Editor's Note

Ronald Hirsch, MD, FACP

Editor, ACPA Update

Member, ACPA Advisory Board

It’s September and that means it is flu shot time. It is going to be an interesting season as vaccine hesitancy seems to have increased. I read that some people are even refusing to get their pets vaccinated for rabies with rumors that the vaccine causes autism in the animals. There is also growing movement to stay “healthy” by drinking one’s own urine or ingesting small amounts of Borax. Yes, you read that right. Now maybe I spend too much time on social media, but I glean a lot of important medical information there. This week the European Society of Cardiology had their annual conference and several cardiologists were sharing the results of important studies that may not make it to the medical literature for months or longer. But social media or not, get your flu shot. I promise it does not contain a tracking chip or a 5G transmitter and will not incorporate foreign DNA into your cells.

I won’t go on about social media craziness so let’s get to what’s in this issue. But first, have you done the Observation Committee questions? If not, do it. No, really. Click on this link and answer the questions. https://www.surveymonkey.com/r/ACPAAug23 

This month is the last President’s Corner from Dr. Juliet Ugarte Hopkins with Dr. Clarissa Barnes taking over. Dr. Ugarte Hopkins has done so much for our organization. From that first meeting of a few docs sitting around a table to what ACPA is today. I will let her describe the accomplishments of her tenure in her note. And do read the other articles. Remember, the goal of ACPA and the newsletter is to advance the practice of the physician advisor and unless you are an expert on sepsis, surgery, appeals, and pediatrics, there is something for you to learn in these articles. 

Remember, ACPA is here for you. Tell us what you want, what you need, and what you can contribute. You can always contact me at signaturedoc@gmail.com. 

Must We Wait for the Pathology to Code a Malignancy?

Erica Remer, MD, CCDS

Clinical Documentation Integrity Committee Chair, ACPA

This article was inspired by an article I read by Cynthia Tang and Richard Pinson (https://libmaneducation.com/coding-of-possible-malignancy-diagnoses-when-the-pathology-report-is-pending/). They expressed their concern about Coding Clinic’s advice to code an uncertain malignancy diagnosis when the pathology report was pending (Be aware that their article referenced 2023 Second Quarter, but the question and answer really appeared in First Quarter). The American Hospital Association’s Coding Clinic for ICD-10-CM/PCS is a quarterly publication giving advice on diagnoses and procedures usually elicited by questions from institutions. The question being referenced regarded a “liver mass, possibly hepatic cholangiocarcinoma,” and the documentation furthermore indicated that the pathology was still pending.

Coding Clinic advised that this did fall under the purview of ICD-10-CM Official Coding and Reporting Guidelines, Section II.H. (https://www.cms.gov/files/document/fy-2024-icd-10-cm-coding-guidelines.pdf), Uncertain Diagnosis. As we know, this guideline allows for the coding of an uncertain diagnosis qualified with a word like, “probable,” “suspected,” “likely,” or such, if the condition has not been ruled out prior to discharge or demise, on the inpatient side. Coding Clinic recommended assigning C22.1, Intrahepatic bile duct carcinoma in this case.

The idea behind the uncertain diagnosis guideline is that the resources utilized to rule out a condition are similar to the resources used to rule it in. The Diagnosis Related Group (DRG) payment system is based on a statistical model recognizing that a given principal diagnosis, in the context of accompanying secondary diagnoses, predictably costs a certain amount of money to work up and treat. If a patient has an infiltrate and you still believe it is due to pneumonia at the time of discharge, then the insurer paying your institution for a pneumonia DRG is reasonable.

It is interesting to use Simple Pneumonia and Pleurisy as an example. This is a three-tiered DRG (MS-DRG 193, with MCC- Relative Weight (RW) 1.3235; 194, with CC- RW 0.8190; 195, without CC/MCC- RW 0.6224). If the discharge summary states, “Probable pneumonia,” as the principal diagnosis, it would establish MS-DRG 193-195 depending on associated secondary diagnoses.

Let’s say the provider decides it was acute bronchitis and not pneumonia. That would land in MS-DRG 202, Bronchitis and Asthma with CC/MCC (RW 0.9527) or 203, without CC/MCC (RW 0.6927), according to secondary diagnoses. If the final diagnoses ended up being cough and fever because pneumonia was ruled out and no alternate explanation was offered, MS-DRG 204, Respiratory Signs and Symptoms, (RW 0.8196) would be assigned. Depending on the comorbidities and the DRG tier, Simple Pneumonia and Pleurisy may not be the most favorable DRG, so routinely making an uncertain diagnosis because some administrator suggested you get paid more might not be the best plan.

For many uncertain diagnoses, there may be no way to ultimately determine a definitive diagnosis. There may be no conclusive way to prove it. No gold standard diagnostic criteria, no cultures, no imaging. It may come down to clinical judgment. 

However, a mass which gets biopsied is a different story. There is a way to resolve the uncertainty. We teach our providers to float an uncertain diagnosis of malignancy if that is their (strong) suspicion, so that we can avoid having to query them if the pathology returns positive. My position has always been that this is important to get right for more than landing in a more favorably reimbursed DRG. The story of the encounter is not accurate or complete if a patient was found to have a malignant neoplasm, but it was not documented and captured. The pathology report should resolve the uncertainty.

In fact, if the provider were to make an uncertain diagnosis of malignancy and the pathology were to return negative, the correct reaction would be to query the provider for clarification to remove the diagnosis, if appropriate. The clinician would need to determine if they still believed there was a malignancy (the biopsy could have missed its mark and be misleading) or if they believe the diagnosis should be amended.

Pinson and Tang point out that it has “always been an HIM and coding practice that coding is not completed or final billed until the pathology report is available for inpatients, particularly to confirm a malignancy diagnosis.” They refer to not coding unconfirmed HIV infection, but I don’t think that is a good analogy. HIV, Zika, COVID-19, and certain identified influenza viruses are only coded as “confirmed cases” but you don’t have to have laboratory proof. The provider’s assertion that the patient has the condition is sufficient. You are just advised to not code uncertain diagnoses of these conditions.

Is it premature to drop the claim before the pathology results return? Should the institution have a policy that the pathology needs to be reviewed prior to billing? I guess it depends on how long the typical pathology turn-around time is, how good the clinician is at suspecting malignancy diagnoses, and how irritated they will get at receiving a query to potentially reverse their diagnosis. My personal opinion is that being branded as having a malignancy has profound implications and it would be preferable to hold encounters with pending pathology to ensure accuracy. If a patient dies, transitions to hospice, or declines a work-up, then an uncertain diagnosis resulting in coding a malignancy without confirmation might be appropriate. 

There is information for the physician advisor and a CDI Tip for the Clinician on pathology reports on our website. Go to Education>CDI Resource Page and scroll down to Miscellaneous. While you are there, check out our other CDI materials!

Dr. Erica Remer is founder and president of Erica Remer, MD, Inc., consulting services for documentation, CDI, and ICD-10, and creator of Dr. Remer’s Documentation Modules, based in Beachwood, OH.

Provider Access to CMS Appeals in Medicare Advantage

Edward Hu, MD

Member, ACPA Emeritus Board

You might think it’s dogma that only non-contracted providers can appeal Medicare Advantage denials using the CMS 5-level appeal process. While some folks want you to think it’s dogma, it is actually neither Medicare Advantage law nor Medicare Advantage regulation. (As all of you know, I am not an attorney and cannot offer legal advice.) While a contracted provider often cannot access the CMS appeal process on his/her own behalf, let’s take a look at what the rules do allow.

The CMS appeals process is primarily designed to protect Medicare Advantage members. In CMS parlance, a Medicare Advantage appeal is called a reconsideration, but I will just refer to it as an appeal. According to SSA 1852(g)(3)(A)(ii), any physician, regardless of affiliation with the MA organization or not, may request an expedited appeal. The federal regulations at 42 CFR § 422.584 clarify that an expedited appeal cannot be used to request payment for services already furnished. CMS regulations separate appeals into two categories: pre-service appeals and payment appeals. If the services are already furnished, the only CMS option is a payment appeal. If the services are not “already furnished,” then the member has the right to a pre-service appeal. Pre-service appeals come in two flavors – expedited and standard.

The law referenced above guarantees that any physician has the right to request an expedited appeal on behalf of the member, as long as the services are not already furnished. No appointment of representative authority is needed. Technically, no notification to the member is needed either, though that remains a good practice. This right of the physician, any physician, comes directly from Medicare Advantage law and is not limited to non-contracted physicians. Keep in mind though, this right is on the member’s behalf, not the provider’s behalf. If a physician acts on behalf of the member, federal regulation requires that the physician receive notice of the decision, and explicitly prohibits any punitive action against the physician acting in support of the member.

