Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 1315 Date: November 15, 2013

Transcription

1 anual ystem Pub One-Time Notification Department of ealth & uman ervices (D) enters for edicare & edicaid ervices () Transmittal 1315 Date: November 15, 2013 hange equest 8508 UBJT: mmediate uspension of Postpayment Patient tatus eviews of npatient ospital dmissions 10/1/13-12/31/13. UY O NG: On ugust 2, 2013, the enters for edicare & edicaid ervices () issued inal ule updating fiscal year Y 2014 edicare payment policies and rates under the npatient Prospective Payment ystem (PP) and the Long-Term are ospital Prospective Payment ystem (LT PP). The final rule modifies and clarifies s longstanding policy on how edicare contractors review inpatient hospital admissions for payment purposes. The rule is applicable to admissions at acute care inpatient hospital facilities, Long Term are ospitals (LTs), ritical ccess ospitals (s) and npatient Psychiatric acilities (Ps), but is not applicable to beneficiary admissions at npatient ehabilitation acilities (s). s are specifically excluded from the 2-idnight inpatient admission and medical review guidelines per eviews to check compliance with inal ule are called patient status reviews. The purpose of this hange equest is to provide the contractors with instruction regarding their post-payment medical review strategy, particularly related to "patient status" reviews. edicare dministrative ontractors (s), ecovery uditors, and the upplemental edical eview ontractor shall not conduct postpayment patient status reviews for inpatient claims with dates of admission 10/1/13 12/31/13. owever, claims with evidence of systematic gaming, abuse or delays in the provision of care in an attempt to surpass the 2 midnight presumption could warrant medical review at any time. s, ecovery uditors and the upplemental edical eview ontractor may continue other types of inpatient hospital review (i.e. reviews for purposes other than determining the appropriateness of the inpatient admission versus treatment as an outpatient/observation, which are known as "patient status" reviews). TV DT: October 1, 2013 PLNTTON DT: December 2, 2013 Disclaimer for manual changes only: The revision date and transmittal number apply only to red italicized material. ny other material was previously published and remains unchanged. owever, if this revision contains a table of contents, you will receive the new/revised information only, and not the entire table of contents.. NG N NUL NTUTON: (N/ if manual is not updated) =VD, N=NW, D=DLTD-Only One Per ow. /N/D PT / TON / UBTON / TTL N/. UNDNG: or iscal ntermediaries (s), egional ome ealth ntermediaries (s) and/or arriers:

2 No additional funding will be provided by ; ontractors activities are to be carried out with their operating budgets or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. does not construe this as a change to the statement of Work. The contractor is not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements. V. TTNT: One-Time Notification *Unless otherwise specified, the effective date is the date of service.

3 ttachment - One-Time Notification Pub Transmittal: 1315 Date: November 15, 2013 hange equest: 8508 UBJT: mmediate uspension of Postpayment Patient tatus eviews of npatient ospital dmissions 10/1/13-12/31/13 TV DT: October 1, 2013 PLNTTON DT: December 2, GNL NOTON. Background: On ugust 2, 2013 the enters for edicare & edicaid ervices () issued inal ule updating fiscal year Y 2014 edicare payment policies and rates under the npatient Prospective Payment ystem (PP) and the Long-Term are ospital Prospective Payment ystem (LT PP). The final rule modifies and clarifies s longstanding policy on how edicare contractors review inpatient hospital admissions for payment purposes. The rule is applicable to admissions at acute care inpatient hospital facilities, Long Term are ospitals (LTs), ritical ccess ospitals (s) and npatient Psychiatric acilities (Ps), but is not applicable to beneficiary admissions at npatient ehabilitation acilities (s). s are specifically excluded from the 2-idnight inpatient admission and medical review guidelines per eviews to check compliance with inal ule are called patient status reviews. The purpose of this hange equest is to provide the contractors with instruction regarding their post-payment medical review strategy, particularly related to "patient status" reviews. edicare dministrative ontractors (s), ecovery uditors, and the upplemental edical eview ontractor shall not conduct postpayment patient status reviews for inpatient claims with dates of admission 10/1/13 12/31/13. owever, claims with evidence of systematic gaming, abuse or delays in the provision of care in an attempt to surpass the 2 midnight presumption could warrant medical review at any time. s, ecovery uditors and the upplemental edical eview ontractor may continue other types of inpatient hospital review (i.e. reviews for purposes other than determining the appropriateness of the inpatient admission versus treatment as an outpatient/observation, which are known as "patient status" reviews). B. Policy: iscal Year 2014 ospital PP inal ule : edicare Program; ospital npatient Prospective Payment ystems for cute are ospitals and the Long- Term are ospital Prospective Payment ystem and iscal Year 2014 ates; Quality eporting equirements for pecific Providers; ospital onditions of Participation; Payment Policies elated to Patient tatus

4 . BUN QUNT TBL "hall" denotes a mandatory requirement, and "should" denotes an optional requirement. Number equirement esponsibility /B edicare dministrative ontractors (s), ecovery uditors, and the upplemental edical eview ontractor shall not conduct postpayment patient status reviews for inpatient claims with dates of admission 10/1/13 12/31/13. NOT: Patient tatus eviews are those reviews conducted to determine if inpatient hospital admission and Part payment was the appropriate status for the care provided. These review types are those that include denial language to indicate that while the patient care provided may have been appropriate, the setting in which it occurred was not warranted (i.e. it could have been provided on an outpatient basis) s, ecovery uditors and the upplemental edical eview ontractor shall continue other types of inpatient hospital reviews (including but not limited to coding reviews, reviews for the medical necessity of a surgical procedure provided to a hospitalized beneficiary, and statutorily mandated therapy reviews) in accordance with their medical review strategy. NOT: edical necessity reviews of the surgical procedures performed will assess whether the procedure was reasonable and necessary for the beneficiary s medical condition and treatment. n example of this type of review includes decisions regarding the medical necessity of a dual-chamber pacemaker based on edicare s National overage Determination requirements npatient hospital reviews for dates of admission prior to 10/1/2013 should continue based on the applicable policy at the time of admission. B D hared- ystem aintainers V W Other ll appli catio ns and busin ess owne rs listed in the backg round sectio n of this., s ll appli catio ns and busin ess owne rs listed in the backg round sectio n of this., s ll appli catio ns and

5 Number equirement esponsibility /B D B hared- ystem aintainers V W Other busin ess owne rs listed in the backg round sectio n of this., s. POVD DUTON TBL Number equirement esponsibility as Provider ducation: ontractors shall post this entire instruction, or a direct link to this instruction, on their Web sites and include information about it in a listserv message within 1 week of the release of this instruction. n addition, the entire instruction must be included in the contractor s next regularly scheduled bulletin. ontractors are free to supplement it with localized information that would benefit their provider community in billing and administering the edicare program correctly. /B B D Other V. UPPOTNG NOTON ection : ecommendations and supporting information associated with listed requirements: N/ "hould" denotes a recommendation. -ef equirement Number ecommendations or other supporting information:

6 ection B: ll other recommendations and supporting information: iscal Year 2014 ospital npatient Prospective Payment ystem (PP) inal ule V. ONTT Pre-mplementation ontact(s): Jennifer Dupee, or Vicki hitwood, or Jennifer Phillips, or Post-mplementation ontact(s): ontact your ontracting Officer's epresentative (O) or ontractor anager, as applicable. V. UNDNG ection : or iscal ntermediaries (s), egional ome ealth ntermediaries (s), and/or arriers: No additional funding will be provided by ; ontractors activities are to be carried out with their operating budgets ection B: or edicare dministrative ontractors (s): The edicare dministrative ontractor is hereby advised that this constitutes technical direction as defined in your contract. do not construe this as a change to the tatement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the ontracting Officer. f the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the ontracting Officer, in writing or by , and request formal directions regarding continued performance requirements.