing home with skilled nurses.  Once hospitalists get past that second midnight with inpatient status while ruling out occult bacteremia in the absence of fever, absence of leukocytosis and the absence of standard of care,  they can easily get their third SNF midnight by documenting their need to confirm acute exacerbation of needs-three-midnights-and-a-place-to-live-upon-discharge.

Alternatively, I'm fascinated by all the acute drug overdose patients who require ventilator support in the ICU that are admitted at 1 am and are discharged by 3 pm.  Apparently, they aren't in the hospital long enough to be admitted inpatient if the hospitalist believes they can be discharged before the following night.  Apparently, they are only being observed on the ventilator to determine whether or not to actually turn the ventilator on.    Being sick on the ventilator for less than one midnight just doesn't cut it anymore.  If you want to qualify your critically ill drug overdose for inpatient, you'd best consider telling the family to go home and get more drugs to double the suicide dose so the hospitalist doesn't extubate them too soon from life support.  It's a matter of life or 2-midnights.

However, If hospitalists document their confidence in their excellent care team and can get their critically ill patient discharged in less than two midnights, their hospital may be  punished.  They should instead consider providing suboptimal care, generate an iatrogenic critical medication error or two and delay the discharge past the second midnight to verify payment under inpatient status.  Or maybe they should just delay their discharge for another midnight so their clearly obvious inpatient care gets paid for as an inpatient and not the less funded observation rate.

Yes folks, Medicare gave hospitalists the 3-midnight rule.     Now they are preparing to give hospitalists the 2-midnight and 1-midnight rules.  On October 1st, 2013, how hospitalists document their social admits will provide a great opportunity for them to show value where none previously existed.  Turn that observation frown upside down and give your 108 year old with a mild case of  too-old-to-calculate-her-age-based-on-her-date-of-birth a golden ticket to inpatient status and one small midnight away from the dream SNF of her choice.  You owe it to her.  She's 108 years old and you're not.

Medicaid Pay Increase For Hospitalists Confirmed For 2013-2014.

Are hospitalists going to get a Medicaid pay raise for 2013 and 2014?  The answer is yes, hospitalists qualify for Medicaid parity (with Medicare) as required by the Affordable Care Act (ACA).  For many states, Medicaid pays physicians and other providers a fraction of Medicare rates.  Legislation signed as part of the ACA mandates Medicaid rates to equal 100% of Part B Medicare rates in calendar year (CY) 2013 and 2014.  That means  if you haven't already seen increased rates, and you are a qualified physician providing qualfied primary care services, you will get increased Medicaid payments retroactively applied to January 1st, 2013.

When folks think of primary care, most likely think of the outpatient clinics for pediatrics, family medicine and internal medicine physicians.  But that's not how ObamaCare defines a primary care specialty.  That's right people, hospitalists, pediatric cardiologists and a whole lot of other practicing physicians now qualify as providers of primary care under ACA rules.

I was first alerted to this stunning CY 2013 and 2014 increase in Medicaid payments for hospitalists after reading an article from The Hospitalist titled Afordable Care Act (ACA) Provision Carries Pay Raise For Some Hospitalists.  Joshua Bowell, the Society of Hospital Medicine's senior manager of government relations, discusses the rules and how they apply to hospitalists.  It's a great article and I encourage all hospitalists to click the link above, read it and forward it to their billing company to make sure all necessary paperwork has been  filed to qualify for increased Medicaid payments and retroactive Medicaid payment increases that are required to start on  January 1st, 2013.

What are the specifics of this law?  You can read the  Fall 2011 rule abstract that implements section 1202 of the Affordable Care Act (ACA)  here.   I have taken the liberty of publishing it below for your review:

Title: Payments for Primary Care Services Under the Medicaid Program (CMS-2370-P)  

Abstract: This proposed rule would implement section 1202 of the Affordable Care Act that requires payment by State Medicaid agencies of at least the Medicare rates in effect in calendar years (CYs) 2013 and 2014 for primary care services delivered by a physician with a specialty designation of family medicine, general internal medicine, or pediatric medicine. This rule would implement the statutory payment provisions uniformly across all States. Specifically, this proposed rule would define, for purposes of enhanced Federal match, eligible primary care providers and identify eligible primary care services, as well as specify how the enhanced payment should be calculated. This proposed rule would also provide general guidelines for implementing the enhanced payment for managed care services.

