CMS Issues Guidance on Hospital Inpatient Admission Decisions

on Wednesday, 02 February 2011. All News Items

CMS recently released a Special Edition MLN Matters Article (SE1037) on “Guidance on Hospital Inpatient Admission Decisions” which reminds inpatient hospitals that medical documentation must demonstrate the clinical need for the patient to be admitted to the inpatient facility and accurately identify subsequent care provided during the inpatient stay. The article addresses providers’ concerns about the use of screening criteria for determination of the medical necessity of inpatient hospital admissions by Medicare review contractors, such as Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs), Fiscal Intermediaries (FIs), and the Comprehensive Error Rate Testing Contractor (CERT).

The article refers providers to the Medicare Program Integrity Manual, Chapter 6, Section 6.5.1 for information concerning medical review of inpatient admissions. This information states that although CMS does require review contractors to use a screening tool for medical review purposes, they do not require or endorse the use of any specific criteria. Contractors may use any of several commercially available screening tools such as Interqual, Milliman, or other proprietary systems. The article stresses that the use of screening criteria is only one tool that may be utilized; reviewers also utilize invasive procedure criteria, CMS coverage guidelines, published CMS criteria and other guidelines (e.g. medically accepted practice guidelines).

And in addition to screening criteria, reviewers shall apply their own clinical judgment to make medial review determinations based on the documentation in the medical record. This means reviewers may deny claims that meet screening criteria or approve claims that do not meet screening criteria. The hospital and admitting physician should consider the following in determining if a patient requires inpatient hospital care:

  • The patient must demonstrate signs and/or symptoms severe enough to warrant the need for medical care and must receive services of such intensity that they can be furnished safely and effectively only on an inpatient basis.
  • Any pre-existing medical problems or extenuating circumstances that make admission medically necessary.
  • 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 care was provided in a less intensive setting.
  • Factors that would only cause the patient worry or inconvenience do not, by themselves, justify an inpatient admission.

The Medicare Benefit Policy Manual, Chapter 1, Section 10, also contains the following relevant information regarding what constitutes an appropriate inpatient admission.

“An inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that he or she will remain at least overnight and occupy a bed even though it later develops that the patient can be discharged or transferred to another hospital and not actually use a hospital bed overnight.

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. Physicians should use a 24-hour period as a benchmark, i.e., they should order admission for patients who are expected to need hospital care for 24 hours or more, and treat other patients on an outpatient basis. However, the decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting. Factors to be considered 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; and
  • The availability of diagnostic procedures at the time when and at the location where the patient presents.

Admissions of particular patients are not covered or noncovered solely on the basis of the length of time the patient actually spends in the hospital.”

Refer to the links above for more information on hospital inpatient admission decisions.

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