Knowledge Base Article

Several years ago, there was a lot of excitement among laboratories and hospitals when CMS stated that a laboratory requisition did not have to be signed by the ordering practitioner. That excitement was short-lived however, when it became apparent that the lack of a signature requirement for lab requisitions did not mean a signed order for the laboratory testing was not required. Upon medical review by a Medicare contractor, the billing entity (such as the hospital) was required to submit a signed practitioner’s order, or other documentation, such as an office progress note, supporting the intent to order the specific laboratory tests. Many laboratories quickly realized it was easier and more efficient to continue to require the physician’s signature on the lab requisition.

Bearing this cautionary tale in mind, what does the proposed policy change to remove the requirement that written inpatient admission orders are a specific requirement for Medicare Part A payment actually mean for hospitals? I certainly do not think it means you no longer need an order for inpatient admission.

In fact, the 2019 Inpatient Prospective Payment System (IPPS) proposed rule states, “This proposal does not change the requirement that an individual is considered an inpatient if formally admitted as an inpatient under an order for inpatient admission.”

What it does mean is a shift in the focus of Medicare reviewers away from the admission order itself. The Proposed Rule affirms that Medicare reviewers will focus on the medical necessity of the inpatient services. The wording in the proposed rule also provides hints as to the types of “technical discrepancies” reviewers may overlook, such as:

• Missing practitioner admission signatures,
• Missing authentication signatures or co-signatures, or
• Signatures occurring after discharge.

Reviewers may also be more willing to allow payment for inpatient admissions when there is not an admission order but “the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record.” This should still be a rare occurrence because hospitals are expected to comply with the Medicare Conditions of Participation which require an admission order.

The rule change for admission orders does not change the “two-midnight” policy. This change, if finalized, will allow hospital personnel to concentrate on ensuring documentation is present in the record to support the medical necessary expectation of a two-midnight stay instead of chasing physicians to obtain signatures before the patient is discharged.