Health Information Management

Questions surround when time starts for proposed inpatient presumption

APCs Insider, May 24, 2013

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By Michelle A. Leppert, CPC

The proposed CMS presumption for inpatient admission includes an interesting nuance that could spell the end of dedicated observation units. According to CMS, the starting point for counting utilization days “would be when the beneficiary is moved from any outpatient area to a bed in the hospital in which the additional hospital services will be provided.”

Does that mean when the patient is moved from the ED to a bed for observation? Or does it mean when the physician writes the order for inpatient services? What happens if the physician writes an inpatient order, but no bed is available? Does that time count towards the two-midnight presumption?
One possibility is that observation time will count towards the utilization days as long as the patient is not in a dedicated observation area. That might mean that observation services provided in an inpatient area count towards the two midnights.
For example, a patient is in bed for observation Monday. The physician writes an order to admit the patient as an inpatient Tuesday and discharges the patient Wednesday. The presumption would be met because the patient was in a bed for two midnights (Monday and Tuesday night), but only one inpatient utilization day.
That in turn could lead to more patients meeting the two-midnight presumption and spell the end of observation units. It also means hospitals will need to focus on ED throughput and making sure patients get from the ED to a bed as efficiently as possible.
The two-midnight presumption is still only a proposal so if you have thoughts or suggestions, be sure to submit comments to CMS.

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