Administrative Memos

200102

FROM: Theodore O. Will, Chief Executive Officer
DATE: Feb 16, 2001
SUBJECT: PEPP Report in Regard to Short Stays: Chemotherapy Admissions
IPRO CONTACTS:

Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, ext 364

Enclosed please find a copy of an IPRO Report entitled "Short Stays: Chemotherapy Admissions". This IPRO-PEPP study examines the appropriateness of short stay admissions (i.e., zero to one-day stays) where the primary procedure was 'Injection or Infusion of Cancer Chemotherapeutic Substance'. We defined these "chemotherapy admissions" as any short stay admission where the primary procedure listed on the inpatient medical claim was ICD-9-CM code 99.25.

As you may be aware, the Office of Inspector General (OIG) intends to look at inpatient hospital payment for beneficiaries discharged after spending one day or less in the hospital (short stay admissions) as part of their Fiscal Year 2001 Work Plan. Approximately 10% of all Medicare patients admitted are released the next day (HHS/OIG Fiscal Year 2001 Work Plan, Health Care Financing Administration, Hospital Page 1), and earlier OIG reports suggest that in many cases the care rendered during these short stay admissions could have been safely provided in an ambulatory setting. These potentially "unnecessary" admissions would be more appropriately billed as outpatient claims.

In 18% of the cases reviewed by IPRO, there was no documentation to justify the admission, either because the patient did not receive chemotherapy (5 cases), or because clinical criteria were not satisfied (26 cases). Inpatient chemotherapy admissions were justified by clinical criteria in 82% of the cases. Specifically, the majority of admissions involved either prolonged infusions or provision of intravenous hydration. In a small percentage of cases, admissions were justified because the patient received a highly toxic agent.

As a result of our study, IPRO recommends:

Review hospital admission criteria for inpatient provision of chemotherapy with clinical staff (i.e., hematologist, oncologists, etc.).
Establish/maintain an assessment system (utilization review and educational feedback) which assures that all patients admitted for inpatient care require the intensity of services and monitoring provided in an acute care setting, and that the documentation in the medical record is reflective of the patient's need for such care.

Should you have any questions in regard to this project, please feel free to contact Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment.