Note from the instructor: As the healthcare world turns...
Medicare Insider, April 1, 2014
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- (A1.3) If a MAC identifies no issues (defined as 0–1 claim denials) during the probe review, the MAC will cease further such reviews for that hospital for dates of admission spanning October 2013 to September 2014, unless there are significant changes in billing patterns for admissions.
Comment: I have often wondered what “minor,” “moderate,” “significant,” or “major” concerns are when reviewing the document “Selecting Hospital Claims for Patient Status Reviews: Admissions On or After October 1, 2013.” There does not appear to be any written guidance to providers to know which category they clearly fall into and why. At least now providers will know that if they have one claim denied out of their sample of either 10 or 25 records, they will not have further reviews conducted unless their billing patterns change. I am not sure if this clarification will be very comforting to providers overall.
- (A2.2) The receiving hospital is allowed to take into account the pre-transfer time and care provided to the beneficiary at the initial hospital. That is, the start clock for transfers begins when the care begins in the initial hospital.
Comment: If a hospital is going to use the outpatient time spent at a transferring hospital to count toward their 2-midnight benchmark time, clear documentation should be obtained and maintained in the receiving hospital’s medical record to support their claim.
- (A4.10) …Thus, CMS does not require the treating physician to admit the beneficiary as an inpatient in these or any other circumstances…Accordingly, where the treating physician expects a beneficiary to require medically necessary hospital care spanning 2 or more midnights, we encourage the physician to consider ordering an inpatient admission, with the understanding that such a claim will not be denied by a Medicare review contractor for inappropriate status if all other requirements are met. CMS may monitor hospital outpatient billing trends for the incidence of prolonged outpatient stays so that we can provide education on when an inpatient admission is generally appropriate under the 2-midnight rule.
- (A4.11) MACs will issue determinations for such claims based on the general 2-Midnight benchmark instruction. In other words, if the physician reasonably expects the beneficiary to require a hospital stay for 2 or more midnights at the time of the inpatient order and formal admission, and this expectation is documented in the medical record, the inpatient admission is generally appropriate for Medicare Part A payment.
- (III.D.1.) If an unforeseen circumstance results in a shorter beneficiary stay than the physician’s reasonable expectation of at least 2 midnights, the patient may be considered to be appropriately treated on an inpatient basis and hospital inpatient payment may be made under Medicare Part A…Examples include unforeseen: death, transfer to another hospital, departure against medical advice, clinical improvement, and election of hospice care in lieu of continued treatment in the hospital.
- In the section titled Patient Status Reviews,hospitals need to be aware that the Medicare review contractors are also assessing compliance with the admission order and certification requirements. Specifically, hospitals should verify that the orders and all elements of the certification are appropriately signed prior to discharge. This may cause challenges for facilities that are using a variety of areas in the medical record for the certification elements (i.e., history and physical, progress notes, order, etc.).
- (B.2.d.) Inpatient status begins at the time of formal admission by the hospital pursuant to the physician order, including an initial order (under (B)(2)(a)) or a verbal order (under (B)(2)(b)) that is countersigned timely, by authorized individuals, as required in this section. If the physician or other practitioner responsible for countersigning an initial order or verbal order does not agree that inpatient admission was appropriate or valid (including an unauthorized verbal order), he or she should not countersign the order and the beneficiary is not considered to be an inpatient. The hospital stay may be billed to Part B as a hospital outpatient encounter.
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