Appropriate inpatient admission for Medicare.
The decision for inpatient hospital admission is complicated based on a physician’s judgment and the need for medically essential hospital care. Inpatient admission is generally appropriate when a patient needs 2 or more midnights of medically necessary hospital care. However, a physician must formally write an order such admission, and the hospital must process admission for a patient to become an inpatient (Medicare.gov, n.d.).
As an example, a patient is in the ED with chest pain. The ED physician and hospitalist decide to admit the patient for at least 2 midnights for close monitoring, work-ups/diagnostics, and referral to a Cardiologist.
Appropriate outpatient admission for Medicare.
Appropriate outpatient admission covers emergency department services, observation services, outpatient surgery, lab tests, X-rays, or other hospital services. These cases are considered outpatient even if a patient stays overnight in the hospital (Medicare.gov, n.d.).
For example, a patient had outpatient surgery, but the surgeon decided to keep the patient in the hospital overnight for high Bp. As a result, the surgeon does not write an order to admit the patient and plan for discharge the next day.
Appropriate Medicare patient appeal for a delay in discharge.
Based on Liang & Alper (2018), when patients are transitioned from one care setting to another, the discharge period is a period of intensified risk and can often be chaotic. Although about 20% of patients encounter adverse events in the first 3 weeks after hospitalization, 61% of those occurrences are preventable. Risks can include a decline linked to the cause for hospitalization, unfavorable drug reactions, hospital-acquired illnesses, and other issues irrelevant to the cause for hospitalization. Many interventions may lessen the risk of injury after discharge. Medicare mandates hospitals to give Medicare patients details about their discharge and appeal rights. The regulations mandate that hospitals give patients two pieces of information about their rights; one right after admission and one before discharge. Within two days of hospitalization, the hospital must provide a patient a notice called “An Important Message from Medicare about Your Rights” (IM) explaining the discharge and appeal rights. The patient must read the notice, sign it, and date it.
For example, a 65 y/o cancer patient experienced severe symptoms caused by her cancer treatments. Hence, she was hospitalized. Two days later, she was still experiencing practically the same symptoms. As a result, the patient’s family requested an evaluation by a specialist. The following day, the nurse announced the planned discharge in the afternoon while taking the patient’s vital signs. The family asked about the specialist. “There will be no specialist,” the nurse replied, “because no one is available to see her before the planned discharge.” In short, the attending physician decided to discharge the patient without being evaluated by a specialist and addressing the cause of the patient’s hospitalization. In this case, it is appropriate that the patient appeals for a delay in discharge until the cause of her hospitalization has been addressed appropriately.
Liang, K. & Alper, E. (April 1, 2018). Patient safety during hospital discharge. Patient Safety Network: Agency for Healthcare Research and Quality. https://psnet.ahrq.gov/perspective/patient-safety-during-hospital-discharge
Medicare.gov (Retrieved February 24, 2022). Inpatient or outpatient hospital status affects your costs. Retrieved from https://www.medicare.gov/what-medicare-covers/what-part-a-covers/inpatient-or-outpatient-hospital-status
Feb 24, 2022, 1:47 PM
The decision to admit a patient is a multifaceted medical decision a clinician needs to make. CMS has designation of inpatient vs outpatient/observation dependent on the patients’ needs. This is a clinical decision but it does impact payment. CMS defines inpatient as needing the following services: “bed and board; nursing services or other related services; use of hospital or critical access hospital services; medical social service; drugs, biologicals, supplies, appliances, or equipment; certain diagnostic or therapeutic services; medical or surgical services provided by residents or interns in training; transportation services” (Centers for Medicare & Medicaid Services [CMS], 2021, 1 section). To be considered inpatient, a clinician must also designate that and the patient is expected to stay two midnights (CMS, 2021, 1 section). For example, a patient who presents to the emergency room with acute respiratory failure secondary to pneumonia who requires mechanical ventilation would meet criteria for inpatient designation.
Many diagnoses that once met inpatient only (IPO) criteria have recently received outpatient or observation designations. For example, in 2018 total knee arthroplasty (TKA) was removed from the IPO for Medicare beneficiaries, meaning they could be performed on an outpatient basis (Barnes et al., 2020). So, in this instance if a surgeon thinks a TKA patient is expected to stay less than two midnights they can be coded as an outpatient (Barnes et al., 2020)
Medicare beneficiaries also have the right be involved in the discharge process which includes appealing their discharge if they believe it is too soon. While the hospital cannot force a patient to leave, they can begin billing for services after a discharge order (CMS, 2021). Beneficiaries should receive Important messages form (IM) on admission or prior to discharge explaining these rights (CMS, 2021). While a discharge appeal can be filed for any reason, Medicare may deny the claim and the patient is financially responsible (CMS, 2021). Appeals need to filed by midnight on the day of discharge and they will have a response within 24 hours; however, the patient is not responsible for fees accrued while waiting for notice (CMS, 2021). For example, a patient may appeal a discharge because they don’t feel safe to go home without a caregiver or they feel they are still sick and not ready to go home.
Barnes, C. L., Iorio, R., Zhang, X., & Haas, D. A. (2020). An examination of the adoption of outpatient total knee arthroplasty since 2018. The Journal of Arthroplasty, 35(6).
Centers for Medicare & Medicaid Services. (2021, August 6). Medicare benefit policy mannual. Centers for Medicare and Medicaid Services. Retrieved February 23, 2022, from