New Inpatient Documentation Regulations
NEW INPATIENT DOCUMENTATION REGULATIONS
CMS IPPS 2013 (Inpatient Prospective Payment System)
As of October 1, 2013, admission regulations will change for hospital care of Medicare patients. Determining patient status (inpatient vs. observation) will be determined by a combination of time (>48hrs vs. <48hrs) AND documentation of medical necessity.
A specific form was not designed to accomplish this new mandate. If the required information is not located together, it should be documented where all of the components can be found in the chart.
The requirements for admission include:
- 1. Physician order stating inpatient or observation
- 2. Estimation of time the patient is expected to remain in the hospital
- 3. Reason for admission (diagnosis must be included)
- 4. Post hospital care plan
- 5. Physician signature
- 6. Date and time
There are 2 distinct policies regarding the 2-midnight rules for admission.
2-midnight benchmark: A physician admits a patient with the expectation that the patient will require care that crosses 2 midnights.
This care would include ALL care provided to the patient while at the hospital, including initial outpatient services (i.e. ER care).
2-midnight presumption: Inpatient care is PRESUMED reasonable and necessary. A patient is actively receiving medical services (i.e. surgical procedures, diagnostic testing).
It is important to understand that admission to the hospital is not determined only by time. There MUST be a medical need for admission AND active care provided. This information must be documented in the medical records to meet both criteria. (Specifically: 2 midnights do not count due to a delay in the timing of care. Combining diagnostic testing and definitive treatment should be performed in the same day).
CLARIFICATION OF SOME QUESTIONS:
When does the time begin?
The time of admission begins when the order is issued.
What if it is unclear if the patient will remain in the hospital greater than 48 hours?
If patient status is unclear at the time of admission, then they should be admitted as observation until it becomes clear that they will require greater than 48 hours to complete care. The order would be changed to inpatient at that time.
Who may write the order for admission?
The order for admission may be written by the attending physician or another physician with knowledge of the case and is authorized by the responsible physician (i.e. residents, fellows). The order MUST be co-signed by the attending/responsible physician BEFORE the patient is discharged.
The order can only be written by a physician with admitting privileges at the hospital (this excludes ED physicians in many institutions). A verbal order may be issued, but MUST be signed by the responsible physician BEFORE the patient is discharged.
Which patients are exempt from this mandate?
Patients that are designated “inpatient only “care are exempt from this regulation. Several diagnoses are considered inpatient only. That means that they could only be provided in a hospital setting. Examples includes: sepsis, respiratory failure, coronary artery bypass grafting (CABG), etc.
Are there circumstances that Medicare will pay for inpatient care despite a less than 48 hour stay?
Yes. There are 4 definite instances that will be covered.
- 1. Patient death
- 2. Patient leaves AMA
- 3. Transfer to another facility
- 4. Patient has an unexpected rapid improvement (must be clearly documented).
The best way to comply with this new mandate is to ensure that documentation is comprehensive. While this may take a few extra minutes, it will ultimately remove question to status. Non-compliance with these rules may lead to refusal for payment to the hospital and/or providers and ultimately our patients.
This is the health care movement as we transition from pay-for-performance to pay-for-value.
The important take home point is that we are already providing excellent care to our patients. The only change that is expected is that we become comprehensive in documenting the care that we are providing.
A formal form to facilitate compliance with this regulation can be found by clicking here.
Stacie Wenk, DO
Director, Utilization Management
St. Mary’s Medical Center