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Proposed rule solicits comments on closing the health equity gap. The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule for Inpatient Rehabilitation Facilities (IRFs) that would update payment policies for FY 2022, update IRF Quality Reporting Program (QRP) requirements for FY 2022, address Public Reporting of Quality…
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The data may allow you to better understand the intricacies of hospital payments. When I teach Medicare regulations to physician advisors, case managers, and utilization review professionals, it is always interesting to see the reactions when I explain how Medicare calculates how much to pay for an inpatient admission. Most…
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Direct verbal communication between referring and consulting physicians is the best practice. Communicating in the chart, while convenient and useful, rarely provides the most accurate and complete information. The same is true for internal physician advisors – the internal physician advisor is essentially a consultant to the medical staff, providing…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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