RACMonitor: Latest Development - The Intersection of IPPS and SDoH

Dr. Ronald HirschMay 2, 2022

Stethoscope on desk with nurse writing

CMS is requesting comments on getting better data on the social determinants of health (SDoH).


As I am sure you have heard, the inpatient proposed rule for 2023 is out. I have not yet read all 1,786 pages, but I can tell you this– it is terribly boring, but who doesn’t like boring?


Sure, there are the usual payment proposals that are of great interest to finance and some code changes that the CDI and coding staff just love, but the Two-Midnight Rule remains intact. And for me, seeing if the Centers for Medicare & Medicaid Services (CMS) tampered with that is always the scary part of these rules.


There was one big thing in my review: CMS is requesting comments on getting better data on the social determinants of health (SDoH).


But let me say this: I told you so!


Just over four years ago, on April 23, 2018, I reported on Monitor Monday that the time had come to start reporting these ICD-10 social determinant codes on claims. To quote myself, “Now I doubt all 88 codes will be used for risk adjustment, but we won’t know which will be used so we should document and code all applicable conditions. And the more a code is used, the more the researchers will realize that it is a factor for them to consider.” To paraphrase Supertramp, “If only everyone had listened then, if they’d known just how right I was going to be.”


Moving on, there has been a lot of online discussion recently about what is referred to as outpatient in a bed. For those unfamiliar, that’s the outpatient who is occupying a bed but does not require hospital care. Maybe it is a patient who needs a guardian appointed, maybe it is snowing, and the patient can’t get a ride home, maybe the family abandoned the person in the ED and went off on vacation. Maybe it’s a day or two, maybe it is for weeks. Someone even noted that they convert inpatients who are stuck in the hospital for weeks or months to outpatients in a bed and if they get sick again, they create a new inpatient admission (although I am not sure that is a compliant method). But whatever the circumstance, the insurer, be it Medicare, Medicare Advantage, Medicaid, or any commercial payer, is not going to pay for the days. But here is the key. Call it what you want, and outpatient in a bed is certainly a perfect description, but you must talk to your billing and coding staff and determine how they are handling the coding of these patients. Those patients are occupying a room, they are getting nursing care, they are being given three meals a day, and environmental services is cleaning the room. Those are real costs. When they are inpatient, there is a daily room charge and you can shift liability to the patient with a properly executed HINN or the days can be made provider-liable with an occurrence span code. Either way, there is an accounting for the services. When patients are receiving observation services, there is an hourly charge for that. If they are recovering from an outpatient surgery, there is a charge for recovery room services. But if you have an outpatient in a bed where none of those apply, how does your system track the costs of that care?


How does your nurse staffing team know there is a patient that needs to be considered? If you are not getting paid, isn’t this considered charity care that can be reported? And if you want to charge the patient to stay, what do you bill them for?


It’s complicated and it is happening more often. I’ll have some answers soon.


Programming Note: Listen to Dr. Ronald Hirsch as he makes his rounds during Monitor Mondays, 10 Eastern and sponsored by R1 RCM.


Read the full article here.

Author Bio: Dr. Ronald Hirsch is Vice President of the Regulations and Education Group at R1 RCM Inc. Dr. Hirsch was a general internist and HIV specialist and practiced at Signature Medical Associates, a multispecialty practice located in Elgin, IL. He was Medical Director of Case Management at Sherman Hospital in Elgin, IL from 2006 to 2012, where he was Chairman of the Medical Records Committee from 1995 to 2012, and also served on the Medical Executive Committee. Dr. Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, certified in Revenue Integrity by the National Association of Healthcare Revenue Integrity, and on the Advisory Board of the American College of Physician Advisors. He is on the editorial board of RACmonitor.com. He is the co-author of The Hospital Guide to Contemporary Utilization Review, with the third edition published in 2021.