C
PSRO coordinator describes concurrent review Virginia C Dallmann, RN Virginia C Dallmann, RN, is a PSRO Coordinator for the Colorado Foundation for Medical Care, Denver. She received her BSN from Michigan State University, East Lansing.
oncurrent review within a Professional Standards Review Organization (PSRO) is most commonly done by a nonphysician review coordinator and a physicianadviser working as a team. The Colorado Foundation for Medical Care (CFMC) was created in 1970 to evaluate health care services in two major settings, the physician’s office and the short-term acute general hospital. The CFMC is the PSRO for Colorado. I am a nurse coordinator for the PSRO which is now operating in 90 hospitals throughout Colorado. PSRO is responsible for developing and operating a quality assurance system based on peer review and continuing education. The following elements have been incorporated into the CFMC hospital review program: 1. criteria for admission and lengthof-stay (LOS) 2. responsible review by physicians arid allied professionals of individual hospital cases 3. payment by third party sources for services certified a s m e d i c a l l y necessary 4. procedures t o assist hospital utilization review committees to gather and analyze recommendations based on information on facility utilization, patient care, and treatment practices 5. p r a c t i c e s a n d p r o c e d u r e s t o facilitate discharge planning and continuity care prior to the expiration of days of hospital stay. CFMC is governed by a 21-member board of directors including 17 physicians and a representative from each of the four provider groups, Colorado Osteopathic Association, Colorado Hospital Association, Colorado Pharmacal Association, and Colorado Health Care Association (state nursing home organization). The state is divided into five
AORN Journal, August 1975, Vol 22, No 2
195
geographical regions each having a council of 15 physicians and a representative from each of the four provider associations. Coordinators employed by CFMC to administrate the review program in individual hospitals may be registered nurses. I am a registered nurse with a background in emergency room and surgical ward nursing. CFMC has 34 coordinators who are registered nurses. A program clerk or medical records technician may be employed to assist the coordinator with clerical functions. My day begins with review of all Medicare and Medicaid admissions from the previous day. For each patient, a uniform hospital discharge abstract is initiated. The admitting diagnosis is coded by using the Hospital International Classification of Diseases. Using the number code, I then refer to the initial length-of-stay guidelines, which are equal to the median stay for age and diagnosis based on statistical data from a number of different admission and length-of-stay reports. As information is accumulated in Colorado, the median length-of-stay by region will be developed. After preparing the uniform hospital discharge abstract, I begin monitoring. All inpatient care as documented by the patient’s chart is monitored a t appropriate intervals while the patient is in the hospital. In the initial review, I check for confirmation of diagnosis, note plan of treatment and make an assessment for proper level of care. For example, diabetes mellitus is an incomplete diagnosis. Diabetes mellitus with leg ulcer or acidosis is a n example of a complete diagnosis giving a more accurate picture of the patient’s problem. If it is a “possible” or “rule out” diagnosis, are there other indications for admission? The admission note or history and physical should indicate other
196
problems that could complicate therapy such as arteriosclerosis or congestive heart failure. I place a n Initial Certification Stamp on the chart, after initial review, which states: This admission has been certified as medically necessary. Continued certification for acute care is being made concurrently with the hospital stay. When appropriate, early discharge planning is encouraged. In my day I also include concurrent review of each patient’s chart. Progress notes are observed to see if they are current, if there is a change in the treatment plan, or if the diagnosis is confirmed, changed, or still in doubt. Nurse’s notes are read to assist with the evaluation of the patient’s condition. I also note treatments and medications given and review the vital sign record. All orders for lab and radiology procedures are noted. The timing and sequence of procedures are checked for proper utilization. The coordinator must develop a working relationship with hospital administration, nursing service, admitting, insurance, social service, medical records and other hospital departments so as to be a part of the team working toward the proper utilization of acute care facilities. If I find, while monitoring the patient’s chart, that there is a change of diagnosis or a diagnostic or surgical procedure has been performed, an adjustment to the LOS is assigned. The chart is stamped notifying the attending physician that the patient has been recertified. Not less than two days prior to the expiration of the initially certified days, a stamp is placed on the chart, which reads: Certification is based on medical necessity. Your documentation within the next 48 hours on the progress notes
AORN Journal, August 1975, Vol 22, No 2
giving the reason for continued hospitalization will be appreciated. Expected number of days needed -. If the attending physician requests an extension, the coordinator consults with the physician adviser. The physician adviser is responsible for making all medical decisions. He is a local practicing physician nominated jointly by the hospital administration and medical staff and must be approved by the Regional Council and PSRO Steering Committee. Each hospital has a t least one physician adviser and an alternate. The physician adviser provides the physician-to-physician contact for the program. When the coordinator brings a question of medical necessity to the physician adviser, he may discuss the question with the attending physician. Should the attending physician wish to appeal the decision of the physician adviser, he may refer his case first to the hospital physician appeals panel and then if desired, to the Regional Council and State Quality Assurance Committee. The coordinator and physician adviser consult on a daily basis. The physician adviser is. reimbursed b y CFMC on a fee-for-time basis. A physician-coordinator consultation interview might involve the following: Coordinator: Mrs R, age 76, was admitted two weeks ago with a diagnosis of cancer of the lung. She is on the oncology unit and receiving radiation therapy. Her attending physician has asked for an extension of seven days. Physician Adviser (PA): Does she live in town? Coordinator: Yes, she has a Denver address. PA: Is she up and about? Does she have any family who could bring her in for radiation therapy? Coordinator: The nursing staff says she is weak and dizzy and requires the
