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PATIENT STATUS ASSIGNMENT
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Standard Operating Procedure
1.
Purpose
To require that the hospital obtain appropriate patient status orders and certification for
Medicare inpatient admissions.
2.
Scope
All hospital staff performing and/or billing Medicare inpatient and/or outpatient services:
acute care staff, employed physicians and their office staff; and all affiliated physicians.
3.
Policy
The Centers for Medicare and Medicaid Services (CMS) have established a two-midnight
benchmark for inpatient status effective October 1, 2013. At the time the physician
determines the patient will need hospital care, and anticipates that the patient will stay at
least two midnights, the physician should complete an order for inpatient admission.
If a patient is expected to stay less than two midnights at the time the physician
determines the patient will need hospital care, the physician should complete an order for
outpatient observation.
Medicare has a list of procedures by CPT code, also known as Addendum E, that is
considered to be inpatient only. If a patient is to receive a procedure on this list, the
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PATIENT STATUS ASSIGNMENT
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physician should admit the patient as an inpatient regardless of the expected length of
stay.
CMS requires that the physician order must be present in the medical record and be
supported by the physician admission and progress notes in order for the hospital to be
paid for hospital inpatient services under Medicare Part A. In addition, the admission
must be certified by the physician. Collectively, these requirements are necessary to
support inpatient admission.
5.
Procedure
1. The hospital CEO shall provide oversight and the hospital CFO is responsible for
implementation of this policy.
2. The hospital must utilize the approved medical record format (Insert here what
you have decided for the hospital to use for admission orders i.e. forms or EMR
formats) for all Medicare patients who need a bed for continuing hospital care. It
must be used for the initial patient status order as well as any subsequent patient
status orders.
3. A Medicare patient is considered an inpatient of a hospital if formally admitted as an
inpatient on an order for inpatient admission by a physician or other qualified
practitioner. The physician’s inpatient admission order:
1. Must be obtained at admission.
2. Must be supported by the physician admission and progress notes.
3. Must be written by a physician who is knowledgeable about the patient’s
hospital course, medical plan of care, and current condition at the time of
admission.
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PATIENT STATUS ASSIGNMENT
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Implementation Date
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SOP Owner
Last Reviewed/Update
Date
Approval
4. The physician’s certification of an inpatient admission begins with the order for
admission. The certification must be completed, signed, dated and documented by
the certifying physician prior to discharge. CMS requires specific content of the
certification (see table below).
Content
Admission order authentication
Reason inpatient services are medically
required
Estimated length of stay
Post hospital care
Requirement is Met By
Signature or countersignature of certifying
physician
Diagnosis, inpatient admission assessment, plan of
care, and/or orders
Admission order written in accordance with two
midnight benchmark, supplemented by physician
notes and discharge planning instructions
Discharge planning instructions
5. In addition to the admission order and certification, documentation by the physician
in other areas of the medical record must be sufficient to support that inpatient
hospital services were reasonable and necessary. The documentation can be present
in the history and physical, progress notes and the discharge summary. The
documentation must include:
1. Patient history and comorbidities;
2. Severity of signs and symptoms;
3. Risk of adverse events; and
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4. Current medical needs requiring inpatient care (e.g., frequent 2-4 hour monitoring, IV
medication requiring hospitalization, high risk of possible infection, etc.).
Hospital status is further explained below:
Outpatient status
When a physician expects a patient to need a bed for continuing hospital care for only
a limited period of time that does not cross two midnights, the services would be
generally appropriate as an outpatient including observation.
When a patient presents with an undetermined diagnosis and it is difficult for the
physician to determine how long the patient will stay, the physician should place the
patient in outpatient status and order observation services.
If a physician has ordered outpatient status with observation services and new
information becomes available that suggests the patient will require hospital services
a total of at least two midnights, the physician should reassess the patient and
consider admission to inpatient status.
Inpatient Status
When a physician expects a patient to require a hospital stay that crosses at least two
midnights, the services would be generally appropriate for inpatient admission.
If the physician expects a two-midnight stay and orders inpatient admission, but the
patient improves more rapidly than the physician’s reasonable, documented
expectation, such cases may be billed as inpatient care.
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PATIENT STATUS ASSIGNMENT
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6.
Last Reviewed/Update
Date
Approval
References
1. CMS-1599-F Medicare Program; Hospital Inpatient Prospective Payment Systems for
Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System
and Proposed Fiscal Year 2014 Rates
2. 42 CFR 412.3 Admissions
3. 42 CFR 424, Subpart B – Certification and Plan Requirements
4. CMS Hospital Inpatient Admission Order and Certification dated 9/5/2013
6. Definitions
Inpatient Status – generally, a Medicare patient who is expected to receive hospital
services for at least two midnights; or a patient who receives services listed on
Medicare Inpatient-Only list, also known as Addendum E.
Outpatient Status – generally, a Medicare patient who is expected to receive
hospital services for only a limited period of time that is not anticipated to cross two
midnights this includes outpatients receiving observation services.