The case for well-researched medical guidelines

This is excerpted from the recent paper, “How hospitals can arm themselves in the war on waste,” by Helen Blumen and Tiffanie Lenderman:

With increased scrutiny by CMS contractors of hospital admission and treatment documentation, scientifically based medical guidelines can be a valuable tool for supporting the physician decision-making process and providing evidence of appropriate care. Whether in reviewing retroactive cases or current billings, contractors will be looking at physician documentation in making their determinations. Supporting records from auxiliary caregivers will count for very little if the physician has not made the right decision and properly recorded it.

As an example, a physician admitted a patient for heart failure, noting respiratory compromise, abnormal renal function ( BUN 27 and creatine 2.0), and a blood oxygen saturation level of 96 percent with the patient on low-flow oxygen at 2L/min. The Milliman Care Guidelines® indications for admission for heart failure include documenting worsening renal function and a blood oxygen saturation level below 90. In this instance, the case manager using the Care Guidelines would provide the physician with the following prompts: “Please document the patient’s renal function prior to admission” and “Please indicate in your notes the patient’s O2 saturation on room air.” With these prompts, the physician taking care of this patient could have chosen to admit the patient for observation and then determine if the patient meets the criteria for admission for heart failure.

Well-researched medical guidelines can help hospitals improve and demonstrate best practices in the face of CMS scrutiny. They can be used to:

  • Provide supporting evidence in case of appeal
  • Help determine appropriateness for admission
  • Prompt physicians to provide documentation to the clinical record