LCD: Acute Inpatient Services versus Observation (Outpatient) Services L32222
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type FI - MAC |
LCD Information
Document Information
L32222 LCD Title Acute Inpatient Services versus Observation (Outpatient) Services Contractor's Determination Number HOSP-001 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 03/17/2012 Original Determination Ending Date Revision Effective Date Revision Ending Date |
CMS National Coverage Policy
Title
XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no
Medicare payment shall be made for items or services which are not
reasonable and necessary for the diagnosis or treatment of illness or
injury.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
CMS Pub 100-02, Ch.1 is the primary reference for Medicare inpatient status determinations.
Social Security Act Section 1862 (a) (2) prohibits payment for which the individual furnished such items or services has no legal obligation to pay.
Code of Federal Regulations Section 421.100 (a) (2) directs the intermediary to take appropriate action to reject or adjust the claim if the services furnished were not reasonable, not medically necessary, or not furnished in the most appropriate setting; or if the claim does not properly reflect the kind and amount of services furnished.
CMS Pub. 100-08, Ch. 6, §6.5, is the review process for IPPS claims
CMS Pub 100-04, Ch. 4., §290 defines observation care.
CMS Pub 100-02, 6 §20.1 discusses the appropriate billing of "Day Stay" patients.
CMS Pub 100-04, 3 §140.2.3 is specific to Inpatient Rehabilitation Facilities
CMS Pub 100-04, Ch. 3, §20.1.2.4 and §30.1.4 delineate provisions regarding reimbursement for a patient that is transferred between hospitals.
CMS Pub 100-04, 3-§10.4 discusses reimbursement for specialized services that do not necessitate a transfer.
CMS Pub 100-02, 6 §20.1 specifies that services provided to an inpatient or outpatient of a hospital are covered only when that primary hospital bills Medicare for the services.
CMS Pub 100-04, Chapter 1, Section 50.3 discusses when an inpatient admission may be changed to outpatient status.
65 FR 18457
CMS Pub 100-01, 5 §10.2
CMS Pub 100-2, 1 §10, 6 §10, 6
CMS Pub 100-04, Ch.2, Ch. 23 §10, Ch.24 §20.2, Ch.25 §50.1 & 60, Ch. 28 §30.2
CMS Pub 100-04, 4 §290, 3 §50.1, 25 §80.2.1, 29 §60.27.3
MIM Transmittal No. 1604
MIM Transmittal No. 1689
OPPS Training Manual Chpt IV: clinical implications of the OPPS-Medical Review Decisions
OPPS Training Manual Chpt V: Outpatient PPS Payment Calculations: Packaging
PRO 19-1010.C
PRO 19-4110.A
Change Request 6492, CMS Pub 100-02, Medicare Benefit Policy Manual, Transmittal 107; and CMS Pub 100-04, Medicare Claims Processing Manual, Transmittal 1745: July 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS) contains clarifications for Observation Services and use of Condition Code 44.
Change Request 6626, CMS Pub 100-04, Medicare Claims Processing Manual, Transmittal 1803: October 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS) contains further clarification regarding Observation Services and use of Condition Code 44.
Title XVIII of the Social Security Act, Section 1862(a)(7). This section excludes routine physical examinations.
Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.
CMS Pub 100-02, Ch.1 is the primary reference for Medicare inpatient status determinations.
Social Security Act Section 1862 (a) (2) prohibits payment for which the individual furnished such items or services has no legal obligation to pay.
Code of Federal Regulations Section 421.100 (a) (2) directs the intermediary to take appropriate action to reject or adjust the claim if the services furnished were not reasonable, not medically necessary, or not furnished in the most appropriate setting; or if the claim does not properly reflect the kind and amount of services furnished.
CMS Pub. 100-08, Ch. 6, §6.5, is the review process for IPPS claims
CMS Pub 100-04, Ch. 4., §290 defines observation care.
CMS Pub 100-02, 6 §20.1 discusses the appropriate billing of "Day Stay" patients.
CMS Pub 100-04, 3 §140.2.3 is specific to Inpatient Rehabilitation Facilities
CMS Pub 100-04, Ch. 3, §20.1.2.4 and §30.1.4 delineate provisions regarding reimbursement for a patient that is transferred between hospitals.
CMS Pub 100-04, 3-§10.4 discusses reimbursement for specialized services that do not necessitate a transfer.
