Q&A: Documenting expected length of stay
Q: Does the physician have to state a patient's expected length of stay (LOS) in the documentation for an inpatient admission?
A: The physician does not have to specifically state the expected LOS (e.g., two midnights) if it can be inferred from the physician’s other documentation such as the plan of care, treatment orders, and notes.
CMS directed auditors to review physician documentation and the reasonableness of the expectation of two midnights of care based on the information known to the physician at the time of admission. Although the entire record may be used to support the physician’s expectation of the need and length of admission, entries after the point of admission are only used by auditors in the context of determining what the physician knew and expected at the point of admission.
For more information, see the Patient Status Training Toolkit for Medicare Utilization Review, Second Edition.