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From the field: Inpatient admission date and time compliance

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This past summer when the first Recovery Audit Contractor (RAC) approved the issue “inpatient admissions without a physician’s inpatient admit order,” it placed an impetus on hospitals to tighten up internal processes to avoid RAC audits and potential recoupments at their facility. Recently, CMS released guidance on hospital inpatient admission decisions, which shows that there is still confusion and room for improvement.

One seemingly prevalent hot-button issue is the date and time for an inpatient/observation admission to an acute-care facility. The admission date and time is determined by the physician’s “admit to inpatient,” order, but sometimes the correct course of action is not so cut and dry.

For example, if a physician makes the decision to “admit to inpatient” at 11 p.m. on January 1, 2011, the inpatient admission date would be 11 p.m. But if the patient is in the emergency room at this time and the order is written at 11 p.m. and the patient is not transferred until midnight, what is the proper time to document?

This is not an uncommon scenario  according to Debbie Mackaman, RHIA, CHCO, regulatory specialist for HCPro, Inc., who suggests that when comes to determining the proper course of action, providers should look toward CMS manuals for guidance, in particular the Medicare Claims Processing Manual, Chapter 3, § 40.2.2.

The manual says that a patient is considered an inpatient upon issuance of a written physician’s order for inpatient care, and if the patient dies/is discharged prior to being assigned and/or occupying a room, the patient is still considered an inpatient on the date of admission and the hospital may charge for room and board, Mackaman says.

“Presumably, this would also mean that if the admission order is written on one date of service, but the patient is not placed in the inpatient bed until the following date, the date of admission for purposes of assessing room and board charges would be the date of the inpatient order for care,” she says.

She continued: “In addition, all orders are required to be timed and dated according to the Medicare Conditions of Participation and The Joint Commission, therefore the date and time of the actual inpatient order is when the patient becomes an inpatient, regardless if the order was written just prior to midnight or where the care is being given.”

In addition, keep in mind that “inpatient” is a status and level of care, and not necessarily a place of service. If the following day is used instead of the actual date like in the above example, other issues may arise and should be considered, according to Mackaman. These include

  • potentially missing the “three-day qualifying stay” for skilled nursing facility admission;
  • reporting actual benefit days for the patient;
  • reporting the actual length-of-stay statistics for the facility;
  • and application of the MS-DRG transfer and post-acute care transfer (PACT) rules.

Hospitals should be cautious about waiting for the patient to be placed in an inpatient bed in a unit instead of using the actual date of the inpatient order, she adds.


  1. CAROL KENDALL says:

    This is an EXCELLENT article. I have been working on this for quite a while. Always helps to have someone else confirm what I have been saying.

    A question…it is my impression that when an inpatient is still in the ED (order written, not transferred to a bed yet) that we should STOP charging for infusions/injections. This assumes that the hospital’s policy is to not charge inpatients for those services. Do you agree? I know we would not be reimbursed for those services for inpatients unless those $$ made the account exceed the cost outlier threshold. The charges would also impact the cost report. Any thoughts re this would be appreciated.

  2. Melanie says:

    Does anyone have any thoughts on this scenario:
    Pt admitted as observation. During the evening pt develops complications that warrant inpatient admission. The inpatient order is not written until the next day. Should the patient be inpatient from time of inpatient criteria or from the time of the order written?

  3. linda hogel says:

    My impression is tha patient is not inpatient until the order is written and you cannot “backdate” the admission to meet the time of the condition but have to use the written order as the guideline.

  4. Thank you Carol! I will pass this information on and try to see if I can locate an answer.

    Jimmy Carroll
    Associate Editor | HCPro

  5. Debbie Mackaman says:

    Let me clarify a few of the questions that have been posted.
    – Once the inpatient order has been written the patient is an inpatient in all aspects, regardless of the location of where the inpatient services are being provided. The hospital should stop billing for services as an outpatient, such as infusions and injections, observation hours, interventions used to determine an E/M level in the ER. All services from the date and time of the order need to be billed according to the hospital’s inpatient criteria. I agree that to continue to add outpatient services/charges after the inpatient order is written potentially could put the hospital into an outlier status.
    – In the scenario where a patient is in OBS, the condition worsens and then inpatient status is ordered, the patient becomes an inpatient at the date and time of the inpatient order. CMS does not support back-dating orders or the inference of orders, regardless of the patient meeting admission criteria hours prior to the order being written.

  6. Samantha says:

    Thanks Debbie

    Where did you find information to support “CMS does not support back-dating orders or the inference of orders, regardless of the patient meeting admission criteria hours prior to the order being written.” We have been having conflict of interest on this subject for some time now and any clarification would be greatly appreciated.

  7. Marlene Allen says:

    I have another question about OBS service. When do you actually start counting OBS hours? Is it as soon as the order is written or is it when you place the patient in an “OBS bed” which could be an hour or more after order is written? The majority of our OBS patients come in thru our ER and this has caused a lot of confusion for us. Also, what time and date do we put on our records as to when OBS starts? It is my understanding that we are now having our Reg Dept put down the time the patient walks into the hospital and I know that can’t be correct. I would appreciate some feedback.