Medicare Advantage law does not address standard pre-service appeals in the same manner, so in 2009 CMS finalized the regulations at 42 CFR § 422.578 to create relative parity in standard pre-service appeals. This regulation states that a treating physician, upon providing notice to the enrollee, may request a pre-service appeal. Again, no representative authority is needed, and contractual status with the MAO is not relevant in terms of this right.

Once the services are already furnished, that’s where the “dogma” that you may have heard may be applicable. But have you ever tried to find the Medicare law or regulation that says contracted providers do not have CMS appeal rights? I’ve yet to find it. The right to appeal a non-pre-service denial is limited to parties to the organization determination. This includes:



• the enrollee or his/her representative, 
• the assignee of the enrollee (defined as a physician or other provider who has furnished a service to the enrollee and formally agrees to waive any right to payment from the enrollee for that service, 
• the legal representative of a deceased enrollee’s estate, and 
• any other provider or entity determined to have an appealable interest in the proceeding.

Reading those options, it isn’t so clear that a contracted provider cannot achieve party status through b) or d). This is where sub-regulatory guidance in the Medicare Managed Care Manual Chapter 13 limits the right to become the enrollee’s assignee only to non-contracted providers who sign a Waiver of Liability, agreeing not to charge the enrollee regardless of the appeal outcome. It is also this guidance that states that contracted providers do not have CMS appeal rights. However, this sub-regulatory guidance only applies to payment appeals, because the law and regulation protect the right of the physician, regardless of contractual status, to appeal denials of services not already furnished.

There is also no federal law, regulation, or sub-regulatory guidance to my knowledge prohibiting the member from appointing the provider to be the member’s authorized representative. In fact, the provider that furnished services to the member is explicitly allowed to serve as an authorized representative but you just can’t charge the member a fee for the representation, according to the regulations at 42 CFR § 405.910.

Finally, there is one last myth that I want to dispel, which is that the member cannot appeal a payment denial once the services are already furnished. Members can appeal adverse “organization determinations,” and the actions that can be appealed are outlined in 42 CFR § 422.566(b). Of the five categories of actions that represent organization determinations, four of them address payment for services, including the issues that we as physician advisors typically see. For further reading, I would direct you to https://www.cms.gov/medicare/appeals-and-grievances/mmcag which contains CMS’ most current sub-regulatory guidance on Medicare Advantage appeals. Let’s create a new dogma, one that is actually based on Medicare Advantage laws and regulations.

Dr Hu is System Executive Director of Physician Advisor Services at University of North Carolina Health Care System

Pediatric Physician Advisors – No Longer an Option for Healthy Hospital Operations

Juliet B. Ugarte Hopkins, MD

President, ACPA

Just as the role of physician advisors has come to the forefront of the healthcare world over the last decade-and-a-half, so too has the subset of pediatric physician advisors in recent years. This has especially taken place with the support of the American College of Physician Advisors (ACPA). While previously, the scope and unique focus of pediatric physician advisors was side-stepped by the greater community due to a handful of key factors (not the least of which is state-by-state differences in Medicaid rule and regulation), their expanding ranks and the critical developments nationwide affecting hospital pediatric units and availability of pediatric services now makes discussion about the importance and future of the role unavoidable.

Three years ago, the ACPA established their Pediatric Committee supported by chair Dr. Denise Goodman, Medical Director of Case Management and Care Coordination and Pediatric Intensivist at Ann & Robert H. Lurie Children’s Hospital of Chicago and Professor of Pediatrics for the Northwestern University Feinberg School of Medicine. Since then, the committee has grown to over 30 members with a larger and more involved contingent of pediatric physician advisors involved in the ACPA’s National Physician Advisor Conference (NPAC) as attendees and featured speakers year over year. 

