How to Approach Inpatient-Only Procedures

by Debbie Mackaman, RHIA, CPCO, CCDS

Inpatient Order Requirements

The clinical decision to admit a patient is complicated and many different elements come into play. The patient’s well-being and outcome must be the primary factor in that decision. Certain documentation requirements must be met when a patient is admitted and the time inpatient admission orders are considered effective should be noted.

Hospital staff who monitor the process for identifying inpatient-only procedures should pay careful attention to the timing of the inpatient admission order. If the order is written by the admitting physician, surgeon, or NPP before the patient presents at the hospital, the time of admission is when the patient is formally admitted. If the order is written after the patient has arrived at the hospital, the time of admission is the time of the order. Verbal inpatient admission orders are effective at the time the verbal order is given, and are only valid when transcribed by the appropriate staff.

If an initial inpatient admission order is written by a proxy provider and countersigned by an ordering physician or NPP, the time of admission is the time of the initial order. Regardless of which practitioner is responsible for the order to admit, the order must be signed prior to discharge to be eligible for payment under Part A. CMS auditors, including MACs, will ignore an inpatient admission order as if it wasn’t present in the documentation if it’s not signed and authenticated[i].

In an ideal situation, inpatient admission orders are written before an inpatient-only procedure is performed. Inpatient admission orders cannot be backdated or timed[ii]. Admission orders must be given before an inpatient-only procedure is performed, except in certain circumstances. See Chapter 2 for more information on these exceptions.

Patients can’t be admitted after they have been discharged or transferred to another hospital. If the patient is discharged or transferred before he or she could be formally admitted, the patient will remain an outpatient.

A hospital’s inpatient admission policy should detail all of these requirements and allow physicians and non-physician practitioners (NPP) to make decisions that are in the best interest of the patient while meeting the complex Medicare regulations through sound documentation.  

Only a qualified, licensed physician or NPP may write an inpatient admission order. The practitioner must have admitting privileges at the facility and must be familiar with the patient’s condition. In other words, the practitioner must be involved in the patient’s care[iii].

Inpatient-Only Pain Points

Several points relating to inpatient-only procedures have caused considerable confusion. Only the hospital’s payment is affected by the inpatient-only rules. In general, a physician will still be paid even if he or she performs an inpatient-only procedure on an outpatient. This can make it difficult to ensure physicians comply with these regulations.

Additionally, physicians and clinical staff are usually directed by CMS to base admission decisions on the 2-midnight rule. However, the inpatient-only procedure regulation takes precedence over the 2-midnight rule. All procedures on the inpatient-only procedure list must be performed as an inpatient, regardless of how long the patient is expected to be in the hospital.

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To view the complete, detailed article that appeared on Medicare Compliance Watch, click here.