assistance of one or two people to get up. Her social service caseworker says she lives alone and her only relative is a niece who works all day. PA: It doesn’t sound as though she would be able to manage a t home alone and come in for radiation therapy on an outpatient basis. I’ll call her attending physician and see what he says. Later that day, the PA calls the coordinator. PA: I’ve talked with Mrs R’s attending physician, and he feels that the patient will need to remain in the hospital until her course of radiation is completed. Then he will plan a transfer to a nursing home. I’ve asked him to document this on the patient’s chart. You may go ahead and recertify Mrs R for another seven days. This illustrates several important considerations. If the patient lived in the mountains or other outlying areas, it might be impossible for her to receive treatment other than as an inpatient in the hospital because of distance and transportation problems. The coordinator needs to have a good working relationship with the nursing staff, social service, and others in the health care team to plan and meet health care needs in the hospital, as well as consideration for the continuity of care needed to handle health problems after hospitalization. Also illustrated is the importance of documentation on the chart by the nursing staff as to the patient’s nursing care needs, as well as progress notes by the attending physician indicating the reason the patient must remain in the hospital and plans for discharge. The following is another case discussed the same day with the physician adviser: Coordinator: Mr K, age 84, was admitted four weeks ago with a cerebrovascular accident. He has right hemiplegia,
AORN Journal, August 1975, Vol 22. No 2
197
aphasia, no gag reflex, and is receiving tube feedings. H e was transferred to the rehabilitation unit last week. I attended the weekly rehabilitation conference yesterday and his case was discussed. The charge nurse: physical, occupation, and speech therapists caring for Mr K; the physician in charge of the rehabilitation unit; a social service representative: visiting nurse; and I attended the meeting. Mr K was admitted to the rehabilitation unit for evaluation of his rehabilitation potential. The consensus of this group after a week of working closely with the patient on the rehabilitation unit was that Mr K showed no rehabilitation potential a t this time. The group recommends his transfer to a skilled nursing facility. PA: Has the attending physician been notified of this decision? Have any discharge arrangements been started? Coordinator: The findings of the rehabilitation team and its recommendations have been typed and added to Mr K’s chart. Social service states the family is resistant to a transfer because they feel Mr K receives better care in the hospital. PA: It appears that Mr K no longer requires an acute hospital setting for his care. I suggest we give him a three-day extension to enable arrangements to be made for his transfer to a skilled nursing facility. I will call Mr K’s attending physician and notify him. If at the end of three days, Mr K has not been transferred, we’ll probably have to give denial letters. A couple of days later the PA calls the coordinator. PA: The attending physician agrees that the patient cannot benefit from additional acute hospitalization at this time. However, the family still resists such a move. We have agreed that denial letters will have to be given. A copy of the denial letter is given to
198
the hospital, the attending physician, and to the patient (or his family). The denial letter indicates the patient’s length of hospital stay a t the time of the letter and defines Medicare payment for these days. The denial letter states: Provided no unforeseen medical complications arise, hospital Medicare benefits will end on the above date. This decision made by the Colorado Foundation for Medical Care for the Medicare claims office is based on the medical necessity of your continued stay. This notice does not mean that a future hospitalization will not be paid for by Medicare, nor that you must be discharged from the hospital; such a decision must be made by you and your doctor. This judgment only means that Medicare benefits for this hospitalization will not be provided beyond the above date. If you continue your hospital stay, please advise the hospital business office in order that necessary financial arrangements may be made. Under Medicare law, you may appeal this decision by contacting the communications department of Colorado Blue Cross. Your attending physician has been notified of this decision. If there is no appeal, termination of Medicare benefits will actually begin 72 hours after the effective date of the denial letter. This is a grace period to allow the patient time to make other arrangements for his continued care. In most instances, extension requests are approved by the physician adviser as long as there is documentation on the chart as to the medical necessity for continued hospitalization. If determined medically necessary, a recertification stamp is placed on the chart notifying the attending physician of extended days granted. T o insure physician involvement, only seven days may be extended a t one time, thus assuring
AORlV Journal, August 1975, Vol 22, No 2
The Journal is interested in learning if nursing audit is being done by operating room nurses, and if so, how is it being done. Perhaps you would like to take a moment to consider the following questions.
