UR / CM's : Does your CM dept deny Medicare admissions?

  1. If a case does not meet criteria for admission - what do you do with it? Do you know if the hospital actually stops billing CMS?
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  2. 5 Comments

  3. by   ASSEDO
    If the patient does not meet inpatient criteria, we write the order for observation status. Only if the patient has not been discharged. After a patient is discharged we cannot write the order as per Medicare Transmittal. An patient can be changed to observation only when the patient is still an admit. Stupid rule, but that is their rule.
  4. by   Mijourney
    Quote from Smithbc1
    If the patient does not meet inpatient criteria, we write the order for observation status. Only if the patient has not been discharged. After a patient is discharged we cannot write the order as per Medicare Transmittal. An patient can be changed to observation only when the patient is still an admit. Stupid rule, but that is their rule.
    Smithbc1, in the above scenario if a retro review was done, can that review result in a return of monies for the inpt stay and a rebilling of the stay by the provider as observation on the basis of a medical denial?
  5. by   ASSEDO
    http://www.cms.hhs.gov/ContractorLea...ads/JA0622.pdf

    This is a great tool.
    If a Medicare patient has been discharged we cannot go back and retro the chart for any reason. The chart stands as it is... The problem for the hospital is if the physician admit a patient and discharges over the weekend and they don't meet inpatient criteria. We cannot go back and make them observation.
  6. by   Mijourney
    Ok so help me understand. If you are a CM or UM nurse working in a facility, you cannot retro a chart to change the status even if the services have not been billed for. So, did I read the physicians can retro the status? Thank you for your patience.
  7. by   ASSEDO
    Regular Medicare: An inpatient cannot be converted to observation service after the patient is discharged even if it is later determined that inpatient care was not medically necessary.
    Managed Health Care of Medicare: Each Managed contract of Medicare have their own "rules" some Managed Care allow 72 hrs for observation, and will let your facility change the status after the fact.

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