Hospital wants us to admit dead patients

[alpinism]

So our notortiously understaffed and underresourced inner city ED just hired a new chairman who previously worked at the well resoured Ivy league ED across town. Since he’s stared over the last few months his main focus has been to increase revenues by any means possible by further increasing billing. This has led to some ridiculous highly questionable department policies centered around critical care.

Now his newest policy is to have us admit cardiac arrest patients even if they’ve been down for 30+ minutes and we declare them dead on arrival. Basically even if we do nothing and they never have a pulse he wants us to have them offically admitted to CCM in the hosptial. I’m not an expert on CMS regulations but it does seem highly illegal even ignoring all of the ethical implications of these kinds of department policies.

---

Members don't see this ad.

 

[oldtown]

So our notortiously understaffed and underresourced inner city ED just hired a new chairman who previously worked at the well resoured Ivy league ED across town. Since he’s stared over the last few months his main focus has been to increase revenues by any means possible by further increasing billing. This has led to some ridiculous highly questionable department policies centered around critical care.

Now his newest policy is to have us admit cardiac arrest patients even if they’ve been down for 30+ minutes and we declare them dead on arrival. Basically even if we do nothing and they never have a pulse he wants us to have them offically admitted to CCM in the hosptial. I’m not an expert on CMS regulations but it does seem highly illegal even ignoring all of the ethical implications of these kinds of department policies.

1) Refuse to do it and be vocal about it
2) Get Fired
3) Go to the press
4) Sue for 8 figures
5) Win

I just mapped out your exit strategy

 

[Rekt]

So our notortiously understaffed and underresourced inner city ED just hired a new chairman who previously worked at the well resoured Ivy league ED across town. Since he’s stared over the last few months his main focus has been to increase revenues by any means possible by further increasing billing. This has led to some ridiculous highly questionable department policies centered around critical care.

Now his newest policy is to have us admit cardiac arrest patients even if they’ve been down for 30+ minutes and we declare them dead on arrival. Basically even if we do nothing and they never have a pulse he wants us to have them offically admitted to CCM in the hosptial. I’m not an expert on CMS regulations but it does seem highly illegal even ignoring all of the ethical implications of these kinds of department policies.

What the ****

 

[GonnaBeADoc2222]

This seems...less than legal

 

[pkwraith]

Why even admit the dead patient to start off. Just never discharge the patients who die in the hospital and keep billing for them. So much easier. Plus dead people never develop CAUDI

 

[Birdstrike]

So our notortiously understaffed and underresourced inner city ED just hired a new chairman who previously worked at the well resoured Ivy league ED across town. Since he’s stared over the last few months his main focus has been to increase revenues by any means possible by further increasing billing. This has led to some ridiculous highly questionable department policies centered around critical care.

Now his newest policy is to have us admit cardiac arrest patients even if they’ve been down for 30+ minutes and we declare them dead on arrival. Basically even if we do nothing and they never have a pulse he wants us to have them offically admitted to CCM in the hosptial. I’m not an expert on CMS regulations but it does seem highly illegal even ignoring all of the ethical implications of these kinds of department policies.

This sounds unethical. It somehow also doesn't surprise me.

 

[BJJVP]

This would never happen at my hospital. We need a nurse to patient ratio of at least 2:1 for a patient that critical.

 

[Janders]

I mean, I am ALL about encouraging more critical care billing (we do SO much critical care that is underbilled) but uh… this sounds decidedly wrong.

 

[Groove]

So our notortiously understaffed and underresourced inner city ED just hired a new chairman who previously worked at the well resoured Ivy league ED across town. Since he’s stared over the last few months his main focus has been to increase revenues by any means possible by further increasing billing. This has led to some ridiculous highly questionable department policies centered around critical care.

Now his newest policy is to have us admit cardiac arrest patients even if they’ve been down for 30+ minutes and we declare them dead on arrival. Basically even if we do nothing and they never have a pulse he wants us to have them offically admitted to CCM in the hosptial. I’m not an expert on CMS regulations but it does seem highly illegal even ignoring all of the ethical implications of these kinds of department policies.