Nursing audit questions
Are you doing nursing audits in your practice? What type of audit are you using? AORN nursing audit retrospective audit concurrent audit Have you written outcome criteria for the operating room? Do you use a joint audit approach with other nursing staff? Who does the audit? What resistance, if any, has been encountered? Is audit contributing to improved patient care in the operating room? The Journal would like to hear your replies. If we receive sufficient information, a summary will appear in a forthcoming Journal.
that the progress of the patient will continue to be closely monitored. Most physicians are aware of the v a l u e of a c c u r a t e a n d c o m p l e t e documentation of a patient’s medical progress on the chart. Physicians are realizing the importance of early discharge planning and have a n increased awareness of services and items that can be effectively provided on an outpatient basis, or more economically in a health care facility other than an acute hospital setting, Upon discharge of the patient, I complete the uniform discharge abstract coding the final diagnosis, and surgical or diagnostic procedures. The coordinator must certify all Medicare and Medicaid bills. The PSRO coordinator is only certifying as to medical necessity and does not guarantee patient eligibility for Medicare or Medicaid, reimbursement rates for hospital services, or payment for hospital services beyond the benefit limit of days. The PSRO statute has specific safeguards designed to ensure patient
anonymity and confidentiality of records. Data or information acquired by any PSRO in the exercise of its functions must be held in confidence and may not be disclosed to any person except 1. to the extent that it may be necessary to carry out the PSRO’s responsibilities 2. in such cases and under such circumstances as the secretary of the US Department of Health, Education, and Welfare may, by regulations, provide to assure adequate protection of the rights and interest of patients, health care practitioners, and pro0 viders of health care services.
AORN Journal, August 1975, Vol 22, No 2
199
PSRO coordinator describes concurrent review Virginia C Dallmann, RN Virginia C Dallmann, RN, is a PSRO Coordinator for the Colorado Foundation for Medical Care, Denver. She received her BSN from Michigan State University, East Lansing.
oncurrent review within a Professional Standards Review Organization (PSRO) is most commonly done by a nonphysician review coordinator and a physicianadviser working as a team. The Colorado Foundation for Medical Care (CFMC) was created in 1970 to evaluate health care services in two major settings, the physician’s office and the short-term acute general hospital. The CFMC is the PSRO for Colorado. I am a nurse coordinator for the PSRO which is now operating in 90 hospitals throughout Colorado. PSRO is responsible for developing and operating a quality assurance system based on peer review and continuing education. The following elements have been incorporated into the CFMC hospital review program: 1. criteria for admission and lengthof-stay (LOS) 2. responsible review by physicians arid allied professionals of individual hospital cases 3. payment by third party sources for services certified a s m e d i c a l l y necessary 4. procedures t o assist hospital utilization review committees to gather and analyze recommendations based on information on facility utilization, patient care, and treatment practices 5. p r a c t i c e s a n d p r o c e d u r e s t o facilitate discharge planning and continuity care prior to the expiration of days of hospital stay. CFMC is governed by a 21-member board of directors including 17 physicians and a representative from each of the four provider groups, Colorado Osteopathic Association, Colorado Hospital Association, Colorado Pharmacal Association, and Colorado Health Care Association (state nursing home organization). The state is divided into five
AORN Journal, August 1975, Vol 22, No 2
195
geographical regions each having a council of 15 physicians and a representative from each of the four provider associations. Coordinators employed by CFMC to administrate the review program in individual hospitals may be registered nurses. I am a registered nurse with a background in emergency room and surgical ward nursing. CFMC has 34 coordinators who are registered nurses. A program clerk or medical records technician may be employed to assist the coordinator with clerical functions. My day begins with review of all Medicare and Medicaid admissions from the previous day. For each patient, a uniform hospital discharge abstract is initiated. The admitting diagnosis is coded by using the Hospital International Classification of Diseases. Using the number code, I then refer to the initial length-of-stay guidelines, which are equal to the median stay for age and diagnosis based on statistical data from a number of different admission and length-of-stay reports. As information is accumulated in Colorado, the median length-of-stay by region will be developed. After preparing the uniform hospital discharge abstract, I begin monitoring. All inpatient care as documented by the patient’s chart is monitored a t appropriate intervals while the patient is in the hospital. In the initial review, I check for confirmation of diagnosis, note plan of treatment and make an assessment for proper level of care. For example, diabetes mellitus is an incomplete diagnosis. Diabetes mellitus with leg ulcer or acidosis is a n example of a complete diagnosis giving a more accurate picture of the patient’s problem. If it is a “possible” or “rule out” diagnosis, are there other indications for admission? The admission note or history and physical should indicate other
