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Interqual experience?

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  • Interqual experience?

    Does anyone have experience with Interqual criteria for inpatient only procedures as it relates to admission status?

    Specifically my dilemma is as follows: I do a subset of procedures which are most often on privately insured patients. These particular procedures typically require overnight admission but not always... occasionally I only do part of the procedure making it much quicker (2 hrs), rendering recovery much more manageable. In these situations the patients often want to go home the same day. In my mind that would make it an outpatient procedure with admission status reflecting that. However, I get significant push back from the hospital to keep these patients as "Inpatients" under the guise of the procedure being performed being on the inpatient only procedure list on Interqual criteria. Their argument is the procedure was pre authorized, and approved, as an inpatient procedure and therefore expected insurance reimbursement would be much higher with patient having that status... even if they still go home the same day. My argument is that its unethical to do that despite the procedure being on the inpatient only procedure list. Am I overthinking it?

  • #2
    Probably. That list is produced yearly by CMS and is about as ‘black and white’ as status determinations go. You could contact some colleagues or people doing the same/similar procedures. Inpatient suggests that a patient is reasonably expected to cross two midnights for Medicare/private or 24 hours for Medicaid. By no means am I questioning your procedure, but is there something unique about what you do or do not do in these procedures that allow for your patients to be discharged more rapidly? I ask because although the code you may be billing for is on the inpatient only list, the procedure you are performing may not be exactly the same.


    • #3
      There is nothing unique that I do that would allow me to code it differently. I know that the exact same procedure is done in ASCs around the country. In fact the same procedure with even more added on to it are done in ASCs. Interestingly, my patients who are admitted rarely stay 2 midnights. The vast majority go home the very next morning/day.

      What I have a hard time wrapping my mind around is why the CMS designation matters for a patient that is not a Medicaid patient?


      • #4
        Because private insurers use CMS for their guidelines as well. Instead of ‘two midnights’ in Medicare or ‘24 hours’ in Medicaid, they typically use ‘protracted hospitalization’.

        The fact of the matter is, if the procedure you perform is on the ‘Inpatient Only’ list, it is highly unlikely you’ll be in trouble for placing them as an inpatient. CMS has decided, for now, that a patient undergoing your procedure will typically cross two midnights or 24 hours, depending upon their coverage. Do what you think is right, but I can understand interqual viewing this as an inpatient case given the CMS guidelines. There’s a huge reimbursement difference between inpatient and outpatient.