Are you assigning admit type based on NUBC guidelines—or a loose interpretation to influence quality metrics?

By Brian Murphy

 Prior to our Off the Record podcast recording my guest Penny Jefferson shared with me a white paper she authored on admit type. I’m going to summarize a bit of it here as it was a substantive basis of our conversation.

The paper begins by differentiating between admit status and admit type. Most in the mid-revenue cycle space know the former pretty well (even though the rules are complex): Inpatient, outpatient, observation.

Admit type is very different, but no less important. From Penny’s paper:

“The cost of getting the admit type wrong is substantial: misclassification distorts public quality metrics such as Patient Safety Indicators (PSIs), affects CMS reimbursement, undermines national benchmarking efforts, and can even influence how hospitals are ranked and rated by third-party evaluators and the government.”

Admit type is regulated by the National Uniform Billing Committee (NUBC), and the three major types are defined as follows:

• Emergent: The patient requires immediate medical intervention due to severe, life-threatening, or potentially disabling conditions. Typically, patients are admitted through the emergency room.
• Urgent: The patient requires immediate attention for the care and treatment of a physical or mental disorder. The patient is admitted to the first available and suitable accommodation.
• Elective: The patient’s condition permits adequate time to schedule a suitable accommodation.

Newborn and trauma are two others.

This all seems straightforward… but admit type is subject to gaming. Savvy hospitals know changing a patient’s admit type from elective to urgent circumvents PSI exclusions, allowing the case to be excluded from elective-only quality measures, such as PSI 10, 11, or 13. Writes Penny:

“This practice introduces gaming opportunities, whether intentional or inadvertent, by using workflow-driven coding logic rather than clinical definitions. It creates a competitive reporting advantage for institutions that inconsistently apply admit type logic, while penalizing those that adhere strictly to CMS intent. Misclassifying a routine elective surgery as “urgent” distorts metrics, misleads payers, and reduces the reliability of national benchmarking.”

You can see how this can occur in the example of a TAVR (transcatheter aortic valve replacement), which Penny describes on the program. A patient comes in for this elective procedure—a TAVR is a way to fix a failing valve without open heart surgery—but physicians realize the patient needs to have an emergent cardiac procedure due to diseased vessels. So the hospital changes the admit type from elective to urgent.

Which is not correct, per NUBC. Admit type should be assigned based on how the patient presented to the hospital for their initial care, Penny explains.

The paper ends with a call for national admit type uniformity.

Kudos to Penny for writing the paper and joining me on the podcast to talk about it. Change doesn’t happen without voices calling for it.

Reference

• Off the Record podcast: An urgent issue: https://www.norwood.com/an-urgent-issue-how-admit-type-can-skew-quality-metrics/