Home Town Health RAC Updates June 8, 2016

Agenda Admissions The Order Admission Expectations Title 42-> Chapter IV -> Subchapter B -> Part 412 ->Subpart A -> Section 412.4 e-CFR data is current as of May 25, 2016 The Order Admission Expectations Less Than 2 Midnights Inpatient Only Admission RAC Update (a) For purposes of payment under Medicare Part A, an individual is considered an inpatient of a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner in accordance with this section and §§482.24(c), 482.12(c), and 485.638(a)(4)(iii) of this chapter for a critical access hospital. This physician order must be present in the medical record and be supported by the physician admission and progress notes, in order for the hospital to be paid for hospital inpatient services under Medicare Part A. In addition to these physician orders, inpatient rehabilitation facilities also must adhere to the admission requirements specified in §412.622 of this chapter.

Admissions An individual is considered an IP if Formally admitted as an IP By a physician or other qualified practitioner Physician order be present in the medical record & supported by the physician admission and progress notes

The Order The order: Must be furnished by a qualified and licensed practitioner who has admitting privileges at the hospital, who Is knowledgeable about the patient's Hospital course Medical plan of care, and Current condition Must be furnished at or before the time of the inpatient admission The practitioner may not delegate the decision (order) to Another individual who is not authorized by the State to admit patients, or Has not been granted admitting privileges applicable to that patient by the hospital's medical staff (b) The order must be furnished by a qualified and licensed practitioner who has admitting privileges at the hospital as permitted by State law, and who is knowledgeable about the patient's hospital course, medical plan of care, and current condition. The practitioner may not delegate the decision (order) to another individual who is not authorized by the State to admit patients, or has not been granted admitting privileges applicable to that patient by the hospital's medical staff. (c) The physician order must be furnished at or before the time of the inpatient admission.

Admission Expectations An IP admission is generally appropriate for payment under Medicare Part A when the admitting physician expects the patient to require hospital care that crosses two midnights The expectation of the physician should be based on such complex medical factors as Patient history and comorbidities The severity of signs and symptoms Current medical needs, and The risk of an adverse event The factors that lead to a particular clinical expectation must be documented in the medical record in order to be granted consideration (d)(1) Except as specified in paragraphs (d)(2) and (3) of this section, an inpatient admission is generally appropriate for payment under Medicare Part A when the admitting physician expects the patient to require hospital care that crosses two midnights. The expectation of the physician should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event. The factors that lead to a particular clinical expectation must be documented in the medical record in order to be granted consideration.

Less Than 2 Midnights If an unforeseen circumstance, such as a beneficiary's death or transfer, results in a shorter beneficiary stay than the physician's expectation of at least 2 midnights, the patient may be considered to be appropriately treated on an inpatient basis, and payment for an inpatient hospital stay may be made under Medicare Part A 2 (ii) If an unforeseen circumstance, such as a beneficiary's death or transfer, results in a shorter beneficiary stay than the physician's expectation of at least 2 midnights, the patient may be considered to be appropriately treated on an inpatient basis, and payment for an inpatient hospital stay may be made under Medicare Part A.

Less Than 2 Midnights Where the admitting physician expects a patient to require hospital care for only a limited period of time that does not cross 2 midnights An inpatient admission may be appropriate for payment under Medicare Part A based on The clinical judgment of the admitting physician, and The medical record support for that determination The physician's decision should be based on such complex medical factors as Patient history and comorbidities The severity of signs and symptoms Current medical needs, and The risk of an adverse event. In these cases, the factors that lead to the decision to admit the patient as an inpatient must be supported by the medical record in order to be granted consideration 2 (3) Where the admitting physician expects a patient to require hospital care for only a limited period of time that does not cross 2 midnights, an inpatient admission may be appropriate for payment under Medicare Part A based on the clinical judgment of the admitting physician and medical record support for that determination. The physician's decision should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event. In these cases, the factors that lead to the decision to admit the patient as an inpatient must be supported by the medical record in order to be granted consideration. [78 FR 50965, Aug. 19, 2013, as amended at 79 FR 67030, Nov. 10, 2014; 80 FR 70602, Nov. 13, 2015]

Inpatient Only Admission An inpatient admission for a surgical procedure specified by Medicare as inpatient only is generally appropriate for payment under Medicare Part A, regardless of the expected duration of care

RAC Update June 2, 2016 - Recovery Auditor Contracting Update CMS is in an active procurement process for the next round of Medicare Fee-for-Service Recovery Audit Program contracts. In anticipation of this contract transition, CMS must ensure that the current Recovery Auditors complete all outstanding claim reviews by the conclusion of the active recovery auditing phase of their current contracts. Providers should note the important dates below: May 16, 2016 - the last day that a Recovery Auditor could send Additional Documentation Request (ADR) letters or semi-automated notification letters July 29, 2016 - the last day that a Recovery Auditor may send notification of an improper payment to providers. This includes sending a review results letter or no findings letter, and/or providing a portal notification to each provider.

RAC Update August 28, 2016 - Recovery Auditors will complete all discussion periods that are in process by this date. Recovery Auditors continue to be required to hold claims for 30 days, starting with the date of the improper payment notification (via letter or portal) to the provider, to allow for discussion period requests. October 1, 2016 - the last day a Recovery Auditor may send claim adjustment files to the MACs. Providers may still receive some correspondence related to the current Recovery Auditors while CMS transitions to the new contracts. However, at no time will providers have to respond to ADRs more frequently than every 45 days, or from two different Recovery Auditors. Providers should contact RAC@cms.hhs.gov for questions concerning the transition. CMS will continue to update this Website with more information on the procurement and awards as information becomes available.

RAC Update May 4, 2016 – CMS has revised the method used to calculate additional documentation request (ADR) limits for Institutional Providers (Facilities). A document describing the new methodology can be found in the “Downloads” section of our Provider Resource page.

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