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Inpatient Admissions Decision Fuels RAC Uncertainty

James Carroll, for HealthLeaders Media, July 26, 2010

Yet Hale points out that this is not in compliance with CMS. In fact, a CMS representative addressed the issue of rolling back an admit order during an Open Door Forum last fall, stating that: "The hospital cannot "roll back" the time or date of admission. If the inpatient stay began with the physician's order at 8:00 a.m. on Tuesday and the patient was admitted directly from observation, the observation charges are included on the inpatient bill. Since the observation is included on the inpatient bill and paid as part of the DRG, there is no separate payment for observation."

Providers receiving inaccurate or contrary information should contact their MAC in writing, and cite the appropriate references from CMS, the Benefit Policy Manual, or the Claims Processing Manual, and ask why their instruction is contradictory to CMS. "This will at least call for some accountability," said Hale.

"The number one thing I would say to providers is to be sure that you've got a properly worded order for admission, and number two, be sure that you're not rolling the date of admission back" she said.

"Also, be sure to have an internal process set up for looking at [the] presence of a properly worded admission order and documented medical necessity of admission from the beginning of the stay, not just based on screening criteria, but also physician advisor review, if screening criteria are not met," Hale said.


James Carroll is associate editor for the HCPro Revenue Cycle Institute.

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