Q&A: Reducing audit risks for short stays

Q: We have heard that Medicare short-stay inpatient admissions may soon come under increasing audit scrutiny by Livanta, the Beneficiary and Family-Centered Care Quality Improvement Organizations (BFCC-QIO) that was awarded the nationwide contract for reviewing these admissions. What can we do to reduce our audit risk?

A: There are two groups of admissions that are subject to audit, says Ronald Hirsch, MD, FACP, CHCQM, CHRI, a vice president at R1 RCM Inc. in Chicago. The first group of short-stay inpatients may come into the hospital and stay a few hours in the ED, or receive outpatient surgery care or observation services, before being admitted as an inpatient. The second group are “pure” one-day stays, Hirsch says, including people who were admitted on the day their care at the hospital began and were subsequently discharged the same or the following day. The second group is at the greater risk for denial, says Hirsch.

In both cases, documentation is critical. For the “pure” short-stay group, organizations will need to prove that the patients improved faster than expected or that they meet the case-by-case exception for high risk and/or high acuity, according to Hirsch.

“If it is a surgery, then it will either need to be an inpatient-only surgery or, once again, the documentation must support rapid recovery or that the patient was admitted under the case-by-case exception due to higher risk,” Hirsch says.

Some other practices to make sure you have in place to reduce your audit risk are as follows:

• Ensure that status decisions are accurate up front
• Ensure that physicians understand and know how to apply the 2-midnight rule and are kept abreast of any changes
• Review all zero and one-day inpatient stays prior to billing
• Self-deny non-compliant claims and resubmit them

For more information on this topic, see April’s issue of Case Management Monthly.