Health Information Management

Tip: Documentation key to ensuring inpatient medical necessity

CDI Strategies, February 17, 2011

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The RACs have ramped up medical necessity reviews. Determining the medical necessity of an inpatient admission can be a complex process so we have to look at several different places for CMS guidance.

According to the Medicare Benefit Policy Manual, Chapter 1, § 10, an “inpatient” is a person that has been formally admitted to a hospital for purposes of receiving inpatient care and is expected to remain overnight and occupy a bed even though it later develops that the patient can be discharged or transferred and does not actually use a hospital bed. However, the fact that a patient did not remain in the hospital overnight does not disqualify the stay as an inpatient stay, so long as there was “the expectation that he or she will remain at least overnight.”
CMS also takes the position that determination of whether a patient should be admitted as an inpatient is a “complex medical judgment” that should be made by the patient’s physician based on the following factors:
  • Severity of the “signs and symptoms” exhibited by the patient
  • Medical probability of an adverse outcome for the patient
  • The need and availability of diagnostic studies
It is ultimately up to the physician or surgeon to clearly document in the medical record the patient specific needs that would require inpatient admission for that procedure. Inpatient care rather than outpatient care is required only if the patient’s medical condition, safety, or health would be significantly and directly threatened if the same care was provided in a less intensive setting.
This section of the Medicare Benefit Policy Manual adds that the medical record must indicate that the inpatient care was medically necessary, reasonable, and appropriate for the diagnosis and condition of the patient at any time during the stay. Once again, CMS states that the documentation must support that the signs and/or symptoms were severe enough to warrant the need for services that can only be furnished safely on an inpatient basis.
If a surgical procedure is not specifically on the inpatient-only list, it will be up to the physician or surgeon to adequately document the medical necessity of the inpatient admission, regardless of the type of procedure being performed. If you use an admission screening tool, it can help to root out documentation weaknesses when the procedure is appropriately performed as an inpatient. Other sources that may be helpful to determine the appropriateness of an inpatient admission for particular procedures would be widely accepted practice guidelines from the medical societies of those particular specialties.
Ultimately, the physician’s or surgeon’s documentation will need to be able to clearly back up their decision to admit for each individual patient. Remember the old saying – if it’s not documented, it never happened and in these types of cases, the admission was not covered!
Editor’s note: This article first appeared on the MedicareMentor Blog. Join the conversation at

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