That sounds highly unethical and if it's not illegal then it's decidedly RIPE for a lawsuit. Did risk management sign off on this? Gigantic balls on your new chair for risking a whistleblower lawsuit with terrible optics. National news would absolutely adore to cover something like that.

 

[EctopicFetus]

This is one of the craziest things i have ever heard. Are the CCM docs on board? Just wondering how far this conspiracy has gone up the food chain.

 

[Mount Asclepius]

I fail to see how this generates increased revenue for the ED. For the professional fee, these are already at least level 5 charts (99285). A CPR procedure (92950) generates almost as much revenue as CC time (99291), which some physicians don't know. If you are billing a CPR procedural charge, it is ethically difficult and potentially fraudulent to also bill critical care time for patients with cardiopulmonary arrest without ROSC and a short ED course. It's also ethically questionable to unnecessarily continue CPR and prolong ED LOS just to try to generate critical care time. The facility fees are more significant, but I don't see how this admission changes the revenue generation for the ED.

Also skeptical that the CCM group is on board. I could see this quickly fizzling out and have the potential for significant bad publicity.

 

[ShockIndex]

I don’t think that this would generate any extra money for the ED. I suspect that the Chair is trying to kiss up to the CEO by generating an admission professional and facility fee. I see a couple of potential problems here:

1) While you can absolutely admit pulseless and apneic patients (ie ECPR on VA-ECMO with no pulsatility), I do not think that you can admit a body that has been declared dead in an outpatient setting. So, are you being specifically told to never call a code in the ED no matter how dead the body is until after an admission order is placed and an admitting provider has examined the patient? Or, are you being told to place an admission order on a dead body that you have already pronounced dead? Both are bad, but the later is directing a lot more risk directly at you.

2) A requirement from hospital leadership that dictates care policies such as this regardless of clinical indications stands a very good chance of running afoul of the False Claims Act. This is especially true when the policies are specifically designed to bill for care or admissions that may not be indicated.

Regardless of whether I‘m right on these two points, this idea sounds a lot like something that would come from the mind of a terrible leader with very questionable ethics. Thus, once you get past this problem, other issues are likely to follow. I’d first talk to partners who you trust to make sure that you have all the facts. If others within your group have the same understanding of what you’re being told to do, I would then document your concern in writing to the chair; there are strength in numbers at this point. If nothing is done or if you feel like your are being retaliated against, then this website is your friend: Reporting Fraud | CMS

 

[Groove]

Yeah, I dare them to provide you this policy in writing. Attorneys would be salivating to get a copy of it.

 

[xaelia]

So our notortiously understaffed and underresourced inner city ED just hired a new chairman ....

I know this guy – Dr. Frankenstein, right?

I wonder what he's up to ....

 

[Fox800]

Umm, wow. I feel like I'm taking crazy pills.

Can't admit a dead patient. Shouldn't your intensivists be raising hell about this or hanging up the phone when you call with this crap?

 

[Mount Asclepius]

I’d love to hear the conversation of this attempted admit.

 

[cyanide12345678]

So our notortiously understaffed and underresourced inner city ED just hired a new chairman who previously worked at the well resoured Ivy league ED across town. Since he’s stared over the last few months his main focus has been to increase revenues by any means possible by further increasing billing. This has led to some ridiculous highly questionable department policies centered around critical care.

Now his newest policy is to have us admit cardiac arrest patients even if they’ve been down for 30+ minutes and we declare them dead on arrival. Basically even if we do nothing and they never have a pulse he wants us to have them offically admitted to CCM in the hosptial. I’m not an expert on CMS regulations but it does seem highly illegal even ignoring all of the ethical implications of these kinds of department policies.

Seriously what does critical care even do on someone who has already been pronounced dead?

 

[xaelia]

I’d love to hear the conversation of this attempted admit.

