Tackling dilemmas in coding, compliance, and revenue integrity: Inpatient admissions and acute MIs

by Ronald Hirsch, MD, FACP, CHCQM

The key to revenue integrity is compliance. But there are times when compliance and revenue integrity can present interesting dilemmas.

Today, I’d like to present an interesting dilemma in coding, compliance, and revenue integrity. In October 2013, CMS introduced the 2-midnight rule which states, in brief, that physicians should admit to inpatient status those patients who have an expectation of a hospital stay that will cross two consecutive midnights and treat others as outpatient. To qualify for a two-midnight stay, the amount of time the patient is expected to spend in the hospital includes both the time spent as an outpatient before the inpatient admission order is written plus the time subsequently spent as an admitted inpatient. At the same time, the treatment of patients who present to the hospital with ST-Elevation Myocardial Infarction (STEMI) has progressed, with door-to-balloon times of under an hour, preferential use of the radial artery for arterial access, and more potent anti-platelet medications. These therapies have led to the reduction of the expected length of stay for many of these patients from a week in the “good old days” down to one day.

At first glance, that means that if a patient presents with an “uncomplicated” myocardial infarction, their expected length of stay of one day would mean that inpatient admission is inappropriate and the patient should be treated as outpatient. When presented with this, many cardiologists were exasperated. They asked how they could possibly treat a heart attack as outpatient, not understanding that the differentiation was based on time and not on the illness or the treatment.

CMS attempted to “fix” this in the 2018 OPPS final rule, by adding CPT® code 92941 (percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, artherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel) to the inpatient-only list. If a CPT code that would be used by the facility to bill for a procedure is on the inpatient-only list the patient must be admitted as inpatient regardless of the expected length of stay for the hospital to bill for the service. CPT code 92941 represents “treatment of coronary artery obstruction during an acute MI…” and is the code that a physician would use when billing for their professional services. But it is not the code that would be assigned by the facility for most cardiac interventions during acute MIs: that would be HCPCS code C9606 (percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel). C9606 differs from 92941 in that it accounts for the added cost to the facility for the drug-eluting stents, whereas 92941 is the facility code used in the rare instance that the less expensive bare metal stents are used.

If a patient has an uncomplicated myocardial infarction and is admitted as inpatient and undergoes stenting, it would likely fall into diagnosis-related group (DRG) 247. If that same patient is treated as outpatient, the applicable Ambulatory Payment Classification (APC) would be 5194, a level IV Comprehensive APC. One would think that the DRG would pay more than the APC for the same patient receiving the same care but for many non-teaching hospitals APC 5194 can result in a payment that is several thousand dollars more than DRG 247. That’s right: the outpatient payment to the hospital may exceed the inpatient payment. And because the patient co-insurance on a highly weighted APC is limited to the inpatient deductible there are no adverse financial consequences for most beneficiaries.

Too add to the confusion, CMS added an exception to the two-midnight expectation in January 2016. The exception allows a physician to admit as inpatient on a case-by-case basis a patient who has an expectation of a one midnight stay but who is deemed to warrant inpatient admission based on the severity of the signs and symptoms and the risk of something adverse happening to the patient during the hospital stay. That means a physician could compliantly treat a patient presenting with an acute MI as either an inpatient based on this exception, or an outpatient based on the expectation of a one midnight stay. If the physician chooses to use the exception and admit the patient as an inpatient, the reason why the patient should be admitted as an inpatient must be fully documented. The documentation must be able to stand up to an external reviewer during a payer audit.

If both inpatient or outpatient are compliant, can reimbursement guide the selection of status? I would argue it can. There is no regulation that states that a hospital must forego compliant revenue by always choosing the option which has the lower payment. In fact, coders who are faced with two diagnoses which could be assigned as the principal diagnosis are instructed to choose the higher weighted diagnosis, resulting in higher revenue for the hospital.

Of course, operationalizing this would be a daunting task. Most physicians want to take care of patients and not be tasked with calculating the payment differential between a DRG and an APC. However, the question is fascinating as an academic exercise. Revenue integrity, compliance, and common sense seem to have collided and created a multiple-choice question where the correct answer is “any of the above.”

Note: Hirsch is the vice president of R1 Physician Advisory Services in Chicago and a NAHRI Advisory Board member.