1. 2015 Inpatient Prospective Payment Services (IPPS) and Insights on Best Practices
Ralph Wuebker, MD, MBA Chief Medical Officer Executive Health Resources

2. Agenda 2014/2015 IPPS Final Rule 2015 proposed OPPS
Transmittal 534/540/541
Appeals Settlement offer
Rebilling
Understand best practices for operating under 2015 IPPS

3. Final IPPS 2015
AKA CMS 1607-F (Published in Federal Register on August 22, 2014)
Calculation of payments. The rule includes a 2.9 percent market basket update, offset by a negative 0.5 percent productivity adjustment and a negative 0.2 percent market basket cut as mandated by the Patient Protection and Affordable Care Act, and a negative 0.8 percent decrease in accordance with the American Taxpayer Relief Act of
Hospital readmission reduction program. CMS has increased the maximum penalty from 2 percent to 3 percent.
Hospital-acquired condition reduction program. Hospitals in the lowest quartile, will have their Medicare pay decreased by 1 percent.
Price transparency. Under the final rule, hospitals are required to make public a list of their standard charges or provide their policies for allowing the public to view a list of those charges in response to an inquiry.
Hospital value-based purchasing program. For 2015, CMS is increasing the applicable percent reduction, the portion of Medicare payments available to fund the value-based incentive payments under the program, to 1.5 percent of Medicare reimbursements, resulting in about $1.4 billion in value-based incentives.
Medicare disproportionate share hospitals payments. As part of the PPACA, Medicare DSH payments will be reduced 75 percent by 2019, or $49.9 billion. The final rule cuts overall Medicare DSH payments by 1.3 percent in fiscal year 2015, compared with fiscal year 2014.

4. Final IPPS 2015 Two Midnight rule remains intact Little to no changes
Pages – pertain to the 2 midnight rule
Several comments regarding defining short or low cost inpatient hospital stays
No additional clinical exceptions added. However, still taking feedback: to:
Although the FY 2015 IPPS/LTCH PPS proposed rule did not include any proposed regulatory changes relating to the 2-midnight benchmark, we nonetheless received a number of public comments regarding the current regulation. 
CAH: finalize a policy that a CAH is required to complete all physician certification requirements no later than 1 day before the date on which the claim for the inpatient service is submitted (pg )

5. Comments found on www.regulations.gov
2015 Proposed OPPS
CMS 1613-P
The 2015 Outpatient Prospective Payment System (OPPS) Proposed Rule was released on July 13, 2014
Comments found on
Highlights include:
Refinements to Comprehensive APC Policy
Significant Packaging of Ancillary Services
Changes to Inpatient Certification Requirements

6. The Proposed Rule and Elements of Certification
Documentation is Key:
There is an expectation that the elements of certification (i.e. the reason for hospitalization, the estimated time the patient will need to remain in the hospital, and the plan of post-hospital care), generally can be satisfied by elements routinely found in a patient’s medical record, such as progress notes (CMS-1613-P at 41057).
“[I]n most cases, the admission order, medical record, and progress notes will contain sufficient information to support the medical necessity of an inpatient admission without a separate requirement of an additional, formal, physician certification” (CMS-1613-P at 41057).
“[W]e believe that evidence of additional review and documentation by a treating physician beyond the admission order is necessary to substantiate the continued medical necessity of long or costly inpatient stays” (CMS-1613-P at 41057).

7. Proposed Changes to Physician Certification Requirements
A separately signed Physician Certification statement would no longer be required to be submitted with each and every Inpatient Hospital claim.
Only required for long-stay (20 days or more) and outlier cases
The Inpatient Admission Order will continue to be required as a condition of payment, but is no longer considered an element of certification.

8. Proposed Changes to Physician Certification Requirements
REMINDER, the 2015 OPPS Proposed Rules if finalized as written, would not take effect, until the implementation date of January 1, Until that time, providers should continue to adhere to current guidelines and regulations pertaining to the Two-Midnight Rule and Physician Certification Requirements

9. “Doc Fix” – HR 4302 Extension of the Probe & Educate
CMS has extended the Inpatient Hospital Prepayment Review “Probe & Educate” review process through March 2015. This means that:
Medicare Administrative Contractors (MACs) will continue to select claims for review and deny claims found not in compliance with CMS-1599-F (commonly known as the “2-Midnight Rule”).
MACs will continue to hold educational sessions with hospitals as described below in “Selecting Hospitals for Review” through March, 2015.
Generally, Recovery Auditors will not conduct post-payment patient status reviews of inpatient hospital claims with dates of admission on or after October 1, 2013 through March  

