February 27, 2018

Documenting Total Knee Replacements: A Different Approach

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The author believes that it is more compliant to assign total knee replacements as outpatient services and then reassess the patient’s progress the next day to determine if there is a need for inpatient status.

First of all, in five years I believe what follows will all be a non sequitur, and total knee replacements will be done routinely across the country as one-day stays. This would be similar to women not staying in a hospital for a week after having a baby, patients with pulmonary emboli being treated with Lovenox from the ED and not even requiring hospitalization, and laparoscopic cholecystectomy patients going home the same day. In healthcare, we just keep getting better, more efficient, and safer every day. But it’s getting there that is painful.

For me, the thought that my orthopedic colleagues could or would provide masterful documentation concerning the likely need for a patient to require more than two midnights of medical care – and to do that in the preoperative documentation – borders on sheer lunacy. To put it simply, it won’t happen at my shop. Even if we could get that sort of documentation, with all the Medicare Administrative Contractor (MAC) probes on DRG 470, preoperative review of the documentation would be wise, and most institutions do not have the necessary manpower.

The thought that many total knee cases can be inpatient-appropriate based on comorbid conditions also seems plain wrong to me. If a good lengthy list of comorbid conditions could protect an inpatient status designation, a huge part of the current administrative law judge (ALJ) backlog never would have existed. I recall hundreds of peer-to-peer Recovery Audit Contractor (RAC) discussions back in 2012-2013 regarding inpatient claims. The number or types of comorbidities never mattered. It all was dependent on severity of illness, with objective supporting data or vital signs that were well-documented. Some documentation on risk could be helpful, although it too, on its own, never saved the case. What worked was actual identifiable acuity of illness and connecting the dots to a documented conclusion that the patient was sick and needed to be in the hospital.  

So if comorbidities require lots of tender loving care and are causing true, active acuity of illness that takes management and can truly be said to adversely impact recovery from a total knee replacement surgery ,that’s fine. I would go inpatient with that too. However, actively sick folks are not usually getting total knee replacements at my institution. Faced with that much comorbid burden, perhaps it would not be the best time to pursue a new joint.

I know the Outpatient Prospective Payment System (OPPS) rule suggested that there should not be wholesale changes in usual status decisions. It was suggested that the volume of knee replacements done as inpatient is not really expected to change. Can someone tell me where to buy a unicorn? Remember when the two-midnight rule discussion suggested that outpatient observation service volume would not be expected to change, and that hospitals could still rely on strong inpatient numbers? 

So, in my best judgment, the safest way to go – the most compliant and most effective approach – seems to be just trying to get it right each day. That is not to say that the occasional patient should not receive an inpatient order if he or she seems likely to need a Skilled Nursing Facility (SNF) stay right from the beginning, but again, SNF placement, at least at my institution, is a relatively rare situation.  That would be a good thing, in my view, as we are all on a rapid highway well into bundled episodic care.  

Hospitals with significant numbers of post-acute care referrals will find themselves very pressured in the future. Based on these thoughts, initial outpatient status for a total knee replacement seems correct, at least most of the time. It is too hard to really predict how a patient will recover.

In fact, I actually find myself in a unique position. Currently, I do many of the preoperative exams for total knee replacements. Every day I make well-educated, well-informed guesses about anticipated lengths of stay for patients with scheduled knee replacements. I am an internist. I get internal medicine comorbidities. As for my guesstimates, I think I am batting .500. 

The frail 80-year-old woman, wobbling in the exam room due to peripheral neuropathy in addition to her bum knee, seems like a great SNF candidate, even if she may not be excited about it. She said her five dogs would need her, which further suggested to me that the likelihood of her going home without a disaster was farfetched.