CMS Pub 100-02, 6 §20.1 specifies that services provided to an inpatient or outpatient of a hospital are covered only when that primary hospital bills Medicare for the services.
CMS Pub 100-04, Chapter 1, Section 50.3 discusses when an inpatient admission may be changed to outpatient status.
65 FR 18457
CMS Pub 100-01, 5 §10.2
CMS Pub 100-2, 1 §10, 6 §10, 6
CMS Pub 100-04, Ch.2, Ch. 23 §10, Ch.24 §20.2, Ch.25 §50.1 & 60, Ch. 28 §30.2
CMS Pub 100-04, 4 §290, 3 §50.1, 25 §80.2.1, 29 §60.27.3
MIM Transmittal No. 1604
MIM Transmittal No. 1689
OPPS Training Manual Chpt IV: clinical implications of the OPPS-Medical Review Decisions
OPPS Training Manual Chpt V: Outpatient PPS Payment Calculations: Packaging
PRO 19-1010.C
PRO 19-4110.A
Change Request 6492, CMS Pub 100-02, Medicare Benefit Policy Manual, Transmittal 107; and CMS Pub 100-04, Medicare Claims Processing Manual, Transmittal 1745: July 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS) contains clarifications for Observation Services and use of Condition Code 44.
Change Request 6626, CMS Pub 100-04, Medicare Claims Processing Manual, Transmittal 1803: October 2009 Update of the Hospital Outpatient Prospective Payment System (OPPS) contains further clarification regarding Observation Services and use of Condition Code 44.
Indications and Limitations of Coverage and/or Medical Necessity
The
determination of inpatient status or outpatient observation services
for any given patient is specifically reserved to the admitting
physician. The quality of care should be the same whether the Medicare
patient is placed in outpatient observation or inpatient care. There are
two main differences between the types of hospital services. First, the
level of resources the beneficiary requires, and second, the billing
and reimbursement method utilized by the facility. It is the difference
in cost that is important to the patient. Typically, one is admitted to a
hospital to receive a service that cannot be provided as an outpatient.
The term "admit" is a non-specific term and can be used in conjunction with inpatient and outpatient observation services. An order simply documented as "admit" will be treated by WPS Medicare as an inpatient admission. A clearly worded order, such as "inpatient admission" or "place patient in outpatient observation" will ensure appropriate patient care and prevent hospital billing errors.
Acute Inpatient Admission:
Acute inpatient hospital care must be supported by both diagnosis and treatment plan.
A DRG (Diagnosis Related Groups) validation is required on Inpatient Prospective Payment System (IPPS), as appropriate to determine medical necessity of inpatient care. Under the IPPS, each inpatient admission is categorized into a DRG. Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG.
Contractors are required to use a screening tool as part of their medical review of IPPS, and Long-Term Care Hospital (LTCH) claims. A specific screening tool criteria is not required by CMS. To make a clinical review determination, the reviewer does apply his or her own clinical judgment, along with the information in the medical record. However, when necessary, medical reviewers shall consult with the Contractor Medical Director (CMD), physicians or other specialists to make an informed medical review determination.
Inpatient admission is based on the following:
A. Medical History:
Risk stratification criteria (such as Intensity of Service and Severity of Illness) are required in considering potential benefits of acute Inpatient admission status. Consideration of medical history is based on how the medical history is impacting this admission.
B. Severity of Illness:
The decision must be based on the physician's expectation of the care that the patient will require. The general rule is that the physician should order an Inpatient admission for patients who are expected to need hospital care for 24 hours or longer. Patients who are expected to need less than 24 hours of care are treated on an Outpatient basis. CMS Publication 100-02, chapter 1 clarifies this and states;
C. Intensity of Service (Current Medical Needs)
Justification for inpatient admission is based on the information available at the time of admission. Subsequent information may support a physician's decision that the patient needed inpatient care, but never serves to refute that original determination.
An inpatient admission is not covered when the care can be provided in a less intensive setting without significantly and indirectly threatening the patient's safety or health. In many institutions there is no difference between the actual medical services provided in inpatient and outpatient observation settings; in those cases the designation still serves to assign patients to an appropriate billing category.
