Providers will continue to use the same definition of inpatient status that they already know. That’s because despite CMS’ consideration of various provider comments, the agency has not establish new criteria.
In its CY 2013 OPPS Proposed Rule, CMS specifically sought provider feedback regarding parameters to establish inpatient status other than medical necessity and the presence of a physician order. These include length of stay and other variables. In particular, CMS wanted to know whether it should establish a point in time after which an encounter becomes an inpatient stay if the beneficiary is still receiving medically necessary care to treat or evaluate his or her condition.
Stakeholders provided comments, and CMS published several of these comments on pp. 761-766 of the CY 2013 OPPS Final Rule. Some of the suggestions included:
- Establishing inpatient criteria that are strictly time-based (i.e., patients automatically become inpatients after 24, 48, or 72 hours). This is based largely on a primary goal of eliminating extended observation cases.
- Assigning inpatient status automatically for patients who have been actively monitored for more than 24 to 48 hours as outpatients under observation and who cannot be safely discharged. These are likely sufficiently complex cases that would “benefit from being admitted as an inpatient regardless of whether they technically meet inpatient admission criteria,” according to the final rule.
- Establishing a second decision point during the observation period, when the physician must reevaluate whether the patient needs to be admitted as an inpatient.
- Limiting observation care to 24 hours with exceptions for physician discretion.
- Structuring an inpatient MS-DRG payment around short-stay admissions where the physician believes added components of care are necessary.
Although CMS stated it would take these comments into consideration going forward, the agency didn’t indicate whether it would eventually redefine inpatient status—a topic that CMS acknowledges has posed ongoing compliance challenges for hospitals.
