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Arkansas Chapter HFMA

Spring 2015 Annual Conference

Two Midnight Rule –

MAC Perspective

Medicare Part A

April 16, 2015

Disclaimer

• All Current Procedural Terminology (CPT) only copyright 2014 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the American Medical Association. Applicable Federal Acquisition Regulation/ Defense Federal Acquisition Regulation (FARS/DFARS) Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

• The information enclosed was current at the time it was presented. Medicare policy changes frequently; links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations.

• Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.

• Novitas Solutions employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.

• This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings.

• Novitas Solutions does not permit videotaping or audio recording of training events.2

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Novitas Solutions

• Education specific to providers in Medicare Administrative Contractor Jurisdiction H (JH) include: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas

• Education specific to providers in Medicare Administrative Contractor (MAC) Jurisdiction L (JL) include: Delaware, District of Columbia, Maryland, New Jersey, and Pennsylvania

• This education contains specific contractor guidance

• If you are not a provider in JL or JH, please contact your Medicare contractor for specific guidance

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Agenda

• Two Midnight Rule Overview

• Two Midnight – Viewpoint from the MAC

• Case Scenarios

• Resources

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Objectives

• Understand the Two Midnight rule

guidelines

• Know the importance of your supporting

documentation including the physician

order and certification

• Discuss and review the Probe & Educate

process

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Acronym List

Acronym Definition

ACH Acute Care Inpatient Hospital

CMS Centers for Medicare & Medicaid Services

CAH Critical Access Hospital

HCPCS Healthcare Common Procedure Code System

MAC Medicare Administrative Contractor

OPPS Outpatient Prospective Payment System

TOB Type of Bill

IPF Inpatient Psychiatric Facility

OSC Occurrence Span Code

LTCH Long Term Care Hospital

IRF Inpatient Rehabilitation Facility6

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Two Midnight Rule Overview

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Appropriateness of Inpatient

Hospital Admissions

• Surgical procedures, diagnostic tests, and other treatments (in addition to inpatient-only services) are generally appropriate for inpatient hospital admission and payment when the physiciano Expects the beneficiary to require a stay that

crosses at least two midnights

o Admits the beneficiary to the hospital based on that expectation

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Documentation of the Two

Midnight Expectation

• Two midnight benchmark based on physician’s expectation of the required duration of medically necessary hospital services at the time the inpatient order is written and the formal admission begins

• Documentation is well rooted in good medical practice• Physicians do not need to include a separate attestation of

the expected length of stay, rather, the information may be inferred from the physician’s standard medical documentation such as the plan of care, treatment orders, and physician’s notes

• Reminder: Skilled Nursing Facility qualified stay has not changedo Beneficiary must have a three day inpatient admission – does

not include date of discharge or dates of observation services

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General Rule for Services on

Medicare’s Inpatient-Only List

• Procedures defined as “Inpatient-Only” are exceptions to the two midnight benchmark

• May be furnished on an inpatient basis regardless of the beneficiary’s length of stay

• “Inpatient-Only” procedures found in Addendum B with Status Indicator “C”o http://www.cms.gov/Medicare/Medicare-Fee-for-

Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html

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Short Inpatient Hospital

Stays (0-1 Midnight)

• Unforeseen circumstance resulting in a shorter beneficiary stay than the physician’s expectation of at least two midnightso The patient may be considered to be appropriately

treated on an inpatient basis and hospital inpatient payment may be made

o Such circumstances must be documented in the medical record

o Examples include� Death

� Transfer to another hospital

� Departure against medical advice

� Clinical improvement where the patient stayed less than the expected two midnights

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Inappropriate Short

Inpatient Hospital Stays

• Situations that do not represent instances

in which an inpatient admission would be

appropriate without an expectation of a

two midnight hospital stay

o Admitted for telemetry

o Admitted to Intensive Care Unit (ICU)

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Rare and Unusual

Circumstances

• Potential exception to the two midnight rule

o Mechanical ventilation initiated during present

visit

� If the physician expects the beneficiary will only require one midnight of hospital care, inpatient admission and Part A payment is generally appropriate

o Suggestions for additional categories of patients

or services to add to the exception

� Email: SuggestedExceptions@cms.hhs.gov

� Subject line: “Suggested Exceptions to the Two Midnight Benchmark”

