Revenue Cycle

CMS issues guidance on hospital inpatient admission decisions

Recovery Auditor Report, January 27, 2011

Medical necessity determinations are not just a hot button issue with RACs, but also with the other ‘usual suspect’ government auditors: Medicare administrative contractors (MACs), fiscal intermediaries (FIs), and comprehensive error rate testing (CERT) contractors. So much, in fact, that CMS felt it prudent to release educational guidance to assist hospitals regarding inpatient admission decisions.

While many hospitals may in fact be utilizing proper screening criteria to analyze documentation and make medical necessity determinations, the fact remains that it’s an imperfect endeavor. And while Interqual and Milliman, as well as other additional systems, may assist facilities in specific jurisdictions, CMS issued a special edition MLN Matters article that points providers toward its own manualsfor guidance.

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