Well…she did great after her surgery and was able to go home without even a thought to skilled nursing. The 300-pound man with a terrible knee and obstructive sleep apnea, fresh off a myocardial infarction 12 months prior and with diabetes under fair control and a blood pressure of 180/104 at the pre-anesthesia visit had “inpatient” written all over his forehead (not to mention the ASA 3 classification). Yet he was able to go home after one midnight! And then there was the funeral hearse driver I saw today, who forced me to document no fewer than 20 comorbid diagnoses into his record. You name it, he had it: obstructive sleep apnea, diabetes, hypertension, chronic obstructive pulmonary disease (COPD), chronic atrial fibrillation, hypothyroidism, stage IV chronic kidney disease, etc. However, all these comorbid conditions were as well-controlled as they could be and he absolutely planned to go home after surgery to the care of his wife. I could not really order inpatient status for him, because I just did not know what his immediate future held. My case management folks certainly do not want me setting them up for CC44 hysteria. The fact remains: some of these folks do great, and of course, some do not. 

In spite of the Centers for Medicare & Medicaid Services (CMS) optimism, I am just not so convinced that it will be easy to put together reliable algorithms or screening tools or parameters that easily identify who will need an SNF stay and who will not. CMS may expect us to do this, but that seems easier said than done. For that last patient I saw today, I do not know if he will need two midnights instead of one. My guess is yes, because so many of them do. The average total knee replacement length of stay at my hospital is about two midnights, but that is not because these patients have acute illness or multiple comorbid problems. It is because they need physical therapy past the day of surgery. They need overall time to recover, get a handle on their pain, and receive good therapy so that they can safely go home. It seems difficult to confidently document this for every patient ahead of time – that inpatient physical therapy will be needed for two full days. Predicting that which I cannot know and basing an inpatient order on that lack of knowledge is discomforting. For me, it seems cleaner and far more compliant for such patients to start as outpatients and then the next day reassess progress. If such a patient is truly in need of ongoing therapy, I then can confidently order up that inpatient status and feel completely virtuous in doing so. When the medical necessity for the second midnight is there, I am not just guessing, not just prognosticating…I am doing what is right.

With this approach, I may be losing an initial midnight that will be needed later, but so many of these patients do not need to go to a nursing home anyway. All of this is very analogous to a short inpatient stay that began as observation for a day and then got upgraded to inpatient for a day. The medical necessity is there, and when it is documented well, the success rate in defending that decision (even as a one-midnight inpatient stay) has been excellent. I do not see that success changing. With this approach it seems that we still get the DRG payment when it is truly deserved. And if by some chance the patient needs an SNF stay, there is a very good chance that the extra midnight is going to be medically necessary anyway.

So there you have it. It is just another take. There is never any one universally right answer. Every approach has to have a foundation built from the knowledge of the medical staff, what that staff can accomplish with documentation, an understanding of the denial/appeal climate for a given facility, the typical lengths of stay for total knee replacements, and the volume of post-acute care. One approach to this issue is institution-specific and medical staff-specific, in my opinion. Context is important. Also, good case managers on the floor can help greatly in getting appropriate documentation. The ability to review the documentation and obtain it when necessary can be achieved in a much more controlled fashion on post-op day one versus a preoperative time frame. If I can finish every day feeling that the patient is in the correct status, at least for that day, then I am a happy physician advisor.

Lisa Banker, MD, FACP

Dr. Lisa Banker is a native of Northwest Indiana and graduated from the University of Notre Dame. She received her MD degree from the Medical College of Ohio and completed an internal medicine residency at Riverside Methodist Hospital in Columbus, Ohio. She has enjoyed an internal medicine career of nearly 25 years in New Bern, N.C. that has included primary care internal medicine with a large multi-specialty medical practice and several years as a hospitalist and program director. She serves as the president of Ideal HealthCare, which offers consultation services in clinical documentation and physician advisory services. In 2011, Dr. Banker became the first physician advisor at CarolinaEast Medical Center. As of 2017, she serves as the corporate vice president and chief physician advisor for McLeod Health system in Florence, S.C.

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