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Transfers

• Pre-transfer time and care provided to the beneficiary at the initial hospital may be taken into account to determine whether the two midnight benchmark was met

• Start clock for transfers begins when the care begins in the initial hospital

• Excessive wait times or time spent in the hospital for non-medically necessary services must be excluded

• Records may be requested from the transferring hospital to support the medical necessity of the services provided and to verify when the beneficiary began receiving care

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Additional Information on

Transfers

• Ensure compliance, deter gaming or abuse

• Claim submissions for transfer cases will be monitored and any billing aberrancy identified by CMS or the Medicare review contractors may be subject to targeted review

• The initial hospital should continue to apply the two midnight benchmark based on the expected length of stay of the beneficiary for hospital care within their facility

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Off-Campus Emergency

Department Transfers

• If an Emergency Department (ED) is established as a provider-based/practice location of the hospital, CMS does not pay to move the patient from an off-campus location of the Medicare hospital to the campus of the same Medicare hospitalo Moving the beneficiary within the hospital that participates in Medicare

under a single CMS Certification Number (CCN) from a provider-based off-campus ED to a separate on-campus unit, or moving the beneficiary from an on-campus ED to a specified floor on the same campus, would be considered the same from a Medicare perspective

• Therefore, if a hospital ED is either an on-campus ED or an off-campus provider-based ED/practice location of a Medicare-certified hospital, the ED is considered part of that hospital for purposes of the two midnight ruleo The total time in the hospital should be counted for purposes of the two

midnight benchmark

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Decision to Admit

• Physician must assesso Whether the beneficiary requires hospital services

o Whether it is expected that such services will be required for two or more midnights

• Decision to keep the beneficiary at the hospital and the expectation of the needed duration of stay are based on complex medical factorso Beneficiary medical history and comorbidities

o Severity of the signs and symptoms

o Current medical needs

o Risk (probability) of an adverse event occurring during the time period for which hospitalization is considered

• Note: It is not necessary for a beneficiary to meet inpatient level of care as defined by a commercial screening tool in order for admission to be appropriate. Just because a beneficiary meets inpatient level of care as defined by a commercial screening tool, does not mean inpatient payment is appropriate

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Clock Time

• Clock time startso When beneficiary begins receiving services following arrival at

the hospital� Observation Services� Emergency department, operating room, other treatment services

o Does not include� Wait times prior to the initiation of care� Triaging activities (such as vital signs)� Time spent in emergency room while awaiting treatment

o Time spent as an outpatient before being formally admitted as an inpatient pursuant to a physician order is not considered inpatient time� Time will be considered during medical review process for purposes of

determining whether the two midnight benchmark was met and therefore, whether payment for the admission is generally appropriate

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Occurrence Span Code

(OSC) 72

• Change Request # 8586o Effective: December 1, 2013

o Implementation: February 25, 2014

• Key Pointso The National Uniform Billing Committee (NUBC) redefined OSC

72 to allow hospitals to capture “Contiguous outpatient hospital services that preceded the inpatient admission”

o Voluntary code, but use is encouraged

o Used to report the number of midnights the beneficiary spent in the hospital from the start of care until formal admission

o CMS can track the outpatient time on an automated basis

• Referenceo http://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/Downloads/R1334OTN.pdf

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Tips For Appropriateness

of Inpatient Admission

• Key questions medical record should

identify

o What is the reason for the admit?

o Can the physician attest that the patient needs two medically appropriate midnights to resolve condition?

o Does the medical record paint a picture of the patient’s situation?