So how does a hospitalist and a  pediatric cardiologist qualify for primary care under the proposed rule above?  Great question.  To understand the answer, one must understand how the rule defines the qualified physician providing the qualified primary care service.   I did a little digging to find out how.  Do you know how hard it is to find all this stuff?  The November 6, 2012 Federal Registrar published the final ruling (with a minor correction published December 14th, 2012) titled RIN 0938-AQ63 as it applies to the regulation mandating Medicaid parity with Medicare Part B payments for qualified primary care physicians.  Here is the lead summary paragraph of the final ruling:

How does this final ruling define a physician delivering a primary care service?   According to the Federal Registrar, the November 6th, 2012 final ruling amends several sections of the Social Security Act, specifically, 1902(a)(13), 1902(jj), 1932(f), and 1905(dd).  Effective March 20th, 2010,  section 1902(jj) of the Social Security Act now defines a primary care service as follows:

There you have it folks.  ObamaCare has defined, through amendment of the Social Security Act, exactly what primary care services are.  It is the delivery of evaluation and management services to title XVIII beneficiaries.  Title XVIII is Medicare.   It appears to me that any physician that submits payment for a qualified  E&M charge is submitting a service for a primary care service. What are the E&M codes eligible to receive higher Medicaid payments?  Evaluation and Management codes 99201-99499 of the Healthcare Common Procedure Coding System (HCPCS) and vaccine administration codes 90460, 90461, 90471, 90472, 90473 and 90474 have been lawfully determined to qualify for Medicaid parity payments in CY 2013 and 2014.

As a hospitalist, that means most E&M charges qualify for higher Medicaid payments.  All initial hospital codes, subsequent care codes, critical care codes, observation codes, and same day admit/discharge codes are included by law.  Yes folks, my critical care is considered primary care.  And my emergency room codes?  If I see a patient in the emergency room and decide not to admit them, my emergency department E&M code is considered a primary care service.  Sorry ER doctor, even though you submit the same code, you do not get parity under this law.  But why?  For many ER doctors, they are the Medicaid patient's primary care provider through dozens of ER visits a year.  If any doctor is the primary care doctor for a Medicaid patient, it's the ER physician because no primary care doctor will see them!  Why can't they get paid the higher rate?

Does any physician who submits an E/M code get parity payments for their primary care service?  Can a urologist get paid Medicaid parity for their office visits? Can a general surgeon get Medicaid parity for their cholecystectomy?  The answer is no.  Why can a pediatric cardiologist get Medicaid parity but a general surgeon can not?  The answer lies in how ObamaCare defines an eligible physician.  Return back to the summary statement above and you'll see the physician must have a specialty designation of family medicine, pediatric medicine or general internal medicine.  A urologist and general surgeon does not meet that requirement. But how does a pediatric cardiologist make the cut?

The answer lies in this law's interpretation. After the proposed rule was published in May, 2012, one hundred and seventy-seven comments were received.  Some of those comments reviewed below helped clarify the who is an eligible physician question.  Read this section thoroughly to fully understand who qualifies and who doesn't.  Click on the picture to take you directly  to the Federal Registrar paragraph contained within.

And that folks is how a pediatric cardiologist gets a Medicaid pay increase for their E&M services in CY 2013 and 2014.  The interpretation of this law adds 44 additional specialty designations to the qualifying list for Medicaid parity.  What is the gist of the argument?  A pediatric cardiologist is trained in the specialty designation of pediatric medicine and thus qualifies for Medicaid fee increases to match Medicare payment rates for 2013 and 2014.   The law says if a physician is recognized by the American Board of Physician Specialities (ABPS), the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA) as a specialist or subspecialist within the primary care categories, they receive Medicaid parity for their E/M charges.