While the unique and impactful role of physician advisors first came to notoriety during the time of the Medicare Recovery Audit Contractor (RAC) audits and exploded from there, the path of recognition for pediatric physician advisors has been a bit more subtle. Pediatric services have never been considered financially impactful, especially within non-children’s hospital settings. Without routine, profitable, diagnostic and preventative procedures like colonoscopies and cardiac catheterizations as in the adult population and the harsh truth that Medicaid and managed Medicaid plans notoriously pay pennies on the dollar for reimbursement of services, the overarching understanding has been that pediatric cost of care will essentially break even for health systems. However, as we have seen in recent years as hospitals close their pediatric units, Pediatric Intensive Care Units, and cut back universally on their pediatric services on an inpatient and outpatient basis, getting paid less than expected for services provided is even worse than being paid what’s expected for services provided. While pediatric medicine is advancing year over year for what decades ago were eventual death sentences by the time a patient reached adolescence, the capability of our nation’s hospitals and health systems to provide this astounding level of care is dwindling due to insufficient payment.

Anyone even remotely familiar with pediatric medicine knows there is no side-by-side comparison with the adult counterpart when it comes to many aspects of patient care. From clinical presentation and clinical trials to treatment modalities and FDA-approved pharmaceuticals, there often are stark differences or even a true lack of comparative data. One impactful example of this in the utilization management space is the content of common clinical guideline criteria used by case/utilization managers and payors for statusing patients. While they may have pediatric-specific criteria for a condition like hypertension, there often is nothing which even mentions major treatment pathways which are usually only seen in pediatrics, such as initiation of a ketogenic diet. 

Additionally, it is very common for payor medical directors to mis-identify the major factors of a case and try to fit complicated diagnoses into simplistic conditions. “I’ve been involved in peer-to-peers where a toddler had an inborn error of metabolism with metabolic crisis precipitated by an intercurrent illness,” recounted Goodman, “and the payor thinks it’s run-of-the-mill gastroenteritis or bronchiolitis. I’ve found myself explaining OTC [Ornithine Transcarbamylase] deficiency or some other genetic condition and talking them through the support needed.” She notes this is just one example of why hospitals which have pediatric departments – even if not a stand-alone children’s hospital – need physician advisors with pediatric expertise. The issue is not simply having internal staff who can appropriately identify patients meeting criteria for Inpatient status, but who also have the ability to explain the reasoning to a payor medical director who lacks this expertise. 

Readmission reduction and efforts toward optimizing hospital length of stay are just as important with pediatric patients as they are with adults. While provision of inpatient medicine is similar, not so when it comes to the outpatient setting. Organizations which provide intensive support in the home or specialized facility caregiving which is sometimes needed to manage incredibly complicated diagnoses and conditions are few and far between in the pediatric realm. 

Network inadequacy for discharge planning is a common challenge. Case managers can obtain a list of 45 potential home health entities but then learn 40 of them do not accept patients under 18 years of age, three accept children but not those with central lines, and the final option has no staffing available for the foreseeable future. Unlike with Medicare, home nursing benefits often are for shifts of time, not interval visits for a focused indication like providing IV antibiotics twice a day. This means families have to muddle through learning the skill to provide it themselves but if they are unhoused or the caregiver has cognitive or mental health issues, this can prevent discharge from the hospital entirely.

Similarly, even if intensive services are not needed, complicated social issues often can hold up a safe discharge for a patient who cannot even come close to caring for themselves. Physician advisors who are well-versed with these challenges can make a big impact in supporting their hospitals by anticipating the issues and proactively setting things into place to address them before multiple, medically unnecessary days pass with the patient remaining in the hospital setting.

Have you had difficulty appealing denials for acute respiratory failure or severity of a respiratory condition when your adult patients require just two liters per minute of supplemental oxygen to maintain normal oxygen saturation? Imagine your patient requiring just 0.1 liter per minute! Or, on the other end of the spectrum, picture making an argument for the severity of a toddler’s asthma exacerbation when his profound presenting signs and symptoms turned around in less than 48 hours with intensive treatment. 

According to Dr. Alyssa Riley, incoming Director, Physician Advisor of Clinical Documentation/Revenue Integrity at Nationwide Children's Hospital Toledo and Vice Chair of the ACPA’s Pediatric Committee, top-hitting diagnoses in hospital pediatrics are not really different from the adult world including sepsis, acute respiratory failure, and malnutrition. However, pediatric training and experience are required to ensure the subtleties of identification, stabilization, and treatment of these conditions in children is completely illustrated in the documentation, captured by the coders, and appreciated by the payors. “NICU [Neonatal Intensive Care Unit] and complex care populations require pediatric physician advisor collaboration with coders to help them understand the nuances of these cases,” Riley said. “I’d strongly advocate for a team of designated pediatric coders if a hospital has a pediatric population imbedded within a larger adult healthcare system.” She also recommends including pediatric physician advisors in quality improvement initiatives related to complications and readmissions to emphasize the need for clear documentation and accurate coding. 

