Health Information Management

News: FY 2014 IPPS proposed rule emphasizes physician rationale for admission

CDI Strategies, June 6, 2013

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Clinical documentation improvement (CDI) experts have reiterated the importance of documentation improvement for quite some time. Now, CMS is stepping onto its soapbox as well with a newly released proposed rule that emphasizes the importance of physician documentation.

In its FY 2014 IPPS proposed rule, the agency not only redefines inpatient status, but it also discusses the ‘why’ and ‘how’ physicians should document the defining characteristic of all admissions: medical necessity.
CMS proposes to define appropriate inpatient stays (i.e., stays that are appropriate for payment under Medicare Part A) as medically necessary stays that span two midnights in the hospital setting. Previously, this benchmark was set at 24 hours.
In its proposed rule, the agency states the following:
Medical review of inpatient admissions will include a presumption that hospital inpatient admissions are reasonable and necessary for beneficiaries who require more than 1 Medicare utilization day (defined by encounters crossing 2 midnights) in the hospital receiving medically necessary services.
This change shouldn’t take coders by surprise. The majority of Medicare Part A improper payments for short-stays have been due to inappropriate patient status. In 2012, inpatient hospital admissions for stays that lasted one day or less had a Part A improper payment rate of 36.1%, according to the Comprehensive Error Rate Testing (CERT) program. Recovery Auditors have also recouped more than $1.6 billion in improper payments because of inappropriate beneficiary patient status.
“We believe the magnitude of these national figures demonstrates that the appropriate determination of a beneficiary’s patient status is a systemic and widespread issue and is not isolated to a few hospitals,” CMS stated its proposed rule.
Editor’s Note:This article is an excerpt from

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