What if the physician is not certified by any of these boards?  The law allows for Medicaid pay raises if  60% of the codes billed in the calendar year of enrollment were for qualified primary care services that has been defined above.  I suspect the 60% applies to the absolute number of codes submitted and not 60% of the total RVU value for the calendar year.  If the answer is absolute codes, then almost any qualifying physician could qualify by virtue of submitting at least two E&M codes for every non E&M procedure code done in the procedure suite.  That would give them a 66% rate of E&M charges which is  above the required 60% threshold.  I'm confident most medical subspecialists could clear the 60% threshold with no problem as long as they average at least two E&M charges for every non E&M procedure code they provide on any given day.

What about services provide by nonphysician practitioners?  Do nurse practitioners, pharmacists, midwives, certified registered nurse anesthetists  or other qualified nonphysician practitioners  receive the mandatory increases in Medicaid payments?  The answer is only if they are billing under the supervision of an eligible physician.  That means the answer is no for independent nonphysician practitioners but yes if they are working with physicians in the qualified specialties listed above.  Seems silly, doesn't it?  A pediatric cardiologist can spend 80% of their time in the cath lab doing procedures, but if they submit at least 60% of their codes as E&M charges they can get Medicaid parity on their office visits, hospital consults and hospital follow-up codes.  But the independently practicing certified nurse midwife administering the flu shot to protect mom and baby cannot.

Oh, and sorry OB/Gyn doctors.  You may be the only physician for your patients and provide 100% primary care to 80% of your patient population, but you don't qualify for federal subsidized Medicaid fee increases because you didn't train in pediatric medicine, family medicine or general internal medicine.   Maybe you should have been a pediatric cardiologist instead.  ObamaCare says they are  providing massive amounts of primary care these days, and by primary care, I mean telling the patient to contact their primary care provider to fill out the Family Medical Leave Act paperwork so they can have mom and dad at the bedside while they take Junior to the cath lab.

What about states that don't plan on expanding Medicaid eligibility?  That has no bearing on the requirement for eligible physicians providing eligible E&M services to get paid 100% of their Part B Medicare rate on their Medicaid charges for CY 2013 and 2014.  Whether states decide to expand Medicaid or not, qualified doctors  providing qualified E&M charges get a raise on their Medicaid payment rates.

What happens after 2014?  As noted in the Federal Registrar, states are required to report Medicaid participation rates to Congress in anticipation of decisions to continue or discontinue the current federal subsidy for qualifying Medicaid charges.  I'm sure that's  going to be another political fight.  I've asked a few of my colleagues about what they intend to do with  Medicaid.  All of them say they have no intention of expanding their clinic slots to include a greater proportion of Medicaid patients.  My facebook post confirms that.  They can easily fill up their clinic with follow-up visits on their current panel of patients with chronic disease. I suspect after these two years are up we're going to see no increase in Medicaid participation.  Physicians don't run their business on a two year horizon.  Imagine expanding a clinic to include a large influx of Medicaid patients only to try and balance the budget based on unstable Medicare politics and a Medicaid policy that falls off the cliff after CY 2014.

What physician in their right mind would budget that?  I'm willing to bet almost none.  The quirks of this law are simply mind boggling.  Pediatric cardiologists and hospitalists will get Medicaid parity for their ICU work but an independently practicing certified nurse midwife trying to take care of mom and baby as the only provider from conception to birth will not.  I don't need to say anything more.  Oh yeah, one last thing.  How much is this little experiment going to cost?  The expected cost to the federal government for this Medicaid parity pay increase is 5.6 billion dollars in calendar year 2013 and 5.745 billion dollars in 2014 (using 2012 constant dollars).  What's another 11 billion dollars we don't have matter, right?