10. Probe & Educate Process
Number of claims in sample that did NOT comply with policy (Dates of admission October–March 2014)
No or minor concern
Moderate to significant concerns
Major concerns
10 Claim Sample
0–1
2–6
7 or more
25 Claim Sample
0–2
3–13
14 or more
Action
Deny non-compliant claims
Send results letters explaining each denial
No more reviews will be conducted under Probe & Educate Process
Deny non-compliant claims
Offer 1:1 Phone Call
REPEAT Probe & Educate process with 10 or 25 claims
Repeat Probe & Educate
If problems continue, repeat P&E with increased claim volume of 100–250.

11. Probe & Educate Status Update
As of February 7, 2014:
As of February 24, 2014:
CMS is requesting that the Medicare Administrative Contractors (MACs) re-review all claim denials under the Probe & Educate process to ensure the claim decision and subsequent education is consistent with the most recent clarifications.
# of medical records requested
# of medical records received
# of medical records with MAC reviews completed
29,158
18,110
6,012
Number of denials: ?????
Published data – NGS 30–75% denied
Source:

12. Examples
Example 3 - Short stays for medical conditions: The beneficiary presented to the ED with recent onset of dizziness and denied any additional complaints. The beneficiary reported a recent adjustment to his blood pressure medication. The physician’s notes stated that the beneficiary was stable and that his blood pressure medication was to be held and dosage adjusted. The notes also indicated that the physician intended to observe the beneficiary overnight. The beneficiary was discharged the next day. The hospital submitted a claim for a 1-day inpatient stay. Upon review of the claim, the MAC denied Medicare Part A payment because the medical record failed to support an expectation of a 2-midnight stay.

13. Examples
Example 4 - Physician attestation statements without supporting medical record documentation: The physician’s order contained a checkbox with pre-printed text stating “The beneficiary is expected to require 2 or more midnights of hospital care.” The physician’s plan of care, however, stated that the beneficiary was to have diagnostics performed post-operatively, with a plan to discharge in the morning if stable. The beneficiary was discharged the following day as planned, after a 1-midnight stay. Upon review of the claim, the MAC denied Medicare Part A payment because the medical record failed to support an expectation of a 2-midnight stay when the order was written.
CMS reminds providers that attestation statements indicating the beneficiary’s hospital stay is “expected to span 2 or more midnights” are not required under the inpatient admissions policy, nor are they adequate by themselves to support the expectation of a 2-midnight stay. Rather, the expectation must be supported by the entirety of the medical record.

14. Transmittal 541, CR 8802
Earlier versions of Transmittal 541 have previously been introduced as Transmittals 505, 534 and 540; however those versions were rescinded.
Issued on September 12, 2014, but Implemented and Effective on September 8, 2014 (date of service)
Provided the MAC, Recovery Auditor, and ZPIC the discretion to deny other related claims submitted before or after the claim in question.
The Recovery Auditors will be allowed to also auto deny if approved by the New Issues Review Board.
CHANGE FROM Transmittal Allowed as one approved example: now only a surgeon’s claim could be automatically denied, but NOT recoded to an appropriate outpatient evaluation and management service following the denial of a hospital’s inpatient admission.
CHANGE FROM Transmittal 540 – Paragraph in Policy section was changed to be consistent with paragraph in Manual, with respect to the surgeon’s claim as outlined above.
Source:

15. The CMS Administrative Agreement

16. Appeals Backlog
The average processing time for appeals decided in fiscal year 2014 is days.
For comparison, the average processing time for a case in 2009 was 94.9 days.
There are currently 480,000 appeals awaiting assignment to an ALJ
In early 2014, OMHA received 15,000 appeal requests per week, up from 1250 appeals per week 2 years ago.
OMHA received a total of 320,000 claims in FY 2012, and over 600,000 claims in FY 2013.
OMHA is currently anticipating the backlog to grow to 1,000,000 appeals by end of FY 2014.
OMHA projects that its FY 2015 caseload will increase to approximately 850,000 total claims.
Processing backlogs
15 weeks from receipt to open mail (though mail is stamped received as of the date it was physically received, not the date it is opened)
20-24 weeks from the date mail is received until it is entered into OMHA’s database (this is the point at which the case becomes searchable in response to inquiries)
Up to 28 months from receipt until case is assigned to a judge
6 months for a hearing date after a case is assigned to a judge
Source:

