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Flash Polls - What did ACPA members think?

Expert Commentary: ACPA members were very divided in the approach to defining sepsis, further underscoring Dr. Antonios' point of the need for a better sepsis definition. However, the current sepsis definition is that defined by Sepsis-3 - life threatening organ dysfunction caused by a dysregulated host response to infection. That is the definition that everyone should be currently following, but clearly that is not happening yet. Why? There are several reasons:
  • A perception that sepsis-3 recognizes sepsis "too late" and that early SIRS based recognition can lead to better outcomes. This perception, however, if flawed because any prospective study that demonstrated survival benefit in sepsis did it in patients with SIRS + organ dysfunction, not merely SIRS alone. The sepsis-3 authors are contending that organ dysfunction, rather than SIRS criteria, is the important piece to recognize early. However, studies to evaluate sepsis survival using SOFA or qSOFA as the clinical recognition tool are not yet available. Preliminary studies so far do indicate that SOFA and qSOFA are better at predicting mortality than SIRS.
  • Surviving Sepsis Guidelines from 2012 were based on Sepsis-2, and form the basis of most current recognition and treatment regimens, including the CMS SEP-1 bundle. While the Surviving Sepsis Guidelines were rewritten in 2017 to reflect Sepsis-3, the CMS bundle has not changed. In an editorial published in JAMA, CMS responded to the Sepsis-3 guidelines with great reservation and indicated no intention to change the SEP-1 bundle sepsis definition anytime soon.
  • Payors are variable as to whether they follow Sepsis-2 or Sepsis-3 guidelines
  • SOFA is an old construct and requires information not always available (such as an ABG). In addition, the "Clinical Criteria" in the Sepsis-3 paper use a SOFA change of 2 or greater from baseline, but the Clinical Criteria are not the sepsis definition - which remains the yet unmeasurable "life threatening organ dysfunction caused by a dysregulated host response to infection."
  • Several clinical governing bodies complained about not being included in the international sepsis-3 consensus panel.

With time, we expect the use of the Sepsis-3 definition and the Sepsis-3 constructs (SOFA and qSOFA) to be more widely adopted by providers and payors. A lot will depend on the clinical research studies using those constructs, and whether they are able to decrease sepsis mortality compared to current care.

Expert Commentary: ACPA members favored option 2, and this commentator agrees with that approach. 2016 MedPAR data show that cases that fell into MS-DRG 470 (which includes most hip, knee, and ankle replacements) had a median length of stay of 3 days. The 10th percentile of LOS was 1 day, and the 25th percentile of LOS was 2 days. If this data is also representative of TKAs, it would suggest that CMS is expecting roughly 75-90% of TKAs to still be performed on an inpatient basis, based on the historical length of stay.

CMS made several statements in the 2018 OPPS Final Rule Preamble that confirm this line of thinking. "We do not expect a significant volume of TKA cases currently being performed in the hospital inpatient setting to shift to the hospital outpatient setting as a results of removing this procedure from the IPO list. At this time, we expect that a significant number of Medicare beneficiaries will continue to receive treatment as an inpatient for TKA procedures."

In the same Preamble, CMS also stated "we remind commenters that the '2-midnight' rule continues to be in effect and was established to provide guidance on when an inpatient admission would be appropriate for payment under Medicare Part A (inpatient hospital services)." Keep in mind that the "2-midnight rule" actually encompasses not only the 2 midnight expectation but also now a case by case exception for inpatient when a 2 midnight stay is not expected. CMS stated that the case by case exception is not "rare and unusual" but arose as an expansion of the "rare and unusual" clause. CMS did also say that stays only expected to last a few hours or less than 24 hours would rarely be appropriate for Part A payment under the case by case exception.

Therefore, it seems reasonable that if a surgeon expects a 2 MN necessary hospital stay for TKA and puts reasonable documentation as to why, then you have an appropriate inpatient stay under the 2-midnight rule. The documentation as to the "why" is the part that is new for most surgeons. If your TKA patient then stays 2 midnights beyond the inpatient order, then your case would also meet the 2-midnight "presumption" and not be subject to review outside of evidence for fraud, abuse, or gaming.
As far as which cases qualify for Part A inpatient payment under the case by case exception regardless of 2 MN expectation, Dr. Ron Hirsch offers the following opinion:

"The most appropriate answer for this case is 'I need more information.' This patient has three comorbities and is morbidly obese. Assuming her BMI is over 40, that alone warrants inpatient admission based on her increased risk. Her three comorbidities, assuming the 'additional information' supports that are not well-controlled, also would allow inpatient admission based on increased risk. CMS made this clear, stating 'We would expect that Medicare beneficiaries who are selected for outpatient TKA would be less medically complex cases with few comorbidities and would not be expected to require SNF care following surgery.' 82 FR 59384  If you are admitting based on increased risk, there does not need to be a two midnight expectation but that risk must be explicitly stated as the reason for inpatient admission. Granted a patient with a BMI of over 40 is unlikely to be able to be discharged the day after surgery but that does not need to be considered at all."

Expert Commentary: Our members were pretty evenly divided on this one!

Prior to January 1, 2016, appropriateness for Part A payment hinged on whether a 2 midnight expectation of hospital care was present, or if an inpatient only procedure was performed. Those were the two scenarios where Part A inpatient payment would be appropriate. After January 2016, we now have the case by case exception, where Part A payment may be appropriate even if a two midnight stay is not expected, based on a complex medical judgment and the documentation present in the medical record.

Prior to January 1, 2016, the most appropriate response would be to rebill Part B inpatient. After January 1, 2016, providers were left with a void on what might be an appropriate scenario to use the case by case exception. That is, until Livanta, a Quality Improvement Organization under contract with CMS, presented this exact case scenario as a case that would be approved for inpatient Part A payment. Livanta is one of the two BFCC-QIOs under contract by CMS, covering New England and the West Coast. What about other parts of the country? CMS communicated with ACPA that education issued by Livanta could be used nationwide, as Livanta and KePRO (the other QIO) are implementing the same Part A policy.

With reasonable documentation by the provider to justify the clinical severity and thought process, this case scenario may now be billed under Part A. There still remains some risk of denial, however, as there is no guarantee that other Medicare contractors see the issue the same way Livanta does.

Observation cannot be ordered retrospectively on a Medicare patient.
Flash Poll
Expert Commentary: The level of care decision hinges on the expectation of the admitting practitioner based on the knowledge available at the time the decision is made. In this case, it is probably reasonable to expect necessary hospital care to cross the first midnight in order to gauge the need for IV medications, monitor po intake, and obtain the necessary rehabilitation and safety evaluations. If the first midnight is all that can be expected out of the gate, then observation would be a reasonable choice.

What about inpatient? Inpatient would be reasonable if either the admitting practitioner made a reasonable argument for a two midnight expectation during the initial assessment, or if that practitioner explained why this case should be inpatient despite a lack of a two midnight expectation (invoking the case-by-case exception that went into effect January 1, 2016). The anticipated need for the Part A sub-acute rehab benefit is not recommended to justify a case-by-case exception alone.

A HINN 1, or preadmission HINN, will grant the beneficiary immediate appeal rights to the QIO, and kick the decision to them regarding coverage of a Part A stay.

Outpatient in a bed is probably the only incorrect answer. You are providing necessary nursing and physician monitoring services that, at a minimum, qualify for observation hourly billing.