D. Predictability of Complications:
1. Failure to respond to outpatient treatment and/or a clear deterioration of the patient's clinical condition;
2. A significant probability that the treatment plan will continue to need frequent clinical
modifications and what specific modifications are necessary;
3. Instability of the patient that is a deterioration from either normal clinical parameters or the patient's baseline;
4. A requirement for more intensive services than provided in observation care and a physician's order for inpatient care.
5. It is the medical judgment of the treating physician that the patient's condition cannot be evaluated or treated within 24 hours.
A person is considered an inpatient if he is formally admitted based on the physician's expectation of a need for an appropriate inpatient stay. If the patient dies, is transferred, leaves against medical advice (AMA) or recovers in a shorter period of time, an inpatient admission is still appropriate
Outpatient Observation Services:
(Pub 100-02, Chapter 6, §20.5) The purpose of observation is to determine the need for further treatment or for inpatient admission.
When a patient arrives at the facility with an unstable medical condition or a medical condition that requires further monitoring or treatment (generally via the Emergency Department), observation services may be reasonable and necessary to evaluate the medical condition(s) and determine the need for a possible inpatient admission to the hospital.
Observation Services Defined:
1. Consist of a set of clinically appropriate services for the following purposes;
Unstable Medical Conditions Defined:
1. Variance from generally accepted normal laboratory values and;
2. Clinical signs and symptoms present that are significantly above or below those of normal range (especially for the patient) and are such that further monitoring and evaluation is needed.
3. Changes in the patient's status or condition are anticipated and immediate medical intervention may be required.
Observation services are considered payable only when provided under a physician's order (or under the order of another person who is authorized by state statute and the hospital's bylaws to admit patients or order outpatient testing).
Outpatient observation services are not to be used as a substitute for medically necessary inpatient admissions. Outpatient observation services are not to be used for the convenience of the hospital, its physicians, and patients, patient's families, or while awaiting placement to another health care facility.
Outpatient observation services must be patient specific and not part of the facility's standard operating procedure or protocol for a given diagnosis or service; observation determinations made by protocol without consideration of the applicability to the specific patient will be considered to be not medically necessary. Outpatient observation services generally do not exceed 24 hours.
Although some patients may require a second day of observation, only in rare and exceptional cases do observation services span more than 48 hours.
When the physician determines the patient is appropriate for outpatient observation services, the patient is considered an outpatient. An outpatient observation bed is defined as an alternate level of health care comprising short-stay encounters for patients who require close nursing observation or medical management. It is an area where the patient is observed and assessed following surgery, during treatment, or to determine a need to be admitted to the hospital as an inpatient. This may take up to or even longer than 24 hours at which time a decision is required whether to send the patient home or admit the patient to the hospital.
Outpatient Surgery
Coverage of observation service is restricted to situations where a patient exhibits an uncommon or unusual reaction to the surgical procedure (e.g., difficulty in awakening from anesthesia, drug reaction, or other post surgical complication) which requires monitoring or treatment beyond that customarily provided in the immediate postoperative period. Routine pre-operative preparation and recovery room services are not to be billed as observation services.
The observation service begins at the point in time when the normal post care ended and an unusual or adverse reaction occurred. Observation service ends when it is determined whether or not the patient required inpatient admission or discharge. Medical review decisions will be based on the documentation in the patient's medical record.
Diagnostic Testing
For scheduled outpatient diagnostic tests which are invasive in nature, the routine preparation before the test and the immediate recovery period following the test is not considered to be an observation service. However, when a patient has a significant adverse reaction (beyond the usual and expected response) as a result of the test that requires further monitoring, outpatient observation or inpatient hospital services may be reasonable and necessary.
If outpatient observation services are medically appropriate the time of the outpatient observation service begins at that point in time when the adverse reaction occurred and would end when it is determined whether or not the patient required inpatient admission. Medical review decisions will be based on the documentation in the patient's medical record.
Outpatient Therapeutic Services
Observation status does not apply when a beneficiary is treated as an outpatient for the administration of blood only and receives no other medical treatment. The use of the hospital facilities is inherent in the administration of the blood and is included in the payment for administration.
When the patient has been scheduled for ongoing therapeutic services as a result of a known medical condition, a period of time is often required to evaluate the response to that service. This period of evaluation is an appropriate component of the therapeutic service and is not considered an observation service.
The observation service begins at that point in time when a significant adverse reaction occurred that is above and beyond the usual and expected response to the service.