One of the key roles physician advisors play is to maintain the financial health of hospitals so they can maintain the health of the communities they serve. It’s high time health systems recognize the pediatric subset of these communities and the critical needs they require to grow up and develop into the educators, artists, change-makers, and even medical professionals we’ll all rely on and be inspired by for generations to come.

Juliet B. Ugarte Hopkins, MD, is founder and CEO of Velvet Hammer Physician Advising LLC, President of the American College of Physician Advisors (ACPA), and a consulting physician advisor for Phoenix Medical Management, Inc., Pediatric Resource Group, Enjoin, and CSI Companies. 

Reconciling Sepsis 2 and Sepsis 3: Are We Missing Something in Between? 

Clarissa Barnes, MD, FACP

President Elect, ACPA

Sepsis. To anyone who treats patients or is involved in clinical documentation, quality, or denials and the revenue cycle, this term causes a lot of angst. It is a serious cause of morbidity and mortality to our patients and an ongoing source of increased cost for healthcare. (1,2) Years after the alarm was sounded about the need to better recognize and treat this diagnosis, confusion and debate on how to even define it persists. But what if the reasons there is no consensus is because neither is quite right and there is opportunity to better define Impending Sepsis. 

The fundamental disagreement comes down to Sepsis-2 vs Sepsis-3. Sepsis-2 is SIRS criteria plus a locus of infection and in that same documentation structure Severe Sepsis is sepsis that has progressed to include end organ damage and Septic Shock includes fluid-resistant hypotension. Sepsis-3 is a dysregulated host response to an infection with evidence of end-organ damage. Septic Shock is the same in Sepsis-2 with sepsis that has progressed to included fluid-resistant hypotension. So, Sepsis-2 Severe Shock is a pretty good match to Sepsis-3 Sepsis. And Septic Shock remains essentially the same. 

Why the disagreement? Part of the issue is philosophical. Is it really sepsis if there is no evidence of damage? Part of the disagreement is practical. Recognizing that sepsis (and missing sepsis) was harming patients in 2015, the Centers for Medicare and Medicaid Services (CMS) added a sepsis quality measure to the Hospital Inpatient Quality Reporting Program (IQRP) that was called SEP-1. (3) This program required hospitals to report compliance for sepsis patients for the 3- and 6-hour treatment bundle which included timely antibiotics, IV fluids, cultures, measuring lactic acid levels, the use of vasopressors for shock/fluid-refractory hypotension, and the repeat bedside evaluations/exams to assess how patients were responding to treatment. Inclusion in these measures uses the SIRS plus infection definition. It is impractical (and frankly ridiculous) to ask clinicians to use different definitions for different purposes and different payers and so Sepsis-2 often becomes the default definition in a system due to CMS’s SEP-1. 

And part of the issue is a fundamental misunderstanding of what the Sepsis-2 definition of Sepsis looks like in a clinical scenario. From those who tell me Sepsis 3 is THE definition of sepsis, they often cite that many patients may have SIRS criteria and an infection, but that does not make them septic. And they are correct. A pancreatitis patient with tachycardia and an elevated respiratory rate who has a concurrent urinary tract infection may not have sepsis. Let me be clear (because I hear this argument on occasion), just because a patient may meet the definition of Sepsis-2, does not mean they have Sepsis. In other words, not all SIRS plus infection is Sepsis. Those measures are necessary, but they aren’t sufficient. The missing piece is the judgement of the treating physician and that is the part that is harder to reflect on chart review. 

I was asked recently to do reviews of clinical denials for a system in New York (where the use of Sepsis-2 is mandated by law). Every chart I looked at had SIRS and had an infection, or at least the concern for one initially on presentation. However, it was often difficult to tell whether the patient truly had sepsis just from the notes. But it was often much clearer when the chart was evaluated to see what had been done. 