17. OMHA Statistical Sampling
In July, 2014, OMHA announced pilot programs to address the high-volume backlog at the Administrative Law Judge level of appeal.
What is OMHA Statistical Sampling?:
A statistical expert develops an appropriate sampling methodology in accordance with Medicare guidelines
Sample units are then randomly selected from a universe of claims based on that methodology
An Administrative Law Judge then reviews the sample units and makes findings and a decision on those sample units in a single appeal
The results of the sample are then extrapolated to the entire universe
Source: (last visited September 10, 2014)

18. OMHA Statistical Sampling
To be eligible for OMHA statistical sampling:
A request for hearing must appeal a Medicare Qualified Independent Contractor (QIC) reconsideration decision.
The appellant must be a single Medicare provider or supplier.
All jurisdictional requirements for a hearing before an Administrative Law Judge must be met for the request for hearing and all appealed claims.
The claims must be currently assigned to one or more Administrative Law Judges or have been filed during the time period currently being assigned by OMHA Central Operations – at this time, that includes appeals that were filed between April 1, 2013, and June 30, 2013.
No hearing on the claim has been scheduled or conducted.
There must be a minimum of 250 claims and all claims must fall into only one of the following categories:
Pre-payment claim denials;
Post-payment (overpayment) non-Recovery Audit Contractor (RAC) claim denials; or
Post-payment (overpayment) RAC claim denials from one RAC.
Source: (last visited September 10, 2014)

19. Administrative Agreement
CMS is offering an Administrative Agreement (Settlement) to:
Any acute care hospital
Those paid via Prospective Payment System (PPS), Periodic Interim Payments (PIP), and Maryland waiver
Critical access hospital (CAH)
Willing to resolve their pending appeals (or waive their right to request an appeal)
In exchange for timely partial payment (68% of the net payable amount).
Source:

20. Cannot Pick & Choose Claims
Eligible Claims
Claims meeting all of the criteria are eligible and ALL eligible claims must be included in the request for Administrative Agreement.
Cannot Pick & Choose Claims
Eligible claims must be included in a spreadsheet that the hospital is required to complete and submitted along with the Administrative Agreement request.

21. Eligible Claims (con’t)
The claim was denied by any entity that conducted a review on behalf of CMS;
The claim was not for items or services furnished to a Medicare Part C enrollee;
The claim was denied based upon a Patient Status Determination - The claim was denied based on an inappropriate setting determination, that is, on the basis that the service might have been reasonable and necessary, but treatment on an inpatient basis was not;
The first day of the admission was before October 1, 2013;
The Hospital timely appealed the denial;
As of the date of an executed Agreement submitted to CMS by the Hospital:
The appeal decision was still pending at the MAC, QIC, ALJ, or DAB levels of review, or
The Hospital had not yet exhausted its appeal rights at the MAC, QIC, ALJ, or DAB level; and
The Hospital did not receive payment for the service as a Part B claim (re-bill).
Source:

22. Payment by CMS
CMS agrees to pay the Hospital sixty-eight (68) percent (‘the percentage”) of the net paid amount of each denied inpatient claim.
“Net paid amount” means the payment on the original inpatient claim net paid amount;
Net Paid amount excludes the out-of-pocket obligations that are included in the “gross” or “allowable” amounts.
This payment will be made in one payment per hospital provider number, or per owner or operator of multiple settling hospitals.
CMS will refund to the Hospital all interest on any claim included in any appeal covered by the Agreement that CMS has collected from the Hospital as of the effective date of the Agreement
If CMS fails to make payment within the allotted sixty (60) days, CMS will pay interest to the Hospital for the period beginning on day sixty-one (61) through the date of payment.
The interest rate shall be the Current Value of Funds Rate (“CVFR”) as promulgated by the United States Department of the Treasury.
Source:

23. Miscellaneous Provisions
If the Hospital has not fully repaid the originally denied amount on a claim included in an appeal listed on the spreadsheet of eligible claims, the Hospital will receive for that claim payment the percentage value applied less the outstanding overpayment balance.
If the Hospital has not yet repaid any of the originally denied amounts on a claim included in an appeal, or where the amount retained by the Hospital exceeds sixty-eight (68) percent of the net paid amount, the Hospital will owe CMS a refund for that claim.
CMS will calculate the refund amount as the difference between the retained amount and sixty-eight (68) percent of the net paid amount.
Any refund owed CMS will be subtracted from the total payment due under this Agreement or from future Medicare payments to the Hospital.
Source: Review/Downloads/AdminstrativeAgreement.pdf

24. Miscellaneous Provisions
The Hospital agrees it will not commence any further appeals or actions of any kind challenging the Medicare contractor’s determination(s) regarding the claims included in the appeals
The Hospital will not attempt to rebill any of those services under Part B.
CMS retains the right to recoup any duplicate or incorrect payments made for claims that were, but should not have been, included under this Agreement
Payments that may have been made in the appeals process or secondary to Part B billing inadvertently included among the payment made under this Agreement.
The Agreement does not include a release of liability of any claims the United States may have under the False Claims Act, (31 U.S.C. section 3729 et seq.), the Civil Monetary Penalties Law, (42 U.S.C. section 1320a-7a), or the common law theories of payment by mistake, unjust enrichment, or fraud.
Source:

25. CMS Settlement Process
Basic Settlement Process:
Decision must be made and process started Oct 31, 2014
Provider submits eligible claims spreadsheet
CMS reviews and provides feedback allowing provider time to abandon/proceed with settlement
Medicare signs initial Administrative Agreement and pays provider for those claims agreed upon
A repeat of the process occurs with respect to any discrepancies concerning the eligibility of claims
CMS employs a final reconciliation process and makes additional adjustments as warranted
Continue to check the CMS website for updates…

26. Patient Deductible Responsibilities
The providers refund responsibility is as follows:
If the Beneficiary co-insurance has been collected at the time the INITIAL administrative agreement is signed by the provider, no refund is required.
b. If the Beneficiary co-insurance has not been collected at the time the INITIAL Administrative Agreement is signed by the provider, the provider must cease collections.
c. If a Beneficiary repayment plan has been executed at the time the INITIAL Administrative Agreement is signed by the provider, the provider may continue to collect the co-insurance in accordance with the repayment plan.
Source:

27. Every Hospital Should be Asking These Questions…
Key Considerations
Every Hospital Should be Asking These Questions…
Is my hospital an eligible facility?
How do I determine which claims are eligible?
How many eligible claims do I have?
What is the total value of the eligible claims?
What is the value of those claims if I rebill under Part B?
What is the administrative burden to engage in the settlement?
How long have my appeals been in the appeals process?
What has been my appeals success rate?

28. Every Hospital Should be Asking These Questions…
Key Considerations
Every Hospital Should be Asking These Questions…
What is my hospital’s financial situation with respect to the settlement?
How much reserve did we assign to denied claims (i.e., was it more or less than 68%)?
What is the impact of denied days on the calculation of GME, IME, and DSH payments?
What percent, if any, of the patient deductible has been paid?

29. Finally No right answer for every hospital
Every hospital should evaluate the offer
Expect some facilities will accept the offer and others will reject the offer

30. Rebilling
If a case has a physician inpatient order, yet fails “expectation 2 midnight stay” or medical necessity:
If patient is still in the hospital, hospital may use Condition Code 44 to reclassify patient as in the past
If patient has been discharged, hospital may use Self Audit/Rebilling if within timely filing requirements
Rebilling:
Submit provider-liable Part A claim
Summit an inpatient claim for payment under Part B and outpatient claim for Part B appropriate services
Status does not change – remains IP
Beneficiary responsible for Part B copayments

31. Rebilling Evolution Prior to new rulings Interim 1455 CMS final rule
Self-auditing
Bill Part B Ancillaries only. Subject to limitations of CC 44
Allows providers to rebill only for claims denied by a Medicare contractor
Allows providers to rebill inpatient Part A claims denied as a result of a “self-audit”
Part B rebilling
Only allowed if Judge determined appropriate. No regulations
Rebilling of covered Part B charges when the Part A claim is denied as not medically reasonable and necessary
Part B rebilling to claims for services rendered to beneficiaries enrolled in Medicare Part B
Timeliness for rebilling
Only if within timely filing (one year) or Judge orders (no time limit)
Allows for rebilling 180 days from denial or lost appeal with date of service before Sept. 30, 2013
Standard timely filing requirements (1 year from the date of service) on rebilled claims with an admission date after October 1, 2013.
Impact to beneficiary
To be held harmless
Upon rebilling, requires hospital to adjust beneficiary billing

