News: CMS issues guidance on hospital inpatient admission decisions

February 3, 2011

Despite the guidance CMS offers about proper inpatient admission decisions, hospitals still struggle with the process. In order to clear up confusion CMS issued a special edition MLN Matters article that includes excerpts from several CMS manuals.

The release is timely. Medical necessity determinations have become a hot button for government auditors such as recovery audit contractors (RAC), Medicare administrative contractors (MAC), fiscal intermediaries (FI), and comprehensive error rate testing (CERT) contractors. Facilities that do not assign appropriate patient status risk losing reimbursement.

While commercial screening products such as Interqual and Milliman, may assist facilities in making patient status determinations, CMS explains in the release that such products are just one of several tools providers can use to make admission decisions. The release includes an excerpt from the Medicare Benefit Policy Manual, which states:

“The physician or other practitioner responsible for a patient’s care at the hospital is also responsible for deciding whether the patient should be admitted as an inpatient.”

It further states that the decision to admit a patient to hospital “is a complex medical judgment which can be made only after the physician has considered a number of factors”… These factors include:

the patient’s medical history
current medical needs
the types of facilities available to inpatients and to outpatients
the hospital’s by-laws and admissions policies
the relative appropriateness of treatment in each setting

According to the article additional factors to consider when making the decision to admit include such things as:

The severity of the signs and symptoms exhibited by the patient
The medical predictability of something adverse happening to the patient
The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted
The availability of diagnostic procedures at the time when and at the location where the patient presents

Providers should use the Special Edition MLN Matters article to help educate physicians, and other clinical staff involved in the decision-to-admit process, says Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., in Danvers, MA.

In addition, CDI specialists should use the article to identify potential documentation improvement areas, Mackaman says. Auditors and compliance staff should also review the specific manual sections to ensure compliance with the regulations.

The release may also pose a challenge for providers that rely heavily on screening criteria, according to Deborah Hale CCS, CCDS, president and CEO of Administrative Consultant Service, LLC, in Shawnee, OK.

“Certainly one can understand the need for physician judgment to determine that an admission is unnecessary but to say that a hospital can’t depend upon screening criteria to determine that an admission is necessary becomes a challenge.”

Editor’s note: To read the Special Edition MLN Matters article, click here: http://www.cms.gov/MLNMattersArticles/Downloads/SE1037.pdf. HCPro Associate Editor Jimmy Carroll and Associate Editor Ben Amirault contributed to this article.

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