CMS recently issued guidance for hospitals on how to determine whether patients should be admitted and thus avoid recoupment by recovery audit contractors or denials by Medicare administrative contractors.
The agency said billing staff should make sure medical documentation shows a clinical need for patients to be admitted and that it fully and accurately details subsequent care provided during that stay.
Some hospital officials have been concerned that RACs and other agencies are using screening criteria, such as Interqual, to analyze medical documentation to determine whether inpatient hospital claims are medically necessary, CMS reported. It then explained how claims are reviewed for appropriate inpatient admissions and cited resources to understand inpatient admission decisions.
The agency said contractors ask whether the inpatient stay was "medically necessary, reasonable, and appropriate," whether the patient's signs or symptoms severe enough to warrant the need for medical care," and whether the patient receive services "of such intensity that they can be furnished safely and effectively only on an inpatient basis."
Read the CMS guidance on Medicare payment (pdf).
Read more coverage of RACs and denials of coverage:
- 8 Steps to Mastering Audits by RACs, Other Agencies
- 10 Tips on Improving RAC Readiness From Kaiser's RAC Expert
The agency said billing staff should make sure medical documentation shows a clinical need for patients to be admitted and that it fully and accurately details subsequent care provided during that stay.
Some hospital officials have been concerned that RACs and other agencies are using screening criteria, such as Interqual, to analyze medical documentation to determine whether inpatient hospital claims are medically necessary, CMS reported. It then explained how claims are reviewed for appropriate inpatient admissions and cited resources to understand inpatient admission decisions.
The agency said contractors ask whether the inpatient stay was "medically necessary, reasonable, and appropriate," whether the patient's signs or symptoms severe enough to warrant the need for medical care," and whether the patient receive services "of such intensity that they can be furnished safely and effectively only on an inpatient basis."
Read the CMS guidance on Medicare payment (pdf).
Read more coverage of RACs and denials of coverage:
- 8 Steps to Mastering Audits by RACs, Other Agencies
- 10 Tips on Improving RAC Readiness From Kaiser's RAC Expert