32. Does Rebilling Make Cents?
Where are you most likely to miss revenue in the UR process?
Without concurrent reviews hospitals risk losing dollars on observation/outpatient cases!
Consider:
INPT DRG
> CC44 with 8 hours obs (APC)
> CC 44 with less than 8 hours of obs (No APC)
> Post discharge rebill 12x
> Claimed denied after 1 year

33. Best Practices to Comply with Current IPPS

34. Conditions of Participations Have Not Changed
Conditions of Participations (CoPs) must be followed
“We did not propose and are not finalizing a policy that would allow hospitals to bill Part B following an inpatient reasonable and necessary self-audit determination that does not conform to the requirements for utilization review under the CoPs.”
Page 50913, 2014 IPPS
(c)(1) The UR plan must provide for review for Medicare and Medicaid patients with respect to the medical necessity of:
Admissions to the institution
Duration of stays
Professional services furnished, including drugs and biologicals

35. Concurrent UM Still Matters
“Use of Condition Code 44 or Part B inpatient billing pursuant to hospital self-audit is not intended to serve as a substitute for adequate staffing of utilization management personnel or for continued education of physicians and hospital staff about each hospital’s existing policies and admission protocols.”
Page 50914, 2014 IPPS

36. Components Required for an IP Claim
Expectation/completion of a 2-midnight stay
UR review must ensure expectation of 2 midnights is “reasonable”
Medical Necessity
UR review must establish hospital level of care is needed to care for the patient
Physician certification/documentation signed by the physician prior to DC
Order, reason for inpatient services, expectation and plan for post-hospital care

37. What is Medical Necessity?
Is the physician's expectation of 2 midnights reasonable?
Achieved with criteria? PA evidence based determination? Other?
Is hospital level of care needed to care for the patient?
Ensure no care for convenience, no delays in treatment/testing or custodial

38. Admission Review – Key Considerations
Initial review for expectation of Length of Stay (LOS)
Physician documentation of an expectation of 2-midnight stay generally falls into three categories:
Supports expectation of 2-midnight stay
“I expect this patient to remain in the hospital for longer than…”
Expected LOS > 2 midnights (in document signed by physician)
No documentation/conflicting documentation
Clearly conflicts with or fails to support expectation of 2-midnight stay
Order – “Discharge in am” (when care has not already crossed at least one midnight)
Progress note – “anticipate d/c in am” (when care has not already crossed at least one midnight)

39. Recommended Hospital Work Flow
Expected LOS greater than 2 midnights or unclear
Yes
Validate or obtain order change
Review elements of certification
Patient presents at hospital*
Inpatient criteria met
Inpatient recommendation
Validate or obtain order change
Review elements of certification
Physician Advisor Review No
Observation/
Outpatient
recommendation
Validate or obtain order change
Re-review as new information is available
Follow this process when:
Physician documentation of expected discharge is greater than 2 midnights; or
There is no documentation of expected discharge
* Patient hospitalized for condition other than Inpatient Only Procedure List

40. Recommended Hospital Work Flow
Expected LOS less than 2 midnights
No +
Expectation correct?
Yes
Resolve conflict between order and expectation
Yes
Condition Code 44
Obtain order change
Patient presents at Hospital*
IP order?
Yes/
observation
Observation criteria met? No
Re-review as new information is available
No/
obtain order change
Follow this process when:
Physician documentation of expected discharge is less than 2 midnights
* Patient hospitalized for condition other than Inpatient Only Procedure List.
+If the expectation is not correct, follow the workflow for an expected length of stay of greater than two midnights.

41. Considerations Regarding the Time of UR Review
Review at admission: IP
2+ midnight expectation AND medical necessity established AND physician certification complete
Observation/Outpatient
Expectation of <2 midnight stay and medical necessity established
NOTA
Review for documentation of care for convenience, a delay in treatment/testing or custodial care
Review after 1+ midnight:
2+ midnights completed or expected AND medical necessity established AND physician certification complete
Observation status should be rare after 2 midnights
Review for documentation of care for convenience, a delay in treatment/testing or custodial care

