As I reported last week for RACmonitor, Livanta released a newsletter about short inpatient stays at the end of July. Their case examples were, to put it mildly, surprising. And as I discussed, I provided them some feedback – and they were kind enough to respond to me. I expected them to backtrack on some points, based on my experiences defending one-day inpatient admissions that had been denied in prior audits, but they stuck to their case examples.
Overall, their interpretation of the provisions of the Two-Midnight Rule seems much more liberal than previous communications from them and the Centers for Medicare & Medicaid Services (CMS).
How so? First, they continue to insist that the Medicare patient presenting to the ED who requires a cholecystectomy or appendectomy can be admitted as an inpatient even if they are likely to go home the next day, and regardless of the patient’s comorbidities.
Now, they did make it clear that the patient’s condition should be emergent, meaning that if the doctor is using the ED to expedite the evaluation and treatment, it would not qualify for inpatient admission. I can see that happening with gallbladder disease, but rarely is a patient with acute appendicitis worked up as an outpatient. Once again, the documentation should support the emergent presentation. While patients with these acute surgical needs are significantly less common than patients with heart failure, the ability to admit these patients as inpatients will lead to an increase in compliant revenue by at least $6,000 – and potentially much more for teaching hospitals and hospitals in underserved areas.
Dr. Ronald Hirsch is Vice President of the Regulations and Education Group at R1 RCM Inc. Dr. Hirsch was a general internist and HIV specialist and practiced at Signature Medical Associates, a multispecialty practice located in Elgin, IL. He was Medical Director of Case Management at