And that is the biggest opportunity for a better definition. In CDI our mission is precise language to accurately reflect what is happening to the patient and the medical decision-making process. Maybe there is a continued struggle between Sepsis-2 and Sepsis-3 because we fundamentally do not have the right language to reflect the clinical space between a localized infection and fully realized sepsis. There should be a way to reflect the difference between a patient who comes to the clinic and has a urinary tract infection and has SIRS criteria for an unrelated reason (such as anxiety causing tachycardia and tachypnea) and the patient who comes to the ER with Impending Sepsis due to a urinary source. There needs to be a better way to clarify because those patients are going to need to be treated very differently by the physician. One will get antibiotics for sure (because there is still an infection) but it will be a script to pick up an oral antibiotic from the local pharmacy. The other will get IV antibiotics, additional testing (lactic acid, blood cultures, etc.), and a higher level of monitoring and care as well as a clear need for hospitalization. And if that patient presents early enough, is recognized soon enough, and is treated, they may never have end-organ damage. That is the very definition of what recognizing sepsis early is about: preventing progression and ultimate harm. 

Personally, using the Sepsis-3 definition for what is realized sepsis makes sense. But it still misses the point of the clinical outcomes that are trying to be impacted by early recognition as someone is starting down that path. And, not having another term for those patients who are clearly between a localized infection and the point at which organs are damaged misses an opportunity to be precise about patient who are truly ill and require more treatment and monitoring and therefore resources because they are at higher risk. Impending Sepsis may be a term that helps bridge that gap or there may be a better term (and if you do, I’d love to hear it!). 

1. Rhee C, Dantes R, Epstein L, et al.: Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014. JAMA 2017; 318:1241–1249
2. World Health Organization.  Global Report on the Epidemiology and Burden of Sepsis: Current Evidence, Identifying Gaps and Future Directions. World Health Organization; 2020.
3. Centers for Medicare & Medicaid Services; Joint Commission: Specifications manual for national hospital inpatient quality measures  https://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx 

Dr Barnes is the South Dakota Medicaid Medical Director. 

Navigating Social Hospitalizations

Tiffany Ferguson, LMSW, CMAC, ACM

Juliet B. Ugarte Hopkins, MD

In the complex landscape of healthcare, the issue of social hospitalizations presents a challenging puzzle that intertwines patient needs, billing concerns, and discharge regulations. The lines have blurred between the complexity of social needs with medical necessity resulting from the systemic issues in communities unable to provide more appropriate alternatives for their residents. The social admission not only stresses the case management (CM) team who must work a miracle to either find or create a “safe” discharge plan for the patient, but it sheds light on the impact for the entire healthcare team which must manage these patients in the least ideal setting, creating greater stressors on treating physicians, coding and billing, and ultimately patient quality and hospital financial reimbursement. 

Social or custodial hospitalizations refer to instances where patients are admitted to a hospital without medical necessity. These cases typically arise when patients are unable to care for themselves, their families are unwilling or incapable of caring for them, or facilities cannot continue to provide care. Such hospitalizations often stem from complex social issues, however, at times may also be impacting the patient’s chronic medical condition(s).

The consequences of social hospitalizations reverberate across various dimensions of our hospitals and health systems:

1. Occupational Strain: Emergency departments and inpatient beds become occupied by non-medical cases, limiting availability for patients who genuinely require acute care.
2. Financial Challenges: Medicare, Medicaid, and commercial payers do not easily cover social hospitalizations, resulting in a lack of reimbursement for services provided.
3. Inadequate Services: Patients subjected to social hospitalizations may receive non-intensive therapy, experience social isolation, and lack cognitive engagement, leading to suboptimal care outcomes.
4. Staff Frustration: Healthcare professionals may struggle with the purpose of providing care when medical necessity is absent.

Healthcare providers and case/utilization managers are particularly affected when providers who are trained to address medical needs face difficulties in handling social admissions. Case managers feel the gleaming eyes from administration with the pressure to expedite patient discharges, putting CMs in the role as ‘the bad guy’, making tough decisions for the patient’s best interest. Collectively it is the ambiguity that stresses all for what to do next when the patient is a ‘head in a bed’. 

Weighing the options and levels of care

When determining the course of action for social hospitalizations, options include intervening in the emergency room to keep the patient out of the hospital while attempting to work a timely miracle back into community-based care. An alternate option is to consider the patient to move out of the ED but provide with them with Advanced Beneficiary Notice (ABN), or hospital created notice for patient’s that are not traditional Medicare informing them of the risk of social admission and potential lack of payer coverage for such services. The third option, however, not recommended by your authors, is to issue a pre-admission HINN and admit the patient as an inpatient. In each of these scenarios, the safety and ethical considerations must weigh into the physician decision for the appropriate level of care. 

