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.