Case Management

Mentor moment: CMS issues guidance on hospital inpatient admission decisions

Case Management Weekly, February 2, 2011

Despite the loads of guidance CMS offers about proper inpatient admission decisions, it appears that hospitals still cannot get it right. In order to clear up any confusion CMS issued a special edition MLN Matters article that includes excerpts from several CMS manuals for guidance.

The release is timely. Medical necessity determinations have become a hot button for government auditors such as recovery audit contractors (RAC), Medicare administrative contractors (MAC), fiscal intermediaries (FIs), and comprehensive error rate testing (CERT) contractors. Facilities that do not assign appropriate patient status risk losing reimbursement.

While commercial screening products such as InterQual® and Milliman®, may assist facilities in making patient status determinations, CMS explains in the release that such products are just one of several tools providers can use to make the call. The release includes an excerpt from the Medicare Benefit Policy Manual, which states, “The physician or other practitioner responsible for a patient's care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient.”

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