42. Summary
“Get It Right” while the patient is in the hospital and as early in the stay as possible
Implications for hospital, patient and physician
Admission review – key considerations:
Order
Expectation
Medical Necessity
Documentation and Certification
Rebill when appropriate
While the time requirement has evolved, the science at the core of medical necessity remains the same

43. Questions? Ralph Wuebker, MD, MBA Chief Medical Officer
Executive Health Resources

44. 2 Midnight Example 1 Symptoms: Order Expectation of LOS
80 year old female admitted with chest pain, positive biomarkers and EKG changes in the emergency room, urgently taken to catheterization lab
Order
Admit as inpatient
Expectation of LOS
“I expect this patient to remain in the hospital for a time greater than 2 midnights”
Medical Necessity
Documentation present to support inpatient admission
Certification
All elements of certification present per document review
Follow up necessary
Patient does not remain for 2 MN
Was (presumption not met) due to: death, transfer, AMA, inpatient-only procedure or “recovery faster than anticipated”?
Evaluate based on start of service to see if benchmark met

45. 2 Midnight Example 2 Symptoms: Order Expectation of LOS
65 year old male, no previous cardiac history, presents with shoulder pain after exertion, physician suspects musculoskeletal, biomarkers below detection threshold, no EKG changes. Monitor overnight if telemetry, enzymes and EKG’s remain negative, anticipate discharge in am. No planned stress test or further evaluation
during hospitalization.
Order
Admit as inpatient
Expectation of LOS
23 hour monitoring
Medical Necessity
Documentation does not support inpatient admission – observation
Certification
Order and physician expectation of 2 midnights are in conflict
Order and medical necessity are in conflict
Follow up necessary
Consider Condition Code 44 if requirements are met
If patient remains in hospital or new information available, re-review for medical necessity at inpatient level
If patient discharged – cannot do Condition Code 44, if within rebilling timeframe, consider for Part B rebilling

46. 2 Midnight Example 3 Symptoms: Order Expectation of LOS
78 year old female admitted for atrial flutter, stabilized in Emergency Room. Although expected to be discharged after medication adjustments, patient developed heart block requiring additional adjustments and possible pacemaker
Order
Place in observation
Expectation of LOS
Anticipate short stay, 23 hour monitoring
Medical Necessity
Delayed review suggests that inpatient may be appropriate
Certification
All elements of certification would need to be completed prior to discharge
Follow up necessary
EHR would recommend inpatient level of service
Call with physician to discuss medical necessity in light of order change requirement
Call with case manager to discuss order change and expectation documentation with regard to certification requirements
Inpatient order, documentation of expectation and all other elements of certification would need to be addressed prior to discharge

47. 2 Midnight Example 4 Symptoms: Order Expectation of LOS
76 year old woman with UTI, treated with intravenous antibiotics. Fevers continue with tachycardia and hypotension requiring fluid support. Immunosuppressed due to post kidney transplant status.
Order
Admit for inpatient services
Expectation of LOS
Admission orders include order for “discharge in am”
Medical Necessity
Would meet for inpatient by criteria, but documentation clearly violates 2 midnight expectation
Certification
Depending on follow-up activity, if inpatient supported confirm all elements of certification prior to discharge
Follow up necessary
Although historically inpatient medical necessity would be met, the documentation does not support 2 MN expectation
Resolve conflict between order/medical necessity and expectation
Update documentation if patient not discharged as planned
Consider Condition Code 44 if expectation of discharge remains

48. 2 Midnight Example 5 Symptoms: Order Expectation of LOS
68 year old male, with a history of stroke, known carotid stenosis, and previous neck irradiation making carotid end-arterectomy high risk. Patient scheduled for carotid angiography and stent placement. .
Order
Observation
Expectation of LOS
Less than 2 midnights
Medical Necessity
Procedure appropriate for inpatient based on inpatient-only status
Certification
All elements of certification except the 2 MN expectation would be required to be documented prior to discharge to support inpatient claim
Follow up necessary
Order should be corrected for procedure on CMS inpatient-only procedure list
For procedures on the inpatient-only list, order must be present on the medical record prior to the initiation of the procedure
Inpatient-only procedures are exempted from the 2 midnight expectation, but all other certification requirements remain

49. About Executive Health Resources
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AHA Solutions, Inc., a subsidiary of the American Hospital Association, is compensated for the use of the AHA marks and for its assistance in marketing endorsed products and services. By agreement, pricing of endorsed products and services may not be increased by the providers to reflect fees paid to the AHA.
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