Medical Necessity for Outpatient Observation
The medical necessity of all outpatient observation hospital care must be documented in the patient's medical record. The physician may determine that outpatient observation care is medically necessary for many clinical situations. Depending on the condition of the patient and the expected outcome the choice of the outpatient observational setting may be medically necessary for, but not limited to, one or more of the following reasons:
Outpatient observation care is only medically necessary when the patient's current medical condition requires outpatient observational hospital services, or when there is a significant risk of health deterioration in the immediate future such that continued observation in a non-hospital environment is inadvisable. Outpatient observation services for the convenience of the patient or others are by definition not medically necessary. Services that are otherwise covered for example, services furnished as part of the standard preparation for or standard recovery from diagnostic testing, etc., are also not covered as outpatient observation services.
The term "admit" is a non-specific term and can be used in conjunction with inpatient and outpatient observation services. An order simply documented as "admit" will be treated by WPS Medicare as an inpatient admission. A clearly worded order, such as "inpatient admission" or "place patient in outpatient observation" will ensure appropriate patient care and prevent hospital billing errors.
Acute Inpatient Admission:
Acute admission is defined as a level of health care in which the patient's severity of illness and intensity of service can only be performed in an inpatient setting.
Acute inpatient hospital care must be supported by both diagnosis and treatment plan.
A DRG (Diagnosis Related Groups) validation is required on Inpatient Prospective Payment System (IPPS), as appropriate to determine medical necessity of inpatient care. Under the IPPS, each inpatient admission is categorized into a DRG. Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG.
Contractors are required to use a screening tool as part of their medical review of IPPS, and Long-Term Care Hospital (LTCH) claims. A specific screening tool criteria is not required by CMS. To make a clinical review determination, the reviewer does apply his or her own clinical judgment, along with the information in the medical record. However, when necessary, medical reviewers shall consult with the Contractor Medical Director (CMD), physicians or other specialists to make an informed medical review determination.
Inpatient admission is based on the following:
A. Medical History:
Risk stratification criteria (such as Intensity of Service and Severity of Illness) are required in considering potential benefits of acute Inpatient admission status. Consideration of medical history is based on how the medical history is impacting this admission.
B. Severity of Illness:
The decision must be based on the physician's expectation of the care that the patient will require. The general rule is that the physician should order an Inpatient admission for patients who are expected to need hospital care for 24 hours or longer. Patients who are expected to need less than 24 hours of care are treated on an Outpatient basis. CMS Publication 100-02, chapter 1 clarifies this and states;
The decision to admit a patient is a complex medical judgment which can be made only after the physician has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available to inpatients and to outpatients, the hospital's by-laws and admissions policies, and the relative appropriateness of treatment in each setting
C. Intensity of Service (Current Medical Needs)
Justification for inpatient admission is based on the information available at the time of admission. Subsequent information may support a physician's decision that the patient needed inpatient care, but never serves to refute that original determination.
An inpatient admission is not covered when the care can be provided in a less intensive setting without significantly and indirectly threatening the patient's safety or health. In many institutions there is no difference between the actual medical services provided in inpatient and outpatient observation settings; in those cases the designation still serves to assign patients to an appropriate billing category.
D. Predictability of Complications:
1. Failure to respond to outpatient treatment and/or a clear deterioration of the patient's clinical condition;
2. A significant probability that the treatment plan will continue to need frequent clinical
modifications and what specific modifications are necessary;
3. Instability of the patient that is a deterioration from either normal clinical parameters or the patient's baseline;
4. A requirement for more intensive services than provided in observation care and a physician's order for inpatient care.
5. It is the medical judgment of the treating physician that the patient's condition cannot be evaluated or treated within 24 hours.
A person is considered an inpatient if he is formally admitted based on the physician's expectation of a need for an appropriate inpatient stay. If the patient dies, is transferred, leaves against medical advice (AMA) or recovers in a shorter period of time, an inpatient admission is still appropriate
Outpatient Observation Services:
(Pub 100-02, Chapter 6, §20.5) The purpose of observation is to determine the need for further treatment or for inpatient admission.
When a patient arrives at the facility with an unstable medical condition or a medical condition that requires further monitoring or treatment (generally via the Emergency Department), observation services may be reasonable and necessary to evaluate the medical condition(s) and determine the need for a possible inpatient admission to the hospital.
