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Note from Hugh

Medicare Weekly Update, November 20, 2007

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In past issues of the Medicare Weekly Update, including November 6, 2007, and October 2, 2007, I have reported on the continuing controversy regarding the implications of CMS prohibition on "retroactive" inpatient admissions (i.e., backdated admission orders).

CMS raised this issue once again during the November CMS Hospital Open Door Forum call of November 8.  During that call, CMS stated that if an admission order is not properly documented in the medical record, the quality improvement organization (QIO) may still allow the hospital to bill an inpatient stay if the QIO makes a determination that "an inpatient stay was intended from the outset." CMS noted, however, that this should only occur under "rare and unusual" circumstances.

CMS also explained during the call that, in accordance with CMS Transmittal A-02-129, where an "inpatient only" procedure was furnished for an outpatient on an emergency basis, the hospital may treat the case as an inpatient case if the physician "promptly completed" an inpatient admission order at the conclusion of the surgery. CMS noted, however, that this should also only occur in "rare and exceptional" circumstances. 

However, in response to a caller's follow-up question, CMS representatives indicated that they are not aware of any other circumstances (other than emergency cases) in which an "inpatient only" procedure performed on an outpatient basis could be treated as an inpatient case. This is significant because hospitals often do not find out that a patient requires an "inpatient only" procedure until the patient is in the surgical suite.

It would be helpful to hospitals if CMS would permit hospitals to admit a patient immediately after surgery and treat the entire case as an inpatient case whenever a determination was made during an outpatient surgery that the patient actually required an inpatient only procedure. Unfortunately, it appears that CMS does not currently permit such admissions except when the surgery was done on an emergency basis, as discussed in Transmittal A-02-129.

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