Book Excerpt: CDI’s role in inpatient-only procedure documentation

By Debbie Mackaman, RHIA, CPCO, CCDS

Connect CDI, utilization review, and case management before the patient is discharged

When a procedure converts to an inpatient-only procedure during the surgery, the documentation process may get a little more complex. Analyze what happened during the procedure itself. If the inpatient-only procedure is performed on an emergency basis, it’s likely the admission order was not obtained prior to the procedure. The outcome for the patient will determine the next steps. If the patient expires, no further action is required by the registration or operating room staff. The coding and billing teams take over resolution of the case.

If the patient does not expire, the surgeon should confirm the type of surgery originally scheduled and the reason for the needed change to the inpatient-only procedure. He or she should do so before the patient leaves the postoperative area. The care team needs to make a determination regarding the admission of that patient. Under current CMS guidance, the three-day payment window may apply in this scenario. The case should be held for billing purposes until a thorough post-discharge review can be completed.

CDI staff may be involved in the initial review of the case. If CDI staff suspect an inpatient-only procedure was performed without an admission order, they should work with the coding team to identify the correct procedure code and verify if the procedure in question meets inpatient-only criteria. If it does, obtaining an inpatient admission order should be a priority. At this point, if necessary, the utilization review (UR)/case management (CM) team can step in.

The involvement of the UR/CM team is also critical when an inpatient-only procedure is canceled after the patient is admitted. Although the patient was admitted with the intention of performing the procedure and, therefore, the admission should be covered, each case should be independently reviewed. If the patient does not need acute medical care, his or her status may be changed from inpatient to outpatient, when appropriate, using Condition Code 44. When all conditions are met, Condition Code 44 allows a hospital to change the status and bill the services on an outpatient claim; however, timing is everything.

Editor’s note: This article is an excerpt from the “Inpatient-Only Procedures Training Handbook” by Debbie Mackaman, RHIA, CPCO, CCDS, an instructor for HCPro’s Medicare Boot Camps. To read the Fiscal Year 2017 inpatient-only list, visit the OPPS page on the CMS website and download Addenda E.