Observation Services Defined:
1. Consist of a set of clinically appropriate services for the following purposes;
a. Short term treatment
b. Assessment
c. Reassessment
Unstable Medical Conditions Defined:
1. Variance from generally accepted normal laboratory values and;
2. Clinical signs and symptoms present that are significantly above or below those of normal range (especially for the patient) and are such that further monitoring and evaluation is needed.
3. Changes in the patient's status or condition are anticipated and immediate medical intervention may be required.
Observation services are considered payable only when provided under a physician's order (or under the order of another person who is authorized by state statute and the hospital's bylaws to admit patients or order outpatient testing).
Outpatient observation services are not to be used as a substitute for medically necessary inpatient admissions. Outpatient observation services are not to be used for the convenience of the hospital, its physicians, and patients, patient's families, or while awaiting placement to another health care facility.
Outpatient observation services must be patient specific and not part of the facility's standard operating procedure or protocol for a given diagnosis or service; observation determinations made by protocol without consideration of the applicability to the specific patient will be considered to be not medically necessary. Outpatient observation services generally do not exceed 24 hours.
Although some patients may require a second day of observation, only in rare and exceptional cases do observation services span more than 48 hours.
When the physician determines the patient is appropriate for outpatient observation services, the patient is considered an outpatient. An outpatient observation bed is defined as an alternate level of health care comprising short-stay encounters for patients who require close nursing observation or medical management. It is an area where the patient is observed and assessed following surgery, during treatment, or to determine a need to be admitted to the hospital as an inpatient. This may take up to or even longer than 24 hours at which time a decision is required whether to send the patient home or admit the patient to the hospital.
Outpatient Surgery
Coverage of observation service is restricted to situations where a patient exhibits an uncommon or unusual reaction to the surgical procedure (e.g., difficulty in awakening from anesthesia, drug reaction, or other post surgical complication) which requires monitoring or treatment beyond that customarily provided in the immediate postoperative period. Routine pre-operative preparation and recovery room services are not to be billed as observation services.
The observation service begins at the point in time when the normal post care ended and an unusual or adverse reaction occurred. Observation service ends when it is determined whether or not the patient required inpatient admission or discharge. Medical review decisions will be based on the documentation in the patient's medical record.
Diagnostic Testing
For scheduled outpatient diagnostic tests which are invasive in nature, the routine preparation before the test and the immediate recovery period following the test is not considered to be an observation service. However, when a patient has a significant adverse reaction (beyond the usual and expected response) as a result of the test that requires further monitoring, outpatient observation or inpatient hospital services may be reasonable and necessary.
If outpatient observation services are medically appropriate the time of the outpatient observation service begins at that point in time when the adverse reaction occurred and would end when it is determined whether or not the patient required inpatient admission. Medical review decisions will be based on the documentation in the patient's medical record.
Outpatient Therapeutic Services
Observation status does not apply when a beneficiary is treated as an outpatient for the administration of blood only and receives no other medical treatment. The use of the hospital facilities is inherent in the administration of the blood and is included in the payment for administration.
When the patient has been scheduled for ongoing therapeutic services as a result of a known medical condition, a period of time is often required to evaluate the response to that service. This period of evaluation is an appropriate component of the therapeutic service and is not considered an observation service.
The observation service begins at that point in time when a significant adverse reaction occurred that is above and beyond the usual and expected response to the service.
Medical Necessity for Outpatient Observation
The medical necessity of all outpatient observation hospital care must be documented in the patient's medical record. The physician may determine that outpatient observation care is medically necessary for many clinical situations. Depending on the condition of the patient and the expected outcome the choice of the outpatient observational setting may be medically necessary for, but not limited to, one or more of the following reasons:
1. A significant reaction following a medical procedure or treatment.
2. Cardiovascular abnormalities such as congestive heart failure (CHF)
3. Chest pain to assess for myocardial infarct (MI).
4. Respiratory abnormalities such as chronic obstructive pulmonary disease (COPD) and asthma
5. Change in neurological status
6. Electrolyte imbalance
7. Head trauma
8. Severe vomiting
9. High fever or hypothermia
10. Abdominal pain
11. Fractures
Outpatient observation care is only medically necessary when the patient's current medical condition requires outpatient observational hospital services, or when there is a significant risk of health deterioration in the immediate future such that continued observation in a non-hospital environment is inadvisable. Outpatient observation services for the convenience of the patient or others are by definition not medically necessary. Services that are otherwise covered for example, services furnished as part of the standard preparation for or standard recovery from diagnostic testing, etc., are also not covered as outpatient observation services.