Understanding that it will take more than SDoH Z code capture to stop the onslaught of social admissions into hospitals, there are things that Physician Advisors and leaders of case management can do to create a proactive approach to alleviate the hospital from what feels like community housing or caregiver respite care. 

Navigating Billing and Patient Rights

Consider connecting with revenue cycle, billing, and the contracting team to evaluate opportunities for coding, and reimbursement coverage for social admissions, at minimum a daily per diem rate to cover the room and board while the care team transitions the patient back into the community. When it comes to billing, make sure there are bed charges available if the care team elects to keep the patient in the ED. 

This will also be a great time to start connecting with your compliance and risk department to make sure the hospital has a considered potential areas of media backlash, appropriate language for patient notices, and considerations for how the hospital defines a ‘safe’ discharge plan. Although, often used as common language, definitions of safety may look different across providers and the hospital should consider waying the ethical implications of keeping a social patient in a hospital bed, while risking the denial of a patient needing medically necessary acute care. 

1. Staff Scripting: Develop clear scripts for case managers and utilization management staff for the various scenarios either at point of entry or when medical care is no longer needed, but the patient has an unideal discharge disposition. 
2. Provider Buy-In: Although the CFO may agree with this plan, the ED physicians may not be on board. Consider the impact of all groups, especially the physician group, so there is a game plan for how social admissions are going to be handled.  
3. Collaboration with Rev Cycle: Establish real-time communication between case managers and billing teams to ensure accurate billing processes, and notice delivery which will involve patient registration/patient access. 
4. Enlist outside help: Consider create means for alternative locations such as setting up single-case agreements with the community facilities who are willing to house patients at a lower cost and better provide for their needs until a longer-term solution is identified by the care team. 

Untangling the complexities of social hospitalizations demands a delicate balance between patient needs, healthcare provider responsibilities, and billing procedures. By establishing a game plan up front while still maintaining necessary compliance and ethical standards, hospitals can address social hospitalizations while upholding financial stability.

Tiffany Ferguson, LMSW, CMAC, ACM is CEO of Phoenix Medical Management, Inc. Juliet B. Ugarte Hopkins, MD is President of the American College of Physician Advisors.

September 2023

It’s time to affix my Lasso of Truth to my hip and ride my unicorn off into the sunset, folks. Two years and nine months ago, I assumed the presidency of the American College of Physician Advisors (ACPA). Over this time period, we:



1. Established the Pediatric Committee and solidified national recognition of the critical but especially nuanced role of physician advisors working with non-adult populations
2. Grew the National Physician Advisor Conference (NPAC) leadership and planning support
3. Added Essentials & Fundamentals, our in-person, beginner physician advisor symposium
4. Launched a routine cadence of virtual town halls providing free education to all
5. Overcame the challenges of the COVID-19 pandemic to foster the most involved, fun-loving, and collaboration-hungry membership of, dare-I-say, any medical community in the United States.

My work here is done! 

The discovery and cultivation of talent within our membership is on full display when you look at our incoming president, Dr. Clarissa Barnes. Over the last year, we have been working together with others in the College’s leadership to shape the future of ACPA. This will feature no less than an update and optimization of The Learning Center (TLC) and the launch of our certification standards – a true measure of what needs to be understood and mastered in order to effectively perform and excel in the physician advisor role.  

It’s an exciting time! And, all of this activity continues to need one more thing – you. Seven years ago, I was a sequined blur of questions and “what-ifs?” with a penchant for profanity, but I ALSO had big ideas for this organization. With the support of many, I have been granted the gift of bringing many of those ideas to fruition and the same can happen for you. It is my sincere hope that one jazz hands selfie at a time, you have all felt welcomed and valued within our ACPA community. In the coming months, there will be significant opportunity to join us and continue to foster the vision. From submitting an article to this newsletter to speaking at NPAC to applying for a spot on our committees or even board of directors, I encourage everyone to consider stepping out of the shadows and into the spotlight.  

I am so gratified by the work accomplished through spirited debate, heartfelt encouragement, and ever-present laughter over these last few years – a gratification which is eclipsed only by my excitement for what the future holds. Thanks to all, and I will see you next year at #NPAC2024 in California!

Juliet B. Ugarte Hopkins, MD

President, ACPA