Me: We need a miracle. It's very important.
Admitting team: Look, I'm retired. And besides, why would you want someone the King's stinking son fired? I might kill whoever you wanted me to miracle.
Me: He's already dead.
Admitting team: He is, eh? I'll take a look. Bring him in.

 

[pkwraith]

I’d love to hear the conversation of this attempted admit.

Hey ICU , got a patient coming up to you. Just acute encephalopathy and respiratory failure secondary to electromechanical dissociation. Just full code from hospice for end stage pancreatic cancer. Thinking hes just really hypotensive so on max epi, norepi, vitamin C, and methylene blue, you'll want to put an art line when he comes up. Make sure your code team is there so we can do our usual high quality no interuption CPR handoff. Thanks. Also, we gave TNK, so just give that bad boy some time to circulate.

 

[emergentmd]

I would not even worry about this. The hospitalists and CCM will take care of it. Even if they all are on board, then all I would do it call it, document appropriately, and let the hospital do whatever they want. This will blow over.

 

[JacobMcCandles]

Should he be admitted since he’s brain dead?

 

[alpinism]

This would never happen at my hospital. We need a nurse to patient ratio of at least 2:1 for a patient that critical.

Heh we routinely have 10:1 ratios even in the critical care pod.

 

[alpinism]

That sounds highly unethical and if it's not illegal then it's decidedly RIPE for a lawsuit. Did risk management sign off on this? Gigantic balls on your new chair for risking a whistleblower lawsuit with terrible optics. National news would absolutely adore to cover something like that.

I'm even sure we have risk management at the hospital.

 

[alpinism]

This is one of the craziest things i have ever heard. Are the CCM docs on board? Just wondering how far this conspiracy has gone up the food chain.

Yep apparently.

 

[alpinism]

I fail to see how this generates increased revenue for the ED. For the professional fee, these are already at least level 5 charts (99285). A CPR procedure (92950) generates almost as much revenue as CC time (99291), which some physicians don't know. If you are billing a CPR procedural charge, it is ethically difficult and potentially fraudulent to also bill critical care time for patients with cardiopulmonary arrest without ROSC and a short ED course. It's also ethically questionable to unnecessarily continue CPR and prolong ED LOS just to try to generate critical care time. The facility fees are more significant, but I don't see how this admission changes the revenue generation for the ED.

Also skeptical that the CCM group is on board. I could see this quickly fizzling out and have the potential for significant bad publicity.

Yeah I'm also very skeptical and more likely it just seems like its more billing for the hospital.

Wouldn't be surprised if there's some backroom deals going on where a portion gets funneled back to the emergency department.

 

[alpinism]

I don’t think that this would generate any extra money for the ED. I suspect that the Chair is trying to kiss up to the CEO by generating an admission professional and facility fee. I see a couple of potential problems here:

1) While you can absolutely admit pulseless and apneic patients (ie ECPR on VA-ECMO with no pulsatility), I do not think that you can admit a body that has been declared dead in an outpatient setting. So, are you being specifically told to never call a code in the ED no matter how dead the body is until after an admission order is placed and an admitting provider has examined the patient? Or, are you being told to place an admission order on a dead body that you have already pronounced dead? Both are bad, but the later is directing a lot more risk directly at you.

2) A requirement from hospital leadership that dictates care policies such as this regardless of clinical indications stands a very good chance of running afoul of the False Claims Act. This is especially true when the policies are specifically designed to bill for care or admissions that may not be indicated.

Regardless of whether I‘m right on these two points, this idea sounds a lot like something that would come from the mind of a terrible leader with very questionable ethics. Thus, once you get past this problem, other issues are likely to follow. I’d first talk to partners who you trust to make sure that you have all the facts. If others within your group have the same understanding of what you’re being told to do, I would then document your concern in writing to the chair; there are strength in numbers at this point. If nothing is done or if you feel like your are being retaliated against, then this website is your friend: Reporting Fraud | CMS

We haven't received anything official in writing but he wants us to admit before pronouncing a patient.

