June 2020 Case #1 - A Stent Is Placed

70 yo male with traditional Medicare with PMhx of HTN and HL who presents to the emergency room with chest pressure and shortness of breath. Patient woke up in the middle of the night with difficulty breathing and called 911. Patient had persistent symptoms for about an hour. Upon evaluation by EMS, he described chest discomfort as a pressure sensation associated with diaphoresis which resolved after administration of nitroglycerin sublingual by EMS. He also endorsed associated palpitations and dizziness for last few days. Patient works as a farmer with a very active lifestyle. Upon arrival in the ED patient’s symptoms had resolved. Initial troponin found to be unremarkable. EKG with PVCs but otherwise no acute ST changes noted. All other basic labs are unremarkable. Patient placed in Observation by cardiology team for further work up. Next morning patient underwent a stress which was found to have a positive ECG response to exercise for evidence of ischemia with a reversible apical perfusion defect. This case was sent to you for second level review given patient was anticipated to cross a second midnight pending cardiac catheterization results. Upon your review there is still no cardiac catheterization report at 5pm since patient was an add-on case for cardiac catheterization. Next morning you review the case again and note that patient received a cardiac stent and therefore spent a second midnight in the hospital post DES placement for monitoring. Patient had no acute events overnight post DES placement and has a discharge order. Would you page cardiology team for an inpatient order prior to patient’s discharge or release this encounter as OBS. 

Committee Discussion

We received a total 25 responses with 64% supporting inpatient status while 36% would recommend continuing observation services. A vast majority of the responses highlighted how this case meets for inpatient based on the fact that medically necessary hospital level care services were provided for two midnights. Initial work up including EKG, troponins, telemetry monitoring and plan for stress test in a patient with risk factor adequately covers first midnight in observation. 

After crossing one midnight, a positive stress test prompted cardiac catheterization. Since the cardiac catheterization demonstrated coronary artery disease resulting in placement of a drug eluting stent, many responses also highlighted the need for hospital level post-stent monitoring. Whereas if the cardiac catheterization had been negative, patient would have been appropriate for observation level of care as discharge would be anticipated after one midnight. Some providers felt both stress test and cardiac catheterization could have been accomplished either in 1 midnight or deferred to outpatient testing, given hemodynamic stability. 

One aspect where responders had differing opinions related to whether inpatient status can be ordered after a discharge order is already placed. Based on discussion with members of the observation committee, we have a few references for further guidance on this topic but please note that many hospitals have formulated policies based on their interpretation of CMS material. CMS Transmittal 299 and MLN Matters SE0622 on Condition Code 44 lists one of the conditions for Code 44 as “the change in patient status from inpatient to outpatient made prior to discharge or release, while the beneficiary is still a patient of the hospital”. This language of “discharge or release” leaves it open to interpretation whether discharge is considered from the time of the discharge order or when patient actually leaves the hospital since often there is always a time lag. 

Please also check out an interesting article on Dr Ronald Hirsch’s website (www.ronaldhirsch.com) titled “Inpatient Order on Day of Discharge” for additional insight. 

Select Responses

Assuming pt is FFS Medicare, the patient approached the 2nd MN with classic anginal symptoms, relieved by NTG, with a positive stress test. High risk for an adverse event; i.e. MI, arrhythmia, sudden death....now requiring continued hospital-based acute care through 2nd MN. Although missed the opportunity to appropriately convert to IP before crossing the 2nd MN, MCR allows the status to be correctly determined up until time of discharge. If discharge not yet effectuated, would convert to IP. Whether the order was changed the previous evening or at time of discharge, will still reflect as a < 2 MN IP admission and will require a span code for the initial MN (s) in OBS. Now, if this is a commercial payer, contracted MCR-Adv, or non-contracted MA... while still IP in my eyes... would be much more challenging to defend the expected denial. 

There was a delay in the cardiac cath due to scheduling. This disqualifies his second MN. 

Based on the medical necessity and complexity of the problem which needed a care more than observation level.