196
problems that could complicate therapy such as arteriosclerosis or congestive heart failure. I place a n Initial Certification Stamp on the chart, after initial review, which states: This admission has been certified as medically necessary. Continued certification for acute care is being made concurrently with the hospital stay. When appropriate, early discharge planning is encouraged. In my day I also include concurrent review of each patient’s chart. Progress notes are observed to see if they are current, if there is a change in the treatment plan, or if the diagnosis is confirmed, changed, or still in doubt. Nurse’s notes are read to assist with the evaluation of the patient’s condition. I also note treatments and medications given and review the vital sign record. All orders for lab and radiology procedures are noted. The timing and sequence of procedures are checked for proper utilization. The coordinator must develop a working relationship with hospital administration, nursing service, admitting, insurance, social service, medical records and other hospital departments so as to be a part of the team working toward the proper utilization of acute care facilities. If I find, while monitoring the patient’s chart, that there is a change of diagnosis or a diagnostic or surgical procedure has been performed, an adjustment to the LOS is assigned. The chart is stamped notifying the attending physician that the patient has been recertified. Not less than two days prior to the expiration of the initially certified days, a stamp is placed on the chart, which reads: Certification is based on medical necessity. Your documentation within the next 48 hours on the progress notes
AORN Journal, August 1975, Vol 22, No 2
giving the reason for continued hospitalization will be appreciated. Expected number of days needed -. If the attending physician requests an extension, the coordinator consults with the physician adviser. The physician adviser is responsible for making all medical decisions. He is a local practicing physician nominated jointly by the hospital administration and medical staff and must be approved by the Regional Council and PSRO Steering Committee. Each hospital has a t least one physician adviser and an alternate. The physician adviser provides the physician-to-physician contact for the program. When the coordinator brings a question of medical necessity to the physician adviser, he may discuss the question with the attending physician. Should the attending physician wish to appeal the decision of the physician adviser, he may refer his case first to the hospital physician appeals panel and then if desired, to the Regional Council and State Quality Assurance Committee. The coordinator and physician adviser consult on a daily basis. The physician adviser is. reimbursed b y CFMC on a fee-for-time basis. A physician-coordinator consultation interview might involve the following: Coordinator: Mrs R, age 76, was admitted two weeks ago with a diagnosis of cancer of the lung. She is on the oncology unit and receiving radiation therapy. Her attending physician has asked for an extension of seven days. Physician Adviser (PA): Does she live in town? Coordinator: Yes, she has a Denver address. PA: Is she up and about? Does she have any family who could bring her in for radiation therapy? Coordinator: The nursing staff says she is weak and dizzy and requires the
assistance of one or two people to get up. Her social service caseworker says she lives alone and her only relative is a niece who works all day. PA: It doesn’t sound as though she would be able to manage a t home alone and come in for radiation therapy on an outpatient basis. I’ll call her attending physician and see what he says. Later that day, the PA calls the coordinator. PA: I’ve talked with Mrs R’s attending physician, and he feels that the patient will need to remain in the hospital until her course of radiation is completed. Then he will plan a transfer to a nursing home. I’ve asked him to document this on the patient’s chart. You may go ahead and recertify Mrs R for another seven days. This illustrates several important considerations. If the patient lived in the mountains or other outlying areas, it might be impossible for her to receive treatment other than as an inpatient in the hospital because of distance and transportation problems. The coordinator needs to have a good working relationship with the nursing staff, social service, and others in the health care team to plan and meet health care needs in the hospital, as well as consideration for the continuity of care needed to handle health problems after hospitalization. Also illustrated is the importance of documentation on the chart by the nursing staff as to the patient’s nursing care needs, as well as progress notes by the attending physician indicating the reason the patient must remain in the hospital and plans for discharge. The following is another case discussed the same day with the physician adviser: Coordinator: Mr K, age 84, was admitted four weeks ago with a cerebrovascular accident. He has right hemiplegia,
AORN Journal, August 1975, Vol 22. No 2
197
