Two weeks ago the Centers for Medicare & Medicaid Services (CMS) published an update to the 2015 Hospital Outpatient Prospective Payment System that included two paragraphs that appear to change a longstanding CMS policy that required an inpatient admission order prior to every inpatient-only surgery. CMS seems to be saying that as of April 1, it is allowing the three-day window for outpatient services to be billed on the inpatient claim to extend to inpatient-only surgery. According to the update, the admission order may be obtained at any time of the day of the surgery or within the next three calendar days as long as the patient is still hospitalized.
“We are revising our billing instructions to allow payment for inpatient only procedures that are provided to a patient in the outpatient setting on the date of the inpatient admission or during the three calendar days (or one calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission to be bundled into billing of the inpatient admission, according to our policy for the payment window for outpatient services treated as inpatient services,” the update reads.
“Effective April 1, 2015, inpatient-only procedures that are provided to a patient in the outpatient setting on the date of the inpatient admission or during the three calendar days (or one calendar day for a non-subsection (d) hospital) preceding the date of the inpatient admission that would otherwise be deemed related to the admission, according to our policy for the payment window for outpatient services treated as inpatient services will be covered by CMS and are eligible to be bundled into the billing of the inpatient admission.”
But before anyone changes their procedures, remember a few things. First, checking for an admission order preoperatively is also an opportunity to check for documentation of medical necessity for the surgery itself. We are starting to see inpatient-only surgery patients going home on the day of surgery, so if you miss the post-operative admission order, you can’t bill for the surgery at all. The three-day rule for Part A nursing home benefits has not changed, so you want to get the inpatient admission order as soon as possible to start that clock ticking. And if the surgery commences and then is cancelled, you cannot obtain an admission order unless there is another reason for inpatient admission.
And of course, we have to try to decide if CMS is serious about this. The agency seemed sincere in wanting to ease physician burden with home care face-to-face documentation, but as discussed in a recent RACMonitor.com article by Andrew Wachler and Jessica Forester, CMS was just teasing us. And then there is the fact that it refers to changes to the Medicare Benefit Policy Manual – stating that “CMS is updating Pub. 100-04, Medicare Claims Processing Manual, chapter 4, sections 10.12 and 180.7 to reflect the revised impatient-only payment policy” – but in that same memo, the section excerpts they reference have absolutely no changes.
So, what should hospitals do? For now, nothing. If you have a process to get the order and check medical necessity pre-op, keep it. If you are working to develop one, keep on going. But if you are one of those hospitals that does not want to anger doctors by insisting on a pre-op order and you only get it post-op, your days of looking over your shoulder for an auditor ready to deny every inpatient-only surgery may soon be coming to an end.
About the Author
Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the American Case Management Association and a Fellow of the American College of Physicians.
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