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
| 011x | Hospital Inpatient (Including Medicare Part A) |
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 083x | Ambulatory Surgery Center |
| 085x | Critical Access Hospital |
Revenue Codes:
CPT/HCPCS Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
| 0760 | Specialty Services - General Classification |
| 0761 | Specialty Services - Treatment Room |
| 0762 | Specialty Services - Observation Hours |
| 0769 | Specialty Services - Other Specialty Services |
Italicized and/or quoted material is excerpted from the American Medical Association, Current Procedural Terminology (CPT) codes.
HCPCS
Codes for Separately Reimbursable Observation Diagnoses (Not applicable
for Inpatient claims or observation services bundled into other APCs)
NOTE:
Billing and coding of physician services is expected to be consistent
with the facility billing of the patient's status as an inpatient or an
outpatient. (These CPT codes are not listed on this LCD.) Because
patient status may change as discussed above, communication among those
involved in the care of the patient is essential. If a physician
provider billing Part B has submitted a claim and learns that the
patient's status has changed, the claim should be resubmitted. Please
see the accompanying billing and coding article for more details.
For 13X bill type only
| G0378 | HOSPITAL OBSERVATION SERVICE, PER HOUR |
| G0379 | DIRECT ADMISSION OF PATIENT FOR HOSPITAL OBSERVATION CARE |
For 085X bill type only
| 99217 | OBSERVATION CARE DISCHARGE DAY MANAGEMENT (THIS CODE IS TO BE UTILIZED BY THE PHYSICIAN TO REPORT ALL SERVICES PROVIDED TO A PATIENT ON DISCHARGE FROM ''OBSERVATION STATUS'' IF THE DISCHARGE IS ON OTHER THAN THE INITIAL DATE OF ''OBSERVATION STATUS.'' TO REPORT SERVICES TO A PATIENT DESIGNATED AS ''OBSERVATION STATUS'' OR ''INPATIENT STATUS'' AND DISCHARGED ON THE SAME DATE, USE THE CODES FOR OBSERVATION OR INPATIENT CARE SERVICES [INCLUDING ADMISSION AND DISCHARGE SERVICES, 99234-99236 AS APPROPRIATE.]) |
| 99218 | INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. |
| 99219 | INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. |
| 99220 | INITIAL OBSERVATION CARE, PER DAY, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. |
| 99234 | OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A DETAILED OR COMPREHENSIVE HISTORY; A DETAILED OR COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING THAT IS STRAIGHTFORWARD OR OF LOW COMPLEXITY. |
| 99235 | OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF MODERATE COMPLEXITY. |
| 99236 | OBSERVATION OR INPATIENT HOSPITAL CARE, FOR THE EVALUATION AND MANAGEMENT OF A PATIENT INCLUDING ADMISSION AND DISCHARGE ON THE SAME DATE, WHICH REQUIRES THESE 3 KEY COMPONENTS: A COMPREHENSIVE HISTORY; A COMPREHENSIVE EXAMINATION; AND MEDICAL DECISION MAKING OF HIGH COMPLEXITY. |
ICD-9 Codes that Support Medical Necessity
Not Applicable
| XX000 | Not Applicable |
Diagnoses that Support Medical Necessity
Not Applicable
ICD-9 Codes that DO NOT Support Medical Necessity
Any diagnosis not listed above.
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
NA
General Information
Acute Inpatient Documentation and Outpatient Observation Care Documentation
1. A physician's order indicating patient's status
2. The admitting diagnosis must be consistent and supported by the treatment rendered. Chronic conditions such as COPD and CHF may contribute to the reason for admitting the patient but are not usually the primary reason for admission. For example, a patient with an exacerbation of COPD due to pneumonia would be coded with pneumonia as the primary diagnosis and COPD-exacerbation as a secondary diagnosis.
3. All documentation must be maintained in the patient's medical record and available to the contractor upon request.
4. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
5. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed. The medical record for inpatient admissions should support the diagnoses, and support the selection of the principal diagnosis.