aphasia, no gag reflex, and is receiving tube feedings. H e was transferred to the rehabilitation unit last week. I attended the weekly rehabilitation conference yesterday and his case was discussed. The charge nurse: physical, occupation, and speech therapists caring for Mr K; the physician in charge of the rehabilitation unit; a social service representative: visiting nurse; and I attended the meeting. Mr K was admitted to the rehabilitation unit for evaluation of his rehabilitation potential. The consensus of this group after a week of working closely with the patient on the rehabilitation unit was that Mr K showed no rehabilitation potential a t this time. The group recommends his transfer to a skilled nursing facility. PA: Has the attending physician been notified of this decision? Have any discharge arrangements been started? Coordinator: The findings of the rehabilitation team and its recommendations have been typed and added to Mr K’s chart. Social service states the family is resistant to a transfer because they feel Mr K receives better care in the hospital. PA: It appears that Mr K no longer requires an acute hospital setting for his care. I suggest we give him a three-day extension to enable arrangements to be made for his transfer to a skilled nursing facility. I will call Mr K’s attending physician and notify him. If at the end of three days, Mr K has not been transferred, we’ll probably have to give denial letters. A couple of days later the PA calls the coordinator. PA: The attending physician agrees that the patient cannot benefit from additional acute hospitalization at this time. However, the family still resists such a move. We have agreed that denial letters will have to be given. A copy of the denial letter is given to
198
the hospital, the attending physician, and to the patient (or his family). The denial letter indicates the patient’s length of hospital stay a t the time of the letter and defines Medicare payment for these days. The denial letter states: Provided no unforeseen medical complications arise, hospital Medicare benefits will end on the above date. This decision made by the Colorado Foundation for Medical Care for the Medicare claims office is based on the medical necessity of your continued stay. This notice does not mean that a future hospitalization will not be paid for by Medicare, nor that you must be discharged from the hospital; such a decision must be made by you and your doctor. This judgment only means that Medicare benefits for this hospitalization will not be provided beyond the above date. If you continue your hospital stay, please advise the hospital business office in order that necessary financial arrangements may be made. Under Medicare law, you may appeal this decision by contacting the communications department of Colorado Blue Cross. Your attending physician has been notified of this decision. If there is no appeal, termination of Medicare benefits will actually begin 72 hours after the effective date of the denial letter. This is a grace period to allow the patient time to make other arrangements for his continued care. In most instances, extension requests are approved by the physician adviser as long as there is documentation on the chart as to the medical necessity for continued hospitalization. If determined medically necessary, a recertification stamp is placed on the chart notifying the attending physician of extended days granted. T o insure physician involvement, only seven days may be extended a t one time, thus assuring
AORlV Journal, August 1975, Vol 22, No 2
The Journal is interested in learning if nursing audit is being done by operating room nurses, and if so, how is it being done. Perhaps you would like to take a moment to consider the following questions.
Nursing audit questions
Are you doing nursing audits in your practice? What type of audit are you using? AORN nursing audit retrospective audit concurrent audit Have you written outcome criteria for the operating room? Do you use a joint audit approach with other nursing staff? Who does the audit? What resistance, if any, has been encountered? Is audit contributing to improved patient care in the operating room? The Journal would like to hear your replies. If we receive sufficient information, a summary will appear in a forthcoming Journal.
that the progress of the patient will continue to be closely monitored. Most physicians are aware of the v a l u e of a c c u r a t e a n d c o m p l e t e documentation of a patient’s medical progress on the chart. Physicians are realizing the importance of early discharge planning and have a n increased awareness of services and items that can be effectively provided on an outpatient basis, or more economically in a health care facility other than an acute hospital setting, Upon discharge of the patient, I complete the uniform discharge abstract coding the final diagnosis, and surgical or diagnostic procedures. The coordinator must certify all Medicare and Medicaid bills. The PSRO coordinator is only certifying as to medical necessity and does not guarantee patient eligibility for Medicare or Medicaid, reimbursement rates for hospital services, or payment for hospital services beyond the benefit limit of days. The PSRO statute has specific safeguards designed to ensure patient
anonymity and confidentiality of records. Data or information acquired by any PSRO in the exercise of its functions must be held in confidence and may not be disclosed to any person except 1. to the extent that it may be necessary to carry out the PSRO’s responsibilities 2. in such cases and under such circumstances as the secretary of the US Department of Health, Education, and Welfare may, by regulations, provide to assure adequate protection of the rights and interest of patients, health care practitioners, and pro0 viders of health care services.
AORN Journal, August 1975, Vol 22, No 2
199