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Hospital Inpatient Admission

Order and Certification

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-

Order-01-30-14.pdf

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Content of Physician

Order

• Beneficiary should be formally admitted for

hospital care

• Must specify admission for inpatient

services

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Ordering/Admitting

Practitioner

• Order must be furnished by a physician or other practitioner who iso Licensed by the state to admit inpatients to the hospital

o Granted privileges by the hospital to admit patients

o Knowledgeable about the patient’s hospital course, medical plan of care and current condition at the time of admission

• Ordering practitionero Makes determination of medical necessity for inpatient care and

renders admission decision

o Not required to write the order but must sign the order reflecting decision to admit the patient

o Not required to be physician who signs the certification

• Admission order may not be delegated to another individual who is not authorized by the state to admit patients, or has not been granted admitting privileges by the hospital

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Qualifications of the

Ordering/Admitting Practitioner

• Resident, physician assistant, nurse practitioner, or

other non-physician practitioner may write inpatient

admission orders on behalf of ordering practitioner

• Ordering practitioner must countersign the order

prior to discharge

• Countersigned satisfies the order part of the

physician certification

o Ordering practitioner must meet requirements for a

certifying physician

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Verbal Orders

• Ordering practitioner verbally communicates the inpatient admission order to staff

• Verbal order may be documented by an individual who is not qualified to admit patients

• Verbal order must be documented in the medical record at the time it is received

• Order must identify the qualified “admitting practitioner”

• Order must be authenticated (countersigned) by the ordering practitioner promptly and prior to discharge

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Inpatient Status Guidance

• Standing orders and protocolso Inpatient admission order cannot be a standing

order

o Only the ordering practitioner (or practitioner acting on his or her behalf) can make and take responsibility for the inpatient admission decision

• Commencement of inpatient statuso Begins at the time of formal admission to the

hospital pursuant to the physician order, including an initial order or verbal order that is countersigned timely by authorized practitioner

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Serving as the Ordering

Practitioner

• Admitting physician of record (attending) • Primary or covering hospitalists• Beneficiary’s primary care practitioner • Surgeon responsible for a major surgical procedure • Physician on call for admitting, primary care, or surgical

physician• Emergency or clinic practitioner at beneficiary’s point of

inpatient admission• Other practitioners qualified to admit inpatients and actively

treating the patient at the point of inpatient admission decision• Utilization review committee physician if actively treating

beneficiary at time of admission and not acting in a utilization review capacity

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Timing of the Order

• Must be furnished at or before the time of the inpatient admission

• Can be written in advance of formal admission (pre-scheduled surgery), but the inpatient admission does not occur until formal admission by the hospital

• Retroactive orders are not permitted

• Authentication required prior to discharge and may be performed and documented as part of the physician certification

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Specificity of the Order

• Must be present in the medical record

• Specify recommendation to admit “to inpatient”, “as an inpatient", "for inpatient services”, or similar language o Use language to clearly express intent to admit the patient as inpatient

that will be commonly understood by any individual that could potentially review documentation� If the order ambiguous, obtain and document clarification from the physician prior

to billing

o Orders that specify outpatient or other limited service will not be treated as meeting inpatient admission requirements� Examples: “admit to ER,” “to Observation,” “to Recovery,” “to Outpatient Surgery,”

“to Day Surgery,” or “to Short Stay Surgery”

• In extremely rare circumstances, the order may be missing or illegible or incomplete, yet the intent, decision, and the recommendation of the physician to admit the patient can clearly be derived from the medical record o May be applied at the discretion of the medical review contractor

o All requirements for the other components of the physician certification must be met

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Physician Certification

Requirements

• Contento Authentication of physician order

� Physician certifies the inpatient services were ordered in accordance with Medicare regulations governing the order

– Includes certification that hospital inpatient services are reasonable and necessary

– Provided as inpatient services in accordance with the two midnight benchmark

– Authentication of the practitioner order may be met by the signature or countersignature of the inpatient admission order by the certifying physician

o Reason for inpatient services

o Estimated (or actual) time the beneficiary requires or required inpatient hospital care� Reflected in the progress notes where assessment and plan are

discussed� May be documented in the order or separate certification/recertification � Part of routine discharge planning

o Plans for post-hospital care as appropriate

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Critical Access Hospitals (CAHs) and

Inpatient Rehabilitation Facilities (IRFs)

• CAHso Physician must certify beneficiary may reasonably be expected to be discharged

or transferred to a hospital within 96 hour after admission to CAH� Time as outpatient doesn’t count towards the 96 hour requirement