6. Medical records will be expected to demonstrate the consistency between the physician order (physician intent), the services actually provided (inpatient or outpatient observation) and the medical necessity of those services, including the medical appropriateness of the inpatient or outpatient observation stay. The medical record must clearly support the medical necessity for outpatient observation and should include a timed order that will support the number of hours billed.
Inpatient Documentation:
1. The term "admit" refers to the decision to provide inpatient care. However, use of the term "admit" without supporting documentation is insufficient to medically support acute inpatient care
2. Documentation of the need for inpatient care includes, but is not limited to, the following;
3. If a patient's status changes from inpatient to outpatient, in accordance with the requirements for use of Condition Code 44, the changes must be fully documented in the medical record.
4. Upon internal hospital review performed before the claim was initially submitted, and upon the hospital determining that the services did not meet its inpatient criteria, an inpatient status may not be automatically changed to observation status. An observation stay must adhere to the criteria as described in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this LCD.
Outpatient Observation Care Documentation
1. Outpatient observation time begins at the clock time documented in the patient's medical record, which coincides with the time the patient is placed in a bed for the purpose of initiating outpatient observation care in accordance with a physician's order.
2. Clock Time: Either the physician's order for observation services or the nurse's admission note must include the clock time of the admission. Physician orders for observation must have a "clock time" or "clock time" can be noted in the nurse's observation admission note.
3. The ending time for outpatient observation occurs either when the patient is discharged from the hospital or is admitted as an inpatient. The time when a patient is "discharged" from observation care is the clock time when all clinical or medical interventions have been completed, including any necessary follow-up care furnished by hospital staff and physicians that may take place after a physician has ordered that the patient be released or admitted as an inpatient. However, observation care does not include time spent by the patient in the hospital subsequent to the conclusion of therapeutic, clinical, or medical interventions, such as time spent waiting for transportation to go home.
4. The beneficiary is under the care of a physician during the period of outpatient observation as documented in the medical record by admission, discharge, and appropriate progress notes.
5. Risk stratification criteria (such as intensity of service and severity of illness) were used in considering potential benefits of outpatient observation care.
6. The physician documentation should clearly differentiate an order for outpatient observation from an order for inpatient admission. The reason for observation must be stated in the orders for observation. [CMS Pubs 100-4, 6-§10, 9-§30.2,23-§10, 24-§20.2, 25-§50.1, 60, 28-§30.2 (Rev. 13-3-1726)]
7. Documentation in the patient's medical record must support the medical necessity of the observation service.
8. Observation claims exceeding 48 hours may be subject to medical review
1. A physician's order indicating patient's status
If the order to admit is missing or defective (i.e., illegible or incomplete), yet the physician intent, physician decision, and physician recommendation to admit to inpatient can clearly be derived from the medical record, contractors have the discretion to substitute this information for a written or electronic admission order. In order for the documentation to provide acceptable evidence of an admission to inpatient status, there can be no disagreement regarding the physician intent, decision, and recommendation to do so and no reasonable possibility that the care could have been adequately rendered in an outpatient setting. TDL-11447, 08-24-11
2. The admitting diagnosis must be consistent and supported by the treatment rendered. Chronic conditions such as COPD and CHF may contribute to the reason for admitting the patient but are not usually the primary reason for admission. For example, a patient with an exacerbation of COPD due to pneumonia would be coded with pneumonia as the primary diagnosis and COPD-exacerbation as a secondary diagnosis.
3. All documentation must be maintained in the patient's medical record and available to the contractor upon request.
4. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
5. The submitted medical record should support the use of the selected ICD-9-CM code(s). The submitted CPT/HCPCS code should describe the service performed. The medical record for inpatient admissions should support the diagnoses, and support the selection of the principal diagnosis.
6. Medical records will be expected to demonstrate the consistency between the physician order (physician intent), the services actually provided (inpatient or outpatient observation) and the medical necessity of those services, including the medical appropriateness of the inpatient or outpatient observation stay. The medical record must clearly support the medical necessity for outpatient observation and should include a timed order that will support the number of hours billed.
