Tag Archives: IP admission

I keep seeing articles and speakers give the advice to “Appeal, Appeal, Appeal“, even to Medicare beneficiaries, who are getting hit with co-pay bills for outpatient services, when they feel that an admission should have been considered an inpatient admission. … Continue reading →

For weeks now, we’ve all been talking about the “changes” and “new” challenges being presented to us by the newest ruling from The Secretary, CMS-1599, the 2014 IPPS Final Rule. The topics of most interest have concerned the “new benchmark” — the moving of the threshold, used for decades by physicians to judge if an inpatient admission could be considered a “reasonable and necessary” step. Before October 1, 2013, the benchmark was “24 hours” — sort of. Ok, actually it was more like “overnight.” But no matter. The idea was, is the patient sick enough to need to stay overnight in the hospital?

Anyway. You know all that or you probably wouldn’t be reading this blog. But the fuss is all about the fact that the Secretary has added language to the regulations that make

(a) physician orders a clear and specific requirement for payment of Medicare claims,

(b) a 24-hour period to qualify as appropriate for inpatient billing must include at least 2 Midnights (which actually makes it 25-hours, but who’s counting), and

(c) a very specific set of statements, called a “certification,” which must all be present somewhere in the medical record and signed by a specific subset of practitioners.

So the question is, is any of this new? The answer is this: Some is new, some is not, the language is certainly new. The need for a physician order is not really new, but the language in the reg is new. the need for “24-hours” is not new, but one can argue that, and the second midnight being included is certainly new. What about the certification? Well, that’s kind of new and kind of not. Yes, it’s kind of always been there, but then all this new language is new, and certainly the requirement for payment is both surprising and maddening, especially considering the “specific subset” of practitioners who will be acceptable signatories is new.

Next question: Why did CMS add this new language? Continue reading →