� Clock time begins once individual is admitted to CAH as an inpatient

� Time in CAH swing-bed does not count toward 96 hour limit

� If something unforeseen occurs that causes the individual to stay longer at the CAH there would be no problem with regards to the CAH designation as long as stay doesn’t cause the CAH to exceed its 96 hour annual average condition of participation requirement

� CAH will not receive Medicare reimbursement for any portion of the individual's inpatient stay if physician cannot certify individual will be discharged or transferred within 96 hours after admission to CAH

• IRFso Documentation that IRFs are already required to complete to meet IRF coverage

requirements may be used to satisfy certification and recertification requirements� Preadmission screening

� Post-admission physician evaluation

� Required admission orders

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Timing of Certification

• Begins with the order for inpatient admission• Must be completed, signed, dated, and documented in the

medical record prior to dischargeo Extenuating circumstances, delayed initial certification or

recertification of an outlier case may be acceptable as long as it does not extend past discharge

• Timing of dischargeo Beneficiary is considered a patient of the hospital until the

effectuation of activities typically specified by the physician as having to occur prior to discharge (example “discharge after supper” or “discharge after voids”)

o Discharge does not always coincide exactly with the time that the discharge order is written, rather it occurs when the physician’s order for discharge is effectuated

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Format

• No specific procedures or forms are required • Provider may adopt any method that permits verification• Certification/recertification statements may be entered on

forms, notes, or records that the appropriate individual signs, or on a special separate form

• Except for delayed certifications, there must be a separate signed statement for each certification or recertification

• If all required information is included in progress notes, the physician’s statement could indicate that the individual’s medical record contains the information required and that the hospital inpatient services are or continue to be medically necessary

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Authorization to Sign the

Certification

• Certifications and recertifications may only be signed byo Physician who is a doctor of medicine or osteopathy

o Dentist in specified circumstances in 42 CFR 424.13 (d)

o Doctor of podiatric medicine if certification is consistent with the functions authorized to perform under state law

• Medicare does not require the certifying physician to have inpatient admission privileges at the hospital

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Serving as a Certifying

Physician

• Admitting physician of record (attending) or physician on call for him or hero May be an emergency department physician or hospitalist

• Surgeon responsible for a major surgical procedure on the beneficiary or surgeon on call for him or her

• Dentist functioning as the admitting physician of record or surgeon responsible for a major dental procedure

• In the specific case of a non-physician, non-dentist admitting practitioner who is licensed by the state and has been granted privileges by the facility

• Physician member of the hospital staff who has reviewed the case and who also enters into the record a complete certification statement that contains all elementso Example: physician member of the utilization review committee

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Inpatient Hospital Review

Process: Probe & Educate

http://www.cms.gov/Research-Statistics-Data-and-

Systems/Monitoring-Programs/Medicare-FFS-Compliance-

Programs/Medical-Review/InpatientHospitalReviews.html

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Probe & Educate Period

• Probe & Educate periodo Probe & Educate process will continue through

3/31/2015

o Conduct reviews on claims submitted by Acute Care inpatient hospital facilities( ACH), Long Term Care Hospitals (LTCH), and Inpatient Psychiatric Facilities (IPF)� Critical Access Hospitals (CAH) are excluded from the

probe & educate process

� Inpatient Rehab Facilities (IRF) are excluded from the two midnight inpatient admission and medical review guidelines per the CMS-1599-F 37

Purpose and Medical Review

Strategy of Inpatient Reviews

• Purpose is to assess the hospital’s compliance witho The admission order requirements

o The certification requirements

o The two midnight benchmark

• Strategy aimed ato Identifying claims non-compliant with CMS-1599-F

o Issuing denials for improper claims for payment

o Educating providers about CMS-1599-F

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MAC Actions Following

Patient Status Probe Reviews

• Number of claims in sample that did not comply with policy (dates of admission October 2013-March 2015)

