Knowledge Base Article

Is your hospital continuing to struggle to comply with Final Rule CMS-1599-F that went into effect on October 1, 2013? Are you still seeking any and all of the additional information that you can find to help comply with the new rules? If the answer is yes, you are not alone.

In the past couple of weeks CMS has been busy providing additional guidance. First, was the release of MLN Matters® Number: MM8586. This article provides guidance for the new use of Occurrence Span Code 72 to identify outpatient time associated with an inpatient hospital admission. Next, they posted updated guidance regarding the Hospital Inpatient Admission Order and Certification and an updated Reviewing Hospital Claims for Patient Status download to their Inpatient Hospital Review webpage. They also held yet another “Special Open Door Forum” (ODF) to discuss the Hospital Inpatient Admission Order and Certification; 2 Midnight Benchmark for Inpatient Hospital Admissions on February 4th.

As the question and answer portion of the ODF became more of a question being asked and CMS requesting that you submit that question to IPPSAdmissions@cms.hhs.gov, it became apparent that no big “aha” moments were going to be happening. It was at this point that all I could think about was the chorus to the Sonny and Cher 1967 hit song The Beat Goes On. For those old enough to remember this one sing along:

“The beat goes on, the beat goes on

Drums keep pounding

A rhythm to the brain

La de da de de, la de da de da.”

Now that this song is firmly stuck in your head, let’s take a look at the new and updated guidance from CMS.

Occurrence Span Code 72; Identification of Outpatient Time Associated with an Inpatient Hospital Admission and Inpatient Claim Payment:MLN Matters(R) Number: MM8586

Effective Date: December 1, 2013

Implementation Date: February 24, 2014

Why is this being implemented?

• “The redefinition of occurrence span code 72 allows providers to voluntarily identify those claims in which the 2-midnight benchmark was met because the beneficiary was treated as an outpatient in the hospital prior to the formal inpatient admission order. In other words, it permits providers and subsequently review contractors to identify the “contiguous outpatient hospital services (midnights) that preceded the inpatient admission,” as well as the total number of midnights after formal inpatient order and admission, on the face of the claim.”

Hospital Inpatient Admission Order and Certification (January 30, 2014)

CMS’s attempt to clarify the September 5th Guidance fell a little short. However, there were a few key pieces of information to point out to you.

• If you have a Medicare beneficiary waiting on a skilled nursing facility (SNF) bed, CMS indicates that “a beneficiary who is already appropriately an inpatient can be kept in the hospital as an inpatient if the only reason they remain in the hospital is they are waiting for a post-acute SNF bed. The physician may certify the need for continued inpatient admission on this basis.”
• Residents, non-physician practitioners and ED physicians who do not have admitting privileges can make the initial admission decision. “In countersigning the order, the ordering practitioner approves and accepts responsibility for the admission decision.” This counter-signature would “satisfy the order part of the physician certification, as long as the ordering practitioner also meets the requirements for a certifying physician.”
• “If the physician or other practitioner responsible for countersigning an initial order or verbal order does not agree that inpatient admission was appropriate or valid (including an unauthorized verbal order), he or she should not countersign the order and the beneficiary is not considered an inpatient. The hospital stay may be billed to Part A as a hospital outpatient encounter.”

The entire update can be found at: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf

Highlights from the February 4, 2014 Special Open Door Forum

• CMS has extended the MAC Probe and Educate Period through September 30, 2014. CMS verified (at a caller’s request) that they have not cancelled or delayed the implementation of the new rule.
• In response to a question about whether or not there had to be a statement indicating the expected length of stay in the record, CMS indicated that there are no “magical words” that need to appear saying the physician certifies the stay. CMS would expect to find “regular good documentation” in the record, not a separate “I certify” statement.
• Another caller asked if the MD does not sign a verbal admit order until after the patient is discharged can we bill for anything? CMS responded that as far as the letter of the law you need the order to submit a Part A claim. If the order was not co-signed then you could submit a Part B Outpatient claim (a 13x type of bill).
• One hospital indicated that they were under the impression that they would receive a letter from their MAC after their records had been reviewed under the Probe & Educate program. CMS indicated that they had asked MACs to hold on letters until additional guidance was released regarding the Inpatient Admission Order and Certification. They went on to indicate that this information was released last week and the MACs should no longer be holding letters.

Reviewing Hospital Claims for Patient Status: Admissions On or After October 1, 2013 (Last Updated: 01/31/14)

There were two specific clarifications made to this Guidance that I would like to point out to you. Prior to this update CMS had indicated that “it is not necessary for a beneficiary to meet an inpatient “level of care,” as may be defined by a commercial screening tool, in order for Part A payment to be appropriate.” In this updated version they further indicate that “In addition, meeting an inpatient “level of care,” as may be defined by a commercial screening tool, does not make Part A payment appropriate in the absence of an expected length of stay of 2 or more midnights.” Once again, CMS is making the point that good physician documentation supportive of a 2 or more midnight admission is the key to the decision to admit a patient as an inpatient.

The other clarification is about the documentation that the MACs would expect to find to support the 2-midnight expectation. CMS indicates that “physicians need not include a separate attestation of the expected length of stay; rather, this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes.”

National Provider Call: 2-Midnight Benchmark: Discussion of the Hospital Inpatient Admission Order and Certification

CMS is already planning additional education through a National Provider Call on Thursday February 27, 2014 from 2:30 PM – 4:00 PM Eastern Time. The target audience for this call includes hospitals, physicians and non-physician practitioners, case managers, medical and specialty societies, and other healthcare professionals. Topics to be covered in this call are the order and certification guidance with case examples, transfers and a question and answer session.

Registration is open and those interested in participating can sign up at the CMS MLN Connects Upcoming Callsregistration website.

It appears that the truism that best applies with the new regulations and guidance is that “The only constant is change.” MMP continues to be on the lookout for updated guidance and education opportunities to pass along to you so, stay tuned.