An innovative case management: Gatekeeper model for Medicare surgeries

Abstract

Mayo Clinic Hospital, Phoenix, AZ, is an academic medical center and is one of three campuses located throughout the United States. The facility includes 268 acute care beds with 65 medical/surgical specialties. Approximately 90,000 Medicare and commercial patients receive services annually.1 In 2011, there were 12,491 surgical procedures performed in 18 operating rooms (ORs), representing a 5% increase over 2010. Three new ORs were opened in January 2012. The number of daily surgeries averaged 51. In addition, 171 cardiac catheterizations, 60 interventional radiology, and 2,326 gastrointestinal (GI) endoscopy patients were recovered in the postanesthesia care unit (PACU).2 The Centers for Medicare & Medicaid Services (CMS) instituted specific reimbursement requirements regarding same-day surgical procedures for the CMS population.3 A list of inpatient-only procedures is compiled by the CMS annually from the Current Procedural Terminology (CPT) codes mandated by the American Medical Association. The Medicare Strategy Unit at Mayo Clinic Hospital updates this list annually, and care management conforms to these regulations.4 Any procedure on the inpatient-only list An Innovative Case Management