NEW RULES REGARDING ADMISSION INPATIENT ORDERS CMS Releases FY 2014 IPPS and Final CMS - 1455 Rule

Effective October 1, 2013 August 2: 2014 IPPS Released September 5: Sub-Regulatory Guidance Released September 19: Recommendations from our Executive Health Resources Contractor September 19: EPIC recommendations published and discussed at User Group Meeting _________________________________________________________________________________ Under the Final Rule, CMS is seeking to clarify its medical review criteria for medical necessity and payment issues relating to hospital inpatient services under Part A, by giving greater weight to the beneficiary’s expected length of stay, the presence of an inpatient order, and the presence of strong documentation supporting the order. The following provides a summary of the most substantial components of these updates:

Inpatient Admission Criteria and the 2‐Midnight “Benchmark”:

In the past, CMS has provided guidance that the expectations of a hospital stay of 24 hours or greater was one of the elements to consider when evaluating a potential admission. CMS has now replaced the 24‐hour benchmark with a 2‐midnight benchmark under which “a physician or other qualified practitioner … should order admission if he or she expects that the beneficiary’s length of stay will exceed a 2‐midnight benchmark or if the beneficiary requires a procedure specified as inpatient‐only under 42 CFR 419.22.” However, CMS emphasizes that “this instruction does not override the clinical judgment of the physician” and that the appropriateness of the inpatient admission hinges on “a reasonable and supportable expectation of a 2‐midnight stay, not the actual length of care...” Additionally, CMS clarifies that “for those hospital stays in which the physician cannot reliably predict the beneficiary to require a hospital stay greater than 2 midnights, the physician should continue to treat the beneficiary as an outpatient and then admit as an inpatient if and when additional information suggests a longer stay or the passing of the second midnight is anticipated.”

Medical Review Criteria and the 2‐Midnight “Presumption”:

Under the 2-midnight presumption, inpatient hospital claims with lengths of stay greater than 2 midnights after formal admission following the order will be presumed generally appropriate for Part A payment and will not be the focus of medical review efforts absent evidence of systematic gaming, abuse or delays in the provision of care…(Page 50949, IPPS) If the stay does not span at least two midnights, the presumption will not apply and Medicare reviewers are directed to review the admission by applying the 2‐midnight benchmark. In doing so, the reviewers will focus on the totality of the record; utilizing the time spent receiving services as a hospital outpatient prior to the actual inpatient admission in determining whether the 2‐midnight benchmark has been met. Medicare contractors will now focus (in addition to their current focus) on those inpatient claims that fail to meet this benchmark (i.e., hospital stays that span less than two midnights). Claims review will address whether the care was provided efficiently and also whether the care was provided in a manner intending to extend the length of the inpatient stay solely to meet the 2‐ midnight threshold.

Physician Orders: CMS has now mandated that a physician order for inpatient admission must be

present in the medical record in order for the hospital to be reimbursed for inpatient services under Part A. Furthermore, in contrast to previous CMS policy, the admission order “must specify admission ‘to or as an inpatient.’” CMS reiterates its position that while a patient is considered an inpatient upon issuance of an admission order by the treating physician; the order is to be given no presumptive weight. Rather, it is to be considered “in the context of the evidence in the medical record.” CMS has allowed for its contractors to use discretion to approve payment of Part A claims in “extremely rare” circumstances in which the order is missing but the medical record reflects “no uncertainty regarding the intent, decision, and recommendation by the physician … to admit the beneficiary as an inpatient…” The order does not have to be signed by the physician responsible for the patient’s care; rather, the Practitioner signing the order must be knowledgeable about the patient’s course, the plan of care, and the current condition of the patient, in addition to having admitting privileges.

Start of Inpatient Status: In the Rule, CMS confirms its existing position that an inpatient

admission starts at the time of an inpatient order. Additionally, CMS has set forth that “the starting point for the 2‐midnight benchmark will be when the beneficiary begins receiving hospital care on either an inpatient or outpatient basis.”

Physician Documentation: Although a patient stay meeting the 2‐midnight threshold would

create a presumption that inpatient care is medically necessary, CMS stresses that physician documentation must “clearly and completely” justify the decision to admit. The admitting physician must still weigh the totality of the patient’s circumstances as set forth in the CMS Benefit Policy Manual (chapter 1, section 10), because “a reasonable expectation of a stay crossing 2 midnights, which is based on complex medical factors [including evidence based clinical medicine] and is documented in the medical record, will provide the justification needed to support medical necessity of the inpatient admission, regardless of the actual duration of the hospital stay and whether it ultimately crosses 2 midnights.” Therefore, admission reviews, will continue to play an important role in ensuring that hospitals remain compliant with CMS guidelines. CMS has indicated that it will produce additional sub- regulatory guidance to address more clearly the documentation requirements.

In Order To Assure That We Are In Compliance:

1. Inpatient Admission Orders will include a prompt to enter the EXPECTED LENGTH OF STAY and a CERTIFICATION STATEMENT. This electronic signature will meet these new requirements along with documentation of medical necessity throughout the stay. Additional element of certification include:

a. Certification (§424.13)

Begins with the order for inpatient admission;

Must include the reasons for hospitalization for inpatient medical treatment;

Must include diagnosis;

Must include the estimated time the patient will need to remain in the

hospital;

Plans for post-hospital care, if appropriate;

o May be entered on forms, notes, or records that the appropriate individual signs (some hospitals

opting for an additional form).

o If information is in different places (i.e. progress notes, H+P) [certification] statement should

indicate where it may be found

– Must include services were provided in accordance with §412.3 of this chapter

– Certification must be signed and documented in the medical record prior to the hospital

discharge

2. A Co-Signature will be required when a resident or mid-level initiates an inpatient admission

order. 3. A verification statement will be entered by the Emergency Physician but the CERTIFICATION

STATEMENT must be completed by the attending physician. 4. An ADMISSION ORDER must be written to start inpatient care. Care Coordination team is

available to assist you with any questions. 5. Medical necessity must be evident in the documentation to support inpatient admission. The

Clinical Documentation team is available to assist with any questions in this area. 6. EPIC questions can be addressed by IS and the physician super users.

Paula Burgmeier, LISW Director, Care Coordination Office: 319-398-6070 Cell: 319-533-3375