CMS Issues Guidance on Hospital Inpatient Admissions

James Carroll and Ben Amirault, for HealthLeaders Media , January 27, 2011

"Providers should use this article to help educate physicians, case managers, and any other clinical staff involved in the decision to admit process," she says.

In addition, Mackaman says coders and CDI specialists should be aware of the article to help identify potential documentation improvement areas in order to show that the inpatient admission was medically necessary and appropriate for the beneficiary. Auditors and compliance staff should also review the specific manual sections to assure compliance with the regulations.

Medicare Benefit Policy Guidance

In addition to the Program Integrity Manual, CMS points providers to the Medicare Benefit Policy Manual for guidance. Chapter 1, Section 10 states that "an inpatient is a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services," and that the physician or practitioner is responsible for deciding whether that patient should or should not be admitted as an inpatient.

According to the manual, the decision to admit a patient is "a complex medical judgment which can be made only after the physician has considered a number of factors, including medical history, current medical needs, available facilities, hospital by-laws and policies, and appropriateness of treatment in each setting. Additional factors include:

  • The severity of the signs and symptoms exhibited by the patient
  • The medical predictability of something adverse happening to the patient
  • The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinarily require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted
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