CMS Issues Guidance on Hospital Inpatient Admissions

James Carroll and Ben Amirault, for HealthLeaders Media, January 27, 2011

Medical necessity determinations are not just a hot button issue with Recovery Audit Contractors RACs, but also with the other 'usual suspect' government auditors: Medicare administrative contractors (MACs), fiscal intermediaries (FIs), and comprehensive error rate testing (CERT) contractors. So much, in fact, that CMS has released educational guidance to assist hospitals regarding inpatient admission decisions.

While many hospitals may in fact be utilizing proper screening criteria to analyze documentation and make medical necessity determinations, the fact remains that it's an imperfect endeavor. And while Interqual and Milliman, as well as other additional systems, may assist facilities in specific jurisdictions, CMS has issued a special edition MLN Matters article that points providers toward its own manualsfor guidance.

In the Program Integrity Manual, CMS states that contractor review staff are required to use a screening tool as part of their medical review process for inpatient claims, but it does not require that the contractor use specific criteria nor endorse any particular brand of guidelines. In addition, "CMS contractors are not required to pay a claim even if screening criteria indicate inpatient admission is appropriate. Conversely, CMS contractors are not required to automatically deny a claim that does not meet admission guidelines of a screening tool."

Most imperative, however, is the part of the manual that states, "In all cases, in addition to screening instruments, the reviewer shall apply his/her own clinical judgment to make a medical review determination based on the documentation in the medical record." According to CMS, for every case, review staff is to utilize the following when making a medical necessity determination:

  • Admission criteria
  • Invasive procedure criteria
  • CMS coverage guidelines
  • Published CMS criteria
  • Other screens, criteria, and guidelines (e.g.; practice guidelines that are well accepted by the medical community).

In addition to providing general guidance to providers regarding medical necessity determinations, this release also places an emphasis on the responsibilities of certain professionals within the hospital setting, according to Debbie Mackaman, RHIA, CHCO,regulatory specialist for HCPro, Inc.


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