Inpatient Documentation:
1. The term "admit" refers to the decision to provide inpatient care. However, use of the term "admit" without supporting documentation is insufficient to medically support acute inpatient care
2. Documentation of the need for inpatient care includes, but is not limited to, the following;
Severity of illness
Intensity of service
Treating physician has a reasonable expectation that the patient's illness or condition cannot be treated within 24 hours
3. If a patient's status changes from inpatient to outpatient, in accordance with the requirements for use of Condition Code 44, the changes must be fully documented in the medical record.
4. Upon internal hospital review performed before the claim was initially submitted, and upon the hospital determining that the services did not meet its inpatient criteria, an inpatient status may not be automatically changed to observation status. An observation stay must adhere to the criteria as described in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this LCD.
Outpatient Observation Care Documentation
1. Outpatient observation time begins at the clock time documented in the patient's medical record, which coincides with the time the patient is placed in a bed for the purpose of initiating outpatient observation care in accordance with a physician's order.
2. Clock Time: Either the physician's order for observation services or the nurse's admission note must include the clock time of the admission. Physician orders for observation must have a "clock time" or "clock time" can be noted in the nurse's observation admission note.
3. The ending time for outpatient observation occurs either when the patient is discharged from the hospital or is admitted as an inpatient. The time when a patient is "discharged" from observation care is the clock time when all clinical or medical interventions have been completed, including any necessary follow-up care furnished by hospital staff and physicians that may take place after a physician has ordered that the patient be released or admitted as an inpatient. However, observation care does not include time spent by the patient in the hospital subsequent to the conclusion of therapeutic, clinical, or medical interventions, such as time spent waiting for transportation to go home.
4. The beneficiary is under the care of a physician during the period of outpatient observation as documented in the medical record by admission, discharge, and appropriate progress notes.
5. Risk stratification criteria (such as intensity of service and severity of illness) were used in considering potential benefits of outpatient observation care.
6. The physician documentation should clearly differentiate an order for outpatient observation from an order for inpatient admission. The reason for observation must be stated in the orders for observation. [CMS Pubs 100-4, 6-§10, 9-§30.2,23-§10, 24-§20.2, 25-§50.1, 60, 28-§30.2 (Rev. 13-3-1726)]
7. Documentation in the patient's medical record must support the medical necessity of the observation service.
8. Observation claims exceeding 48 hours may be subject to medical review
Appendices
Utilization Guidelines
In accordance with
CMS Ruling 95-1 (V), utilization of these services should be consistent
with locally acceptable standards of practice.
Sources of Information and Basis for Decision
Friedman, H,
Weber-Bornstein, N. et al (1987, April 1). Cardiac care unit admission
criteria for suspected acute myocardial infarction in new-onset atrial
fibrillation. The American Journal of Cardiology; 1987; 59:866-869.
Goldman, L., Kirtane, A.J. (2003, December 16). Triage of patients with acute chest pain and possible cardiac ischemia: The elusive search for diagnostic perfection. Annals of Internal Medicine, 139;12:987-996. Retrieved 08/23/2011 from the internet at http://www.annals.org
Highmark Medicare Services LCD
Other Contractor's policies
Goldman, L., Kirtane, A.J. (2003, December 16). Triage of patients with acute chest pain and possible cardiac ischemia: The elusive search for diagnostic perfection. Annals of Internal Medicine, 139;12:987-996. Retrieved 08/23/2011 from the internet at http://www.annals.org
Highmark Medicare Services LCD
Other Contractor's policies
Advisory Committee Meeting Notes
Meeting Date:
J5 MAC 10/06/2011
Open Meeting: 09/01/2011
*- An asterisk indicates a revision to that section of the policy.
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
J5 MAC 10/06/2011
Open Meeting: 09/01/2011
*- An asterisk indicates a revision to that section of the policy.
This policy does not reflect the sole opinion of the contractor or Contractor Medical Director. Although the final decision rests with the MAC contractor this policy was developed in cooperation with advisory groups which include representatives from various specialties, and adapted for the purpose of converting to MAC jurisdiction.
Start Date of Comment Period
10/06/2011
End Date of Comment Period
11/20/2011
Start Date of Notice Period
02/01/2012
Revision History Number
X
Revision History Explanation
Reason for Change
Related Documents
This LCD has no Related Documents.
LCD Attachments
Final CommentsAdobe Portable Document Format (a comment and response document) (PDF - 23 KB)
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Page Last Updated: Thursday, 22-Mar-2012 08:38:57 CDT
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