So for example lets say we have a GSW head that shows up DOA with no signs of life:

1. Call a full trauma activation
2. Wait for the full team to arrive
3. Admit to our trauma service
4. Call time of death

It's my understanding this allows them to bill a full activation fee and admission fee as well as increases their overall trauma numbers which then leads to more funds from the state government that goes to our hospital as well as the emergency department.

 

[Mount Asclepius]

I agree this is just a billing game. Although I think we are all majorly skeptical of this admin decision as it completely bucks common sense.

We used to do this with sepsis. Called everyone septic if admitted with an infection given the facility can bill much higher than if just infection + SIRS. Then CMS got smarter and started withholding payments for not improving on the bundle year over year. Now back to trying to limit who is diagnosed with sepsis to increase bundle compliance numbers.

I see this being a decision that could shoot your hospital in the foot when they start withholding payment for an unusually high percentage of admitted patients dying.

 

[wholeheartedly]

Didn’t something sketchy a similar sense this make the national news? calling a bunch of minor stuff traumas to get trauma activation fee (or something, this is waay outside my wheelhouse)


Also, couldn’t they wind up getting dinged on the hospital side for some poor outcome metric?


I’d be very interested in they’re willing to put this in writing.

 

[The Knife & Gun Club]

I’m surprised the CCM department is on board with this. Because logistically you’re going to be admitting them to a CCM doc who has never seen the patient, probably got minimal to no signout (because of there being a damn code in progress), never examined or wrote a proper note or dictated their care, but now is legally liable for the outcome along with the ED doc.

Unless of course they’re calling the ICU down for every code, which seems like an immense waste of time and resources that could be used to you know, generate billable income for the hospital.

 

[The Knife & Gun Club]

Didn’t something sketchy a similar sense this make the national news? calling a bunch of minor stuff traumas to get trauma activation fee (or something, this is waay outside my wheelhouse)


Also, couldn’t they wind up getting dinged on the hospital side for some poor outcome metric?


I’d be very interested in they’re willing to put this in writing.

Yea a couple of the HCA hospitals in Florida had some very liberal trauma activation criteria and were billing astronomical fees for trauma activations.

Like any head trauma in a patient over 65 or on thinners is automatically a level 1 trauma. Any injury suspected to be a fracture proximal to the knee or elbow. Any fall in a patient over 65 or on thinners.

Which in Florida is a lot of the patients 😂

 

[Goro]

If they're that desperate, why don't they just raid the local cemeteries for bodies?

 

[Mount Asclepius]

If they're that desperate, why don't they just raid the local cemeteries for bodies?

🤫 Don’t give them ideas.

 

[EctopicFetus]

I got a new idea. Put all patients on a monthly recurring bill regardless of if they show up.

 

[emergentmd]

Just put everyone with CP, abd pain, migraines in obs. You will make much more this way.

Imagine reviewing a chart where the admission physical is, “unresponsive, no pulse, no resp effort, cold, blue in rigor mortis”

Plan - admit for reveal and serial exams.

This new EM chair is utterly insane and not fit for the job.

 

[Siggy]

I’d love to hear the conversation of this attempted admit.

'
["The Former Guy" voice] You've never seen a patient as stable as this. No one was ever this stable! [/TFG]

 

[Siggy]

Seriously what does critical care even do on someone who has already been pronounced dead?

If it's an OPO patient, a central line, bronchs with BALs from both lungs... and what ever else the OPO rep wants.

...but we're talking about death by cardiac criteria, not death by neuro criteria.

[edit: Adjusted wording to clarify last sentence]

 

[W22.0]

Oh I'll raise you one- TeamHealth site I worked for a hot min encouraged and demanded acceptance of anyone declared dead at an outside hospital seeking transfer to trauma center. Also left nice snacks for EMS so they would bring anyone they'd otherwise declare dead in the field. I've never seen so many Thumper devices in my career. It was like Weekend at Bernie's with more rib fractures and moral injury.

 

[Apollyon]

OK, this reminded me to roll out this joke, again...

So, pt is in hospital for his cancer. It's time for his chemo. So, the oncologist mixes it up, and goes to the pt room. But, pt isn't there. Charge nurse says pt expired. Now, onc thinks, "We can't let this go to waste. Also, I can't bill for it". So, he goes down the morgue.

He opens the drawer, but, it's empty. There IS, though, a note - "The patient is in dialysis. They'll be back soon"!

 

[southerndoc]

This policy is going to shoot the hospital in the foot when they report their mortality data.

I reference you to this post if you have any questions regarding this policy: Hospital wants us to admit dead patients

 

[WorkNoteEmergency]

Look on the bright side, makes those elevator rides up to the Unit on those dicey patients a lot less stressful.

 

[TooMuchResearch]

So our notortiously understaffed and underresourced inner city ED just hired a new chairman who previously worked at the well resoured Ivy league ED across town. Since he’s stared over the last few months his main focus has been to increase revenues by any means possible by further increasing billing. This has led to some ridiculous highly questionable department policies centered around critical care.

Now his newest policy is to have us admit cardiac arrest patients even if they’ve been down for 30+ minutes and we declare them dead on arrival. Basically even if we do nothing and they never have a pulse he wants us to have them offically admitted to CCM in the hosptial. I’m not an expert on CMS regulations but it does seem highly illegal even ignoring all of the ethical implications of these kinds of department policies.

Tell them that if you're not qualified to determine when a patient is dead, you shouldn't run the code. Advise EMS that these patients are now direct admissions as you are not qualified to care for them.

But really, get this policy in writing and report it as others have recommended. Your hospital is advising you to admit corpses to the facility to extract money from the family, the insurer, and the taxpayer.

 

[Pudortu]

I fail to see how this generates increased revenue for the ED. For the professional fee, these are already at least level 5 charts (99285). A CPR procedure (92950) generates almost as much revenue as CC time (99291), which some physicians don't know. If you are billing a CPR procedural charge, it is ethically difficult and potentially fraudulent to also bill critical care time for patients with cardiopulmonary arrest without ROSC and a short ED course. It's also ethically questionable to unnecessarily continue CPR and prolong ED LOS just to try to generate critical care time. The facility fees are more significant, but I don't see how this admission changes the revenue generation for the ED.

Also skeptical that the CCM group is on board. I could see this quickly fizzling out and have the potential for significant bad publicity.

A former colleague told me you can bill both CPR and critical care but you have to put stuff down like "preparing the room when call came in from EMS, gather the team, assigning roles, prepping equipment (US), gathering previous data from EMR etc" and you can do both. I find it nebulous at best. Does anyone do this?

 

[LChristmas]

A former colleague told me you can bill both CPR and critical care but you have to put stuff down like "preparing the room when call came in from EMS, gather the team, assigning roles, prepping equipment (US), gathering previous data from EMR etc" and you can do both. I find it nebulous at best. Does anyone do this?

I guess critical care time just needs to be "exclusive of separately billable procedures," but it seems a bit of a stretch to say it takes more than 30 minutes to do those things.

 

[Siggy]

A former colleague told me you can bill both CPR and critical care but you have to put stuff down like "preparing the room when call came in from EMS, gather the team, assigning roles, prepping equipment (US), gathering previous data from EMR etc" and you can do both. I find it nebulous at best. Does anyone do this?

From a Critical Care standpoint, I've certainly had cases where there was short lived ROSC after the initial code where I've dropped a full consult note for the time between ROSC and the second, final code. However I can't imagine dropping a consult note on a patient who never had ROSC in the first place.

 

[southerndoc]

A former colleague told me you can bill both CPR and critical care but you have to put stuff down like "preparing the room when call came in from EMS, gather the team, assigning roles, prepping equipment (US), gathering previous data from EMR etc" and you can do both. I find it nebulous at best. Does anyone do this?

A 99285 + CPR procedure code (92950) + intubation is more appropriate for most of our cases. If you get ROSC and >30 mins critical care (excluding the CPR code), then by all means bill a 99291 and 92950.

Even 1 minute of CPR gets a CPR procedure note. I have a template note that I insert into the procedure section of my note. Only requirement is that you document you supervised CPR being performed (don't need to personally do it) and you were in attendance for the entirety of the CPR procedure.

A person who comes into the ED, has CPR performed, gets intubated, has ROSC and is admitted to ICU should have a 99291, 92950, and 31500 (intubation) billed. Central venous catheters and arterial lines, if placed, should also be billed.

 

[dozitgetchahi]

Why even admit the dead patient to start off. Just never discharge the patients who die in the hospital and keep billing for them. So much easier. Plus dead people never develop CAUDI

This is how they do it at the VA! /s

No, seriously, when I was a resident covering the VA there were several incidents where nurses after a shift change found a long deceased, cold patient laying in their hospital bed…

 

[Pudortu]

A 99285 + CPR procedure code (92950) + intubation is more appropriate for most of our cases. If you get ROSC and >30 mins critical care (excluding the CPR code), then by all means bill a 99291 and 92950.

Even 1 minute of CPR gets a CPR procedure note. I have a template note that I insert into the procedure section of my note. Only requirement is that you document you supervised CPR being performed (don't need to personally do it) and you were in attendance for the entirety of the CPR procedure.

A person who comes into the ED, has CPR performed, gets intubated, has ROSC and is admitted to ICU should have a 99291, 92950, and 31500 (intubation) billed. Central venous catheters and arterial lines, if placed, should also be billed.

If EMS intubates the patient, and I recheck placement with a glidescope, can I do an intubation procedure note there?

 

[Fox800]

If EMS intubates the patient, and I recheck placement with a glidescope, can I do an intubation procedure note there?

This seems like an unnecessarily risk thing to routinely do (hello, extubation), but YMMV.

Waveform end-tidal capnography has been a thing since I was working in EMS in 2004...20 years ago...

Maybe I'm just salty because the RT extubated the last patient I intubated while they were securing the tube, and didn't recognize it. Hello, the BVM has a loss of resistance to bagging and sounds like fart sounds + diminished chest rise. Yay, two intubation notes on the same patient!

Also pretty certain that if was handled by an "emergency NP" working unsupervised, they would have left the room, patted theirselves on the back for the tube, then the patient would have coded from hypoxia.

 

[allantois]

Why even admit the dead patient to start off. Just never discharge the patients who die in the hospital and keep billing for them. So much easier. Plus dead people never develop CAUDI

This sounds awfully close to Gogol's Dead Souls..

 

[The Knife & Gun Club]

This seems like an unnecessarily risk thing to routinely do (hello, extubation), but YMMV.

Waveform end-tidal capnography has been a thing since I was working in EMS in 2004...20 years ago...

Maybe I'm just salty because the RT extubated the last patient I intubated while they were securing the tube, and didn't recognize it. Hello, the BVM has a loss of resistance to bagging and sounds like fart sounds + diminished chest rise. Yay, two intubation notes on the same patient!

Also pretty certain that if was handled by an "emergency NP" working unsupervised, they would have left the room, patted theirselves on the back for the tube, then the patient would have coded from hypoxia.

I’m geographically limited but have yet to see an EMS rig that uses ETCO2 - is this standard in the rest of the country outside the super south?

Have had a couple of cases now where EMS brings in a patient they “tubed”, ED doc doesn’t check the tube but can’t figure out why they’re desatting despite max vent support, and it’s because the ETT was never confirmed by anyone.

Obviously the vast majority of us do a great job ensuring the tube is either placed properly on the ED or confirmed by us on arrival but the lack of “standard” confirming ETT placement with capno is def still not a thing in many parts of the country.

Hell we only have 9 ETCO2 monitors for our main ED which sees 90,000+ per year.