Health Information Management

News: Inpatient admissions decision fuels RAC uncertainty

CDI Strategies, September 16, 2010

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Recent approval of a RAC issue for inpatient hospital claims review has initiated uncertainty and places an onus on providers to lean on CMS guidance and policy manuals. The issue, “inpatient admissions without a physician’s inpatient admit order,” can be referenced in the Medicare Claims Processing Manual, Section 50.3, which states that “patients are admitted to the hospital as inpatients only on the recommendation of a physician or licensed practitioner permitted by the [s]tate to admit patients to a hospital.”

While the posting of this issue may have come as a bit of surprise, it has always been one of the basic premises of accurate billing, according to Deborah Hale, CCS, CCDS, president and CEO of Administrative Consulting Service, LLC in Shawnee, OK.
“The decision to admit as inpatient is a complex medical judgment that can only be made after a physician has taken into consideration a number of clinical and safety factors,” she says. “It [the manual] stresses the importance of the physician making a conscious decision to admit as inpatient, and that is the foundation for everything in this process.”
Many have dubbed this new RAC issue as the first official medical necessity issue approved by CMS. In short, if facilities “don’t have an order, they don’t have a billable inpatient admission,” Hale says.
“…Be sure you’ve got a properly worded order for admission, and …be sure to have an internal process set up for looking for the presence of a properly worded admission order and documented medical necessity of admission from the beginning of the stay, not just based on screening criteria but also physician advisor review if screening criteria are not met.”
Editor’s Note: This article first appeared in The Revenue Cycle Institute.

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