Claim Sample No or Minor Concerns Moderate to Significant Concerns

Major Concerns

10 claim sample 0-1 2-6 7 or more

25 claim sample 0-2 3-13 14 or more

Action For each provider with no or minor concerns, CMS will direct the MAC to: 1. Deny non-compliant claims 2. Send summary letter to providers indicating: • What claims were denied and the reason for the denials • That no more reviews will be conducted under the Probe & Educate process. • That the provider will be subjected to the normal data analysis and review process 3. Await further instruction from CMS

For each provider with moderate to significant concerns, CMS will direct the MAC to : 1. Deny non-compliant claims 2. Send detailed review results letters explaining each denial 3. Send summary letter that: • Offers the provider a 1:1 phone call to discuss • Indicates the review contractor will REPEAT Probe & Educate process with 10 or 25 claims 4. Repeat Probe & Educate of 10 or 25 claims with dates of admission October 2013 –

March 2015

*If a provider has an incomplete or

zero probe sample, they shall be

considered to be of moderate

concern for educational purposes.

For each provider with major concerns, CMS will direct the MAC to : 1. Deny non-compliant claims 2. Send detailed review results letters explaining each denial 3. Send summary letter that: • Offers the provider a 1:1 phone call to discuss • Indicates the review contractor will REPEAT Probe & Educate process with 10 or 25 claims 4. Repeat Probe & Educate of 10 or 25 claims with dates of admission October 2013 –

March 2015

5. If problem continues, Repeat Probe & Educate of 10 or 25 claims with dates of admission October 2013 –

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Documenting the Need for

Inpatient Hospital Services

• Evaluate whether, at the time of the admission order, it was reasonable for the admitting practitioner to expect the beneficiary to require medically necessary services (including inpatient and outpatient services) over a period of time spanning at least two midnights

• Medical necessity assessment as whether the beneficiary’s clinical presentation, prognosis, and expected treatment support the expectation of the need for hospital care spanning two or more midnights

• Beneficiary’s severity of illness and intensity of service are complex medical factors should be consideredo Note: It is not necessary for the beneficiary to meet an inpatient

level of care as defined by a commercial screening tool in order for Part A payment to be appropriate

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Additional

Documentation Reminder

• The expectation is that all documentation within a medical record will be legible, as sequential as possible; and that the detailed events (including dates, times, and data) will correspond accordingly

• The plan of care and progress notes should includeo Specifically whether services are outpatient/observation or inpatient at

the time of the documentation

o Date, time, diagnosis, plan, and legible signature

o The anticipated time-frame for completion of the defined treatment plan

o Any and all rationale or events that precipitated any change in patient status from observation to inpatient services

• All medical records will be reviewed to determine if the physician had a reasonable expectation that the beneficiary would require hospital care for two or more midnights to support inpatient admission and Part A payment

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2 Midnights - Viewpoint from the

MAC

Debra L. Patterson, M.D., F.A.C.P.

Vice President Clinical Affairs

JH and JL Executive Medical Director

Novitas Solutions, Inc.

April 16, 2015

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Probe and Educate Medical

Reviews – First Round

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#

Providers

# Claims

Reviewed

# Claims

Denied

% Claims

Denied

JH 1004 3794 2206 58%

JL 586 2712 1720 63%

Probe and Educate Medical

Reviews – Second Round*

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# Claims

Reviewed

# Claims

Denied

% Claims

Denied

JH 4515 2582 57%

JL 2712 1720 63%

* To date

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Top Reasons for Denial –

First RoundDenial Reason % Denials JH % Denials JL

Documentation did not support two

midnight expectation (did not support

physician certification of inpatient

order)

50% 51%

No Records Received 29% 28%

Documentation did not support

unforeseen circumstances

interrupting stay

11% 11%

No inpatient admission order 3% 3%

Admission order not validated/signed 4% 3%

Other 3% 4%

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Top Reasons for Denial –

Second RoundDenial Reason % Denials JH % Denials JL

Documentation did not support two

midnight expectation (did not support

physician certification of inpatient

order)

56% 53%

No Records Received 21% 20%

Documentation did not support

unforeseen circumstances

interrupting stay

3% 2%

No inpatient admission order 7% 13%

Admission order not validated/signed 6% 6%

Other 3% 1%

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Problematic Clinical

Situations

• Inadequate historical detail to understand symptoms of unknown significance in patients with underlying diseases

• Unstated or unclear impressions and treatment plans• Admissions for management based on clinical guidelines and

algorithms then not following those guidelines• Variations in descriptions of patient condition by different

physicians without explanation or reason• Disconnects (and disagreements) between admitting

physician and attending physician and between attending physician and specialist physicians

• Unforeseen circumstance vs. incorrect admitting diagnosis and treatment plan

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Examples

• Transient Cerebral Ischemia• Vague neurologic changes, altered mentation,

uncomplicated syncope• Gastrointestinal bleeding• Cardiac arrhythmias (atrial fibrillation)• Tube replacements• Volume depletion• Same day outpatient procedures• Psychiatric problems, suicidal ideation, patient

non-compliance, alcohol inebriation

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Case Scenarios

*Note that these case scenarios are being provided for educational

purposes only. Compliance with the two midnight rule is considered

on a case-by-case basis, in accordance with the information

contained in the medical record.

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Case Scenario 1

• Documentation does not support the two midnight expectation • 2/6/2014

o 21:30 – Patient presents to ER with complaints of right arm tingling, numbness, cold sensation over the past two days.

o 23:18 – Electronic entry of certification – “Admit to inpatient and LOS 2 or more midnights. Reason: TIA r/o CVA”

o 23:51 – Dictated H&P includes plan to admit to telemetry, neurology consult completed within ER, scheduled MRI, q4hour neurology checks, and labs. Documentation in the H&P indicates patient likely to be discharged tomorrow.

• 2/7/2014o 16:30 – Patient cleared by neurology for discharge. MRI brain

mild nonspecific changes and CT angiogram of brain unremarkable, symptoms resolved and patient discharged.

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Case Scenario 1 Denial

Message

• 5MEXPo Medicare payment for the admission is

denied. Although it was necessary for this beneficiary to seek and receive medical care, the clinical information received does not support a two midnight expectation. If the physician expects to keep the patient in the hospital for 0-1 midnights, the services are generally inappropriate for inpatient admission. Please refer to 42 CFR 412.3 (e).

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Case Scenario 2

• No Inpatient Order

• No expectation patient will stay two midnights

• 11/08/2013o 10:00 – Patient presents to ER with AMS, hypoglycemic,

and elevated BP. Patient was given intravenous solution of D10 in ER, patient was fed, and every 2 hour blood sugars were monitored for 24 hours.

o 12:40 – ER physician indicates disposition as ‘observation”o 13:51 – Physician H&P dictated indicating “Patient is

clearly stable for observation admission. She will be admitted to the telemetry unit”.

• 11/9/2013o 9:11 – Discharge order written.

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Case Scenario 2 – Denial

Message

• 5NMDO

o Medicare payment for the admission is denied. Review of the medical records indicates that there is no physician order to cover the inpatient admission. Please refer to 42 CFR 412.3 (e).

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Case Scenario 3

• Unforeseen Circumstance (after formal admission)o CMS case example

� http://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2014-01-14-midnight.html

• Disabled 50 year-old man presents to ED from home with history of cancer, now with probable metastases and various complaints, including nausea and vomiting, dehydration and renal insufficiency.

• 1/1/2014 o 10:00 pm - presents to the ED at which time the admitting

provider evaluates and orders diagnostic/therapeutic modalities.

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Case Scenario 3

(continued)

• 1/2/2014

o 4:00 am - Physician writes an order to admit. Patient is formally admitted with the expectation of medically necessary hospital level of care/services for 2 or more midnights.

o 9:00 am - Appropriate designee and the family discuss with the primary physician the desire for hospice care to begin for this patient immediately.

o 3:00 pm – Patient is discharged with home hospice.

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Case Scenario 3 Outcome

• Hospital may bill this claim for inpatient Part A payment. Claim will demonstrate 1 midnight of inpatient services. This represents an unforeseen circumstance interrupting an otherwise reasonable admitting practitioner expectation for hospital care. Upon review, this would be appropriate for inpatient admission and payment so long as the physician expectation and unforeseen circumstance were supported in the medical record.

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Questions?

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Thank you for attending this session

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