Change to the inpatient admission order considered to be major. Late last week, the Centers for Medicare & Medicaid Services (CMS) released the Inpatient Prospective Payment System Final Rule, which becomes effective on Oct. 1. It’s 2,593 pages, so get reading. I have to commend the CMS staff for their…
Recoupment and one-day inpatient admission for total knee replacement. EDITOR’S NOTE: The following is a summary of a broadcast segment on Monitor Monday, May 7 by the author. While we are still trying to make sense of what the Centers for Medicare & Medicaid Services (CMS) meant with its proposal…
Not all P2Ps should be pursued. In my reporting a few weeks ago, I encouraged physician advisors and other leaders in case management to analyze the outcomes of their peer-to-peers (P2Ps). As a reminder, P2P conversations revolve around the appropriateness of Inpatient status and take place between the medical director…
An analysis of your peer-to-peer process might lead to your abandoning the program. The peer-to-peer (P2P) process is a particularly abhorrent chore for physicians. These phone conversations are generally offered by commercial and managed insurance plans when their clinical case manager or medical director does not feel that inpatient status…
CMS requires that all total knee replacements performed on fee-for-service Medicare beneficiaries are performed in a hospital.  AUTHOR’S NOTE: Since the release of the 2018 Outpatient Prospective Payment System (OPPS) Final Rule, there have been many varying opinions on how to determine the proper status for patients undergoing total knee…
Will CMS address the “absurdity” embedded in the rules of outpatient coding? Every once in a while, something comes to my attention that I choose not to discuss in public. Over a year ago, I was asked about physician billing for observation services. When a patient is hospitalized, the physician…
Treating a heart attack as outpatient may sound ludicrous, but for some hospitals it may be the right choice. The two-midnight rule threw the hospital utilization review community into turmoil when it was implemented on Oct. 1, 2013. In brief, that rule mandates that the decision of whether to enact…
Changes in reimbursement policies, laws, and regulatory oversight are forcing healthcare organizations to respond to increased regulatory scrutiny and audits. Medicare audits have increased 936 percent in the last five years alone, according to Becker’s Hospital CFO, and ad hoc inpatient audits are no longer enough of a defensive strategy.…
As I discussed in my RACmonitor article published last week, the Centers for Medicare & Medicaid Services (CMS) has left the mechanics of the two-midnight rule intact in its proposed Inpatient Prospective Payment System (IPPS) rule for 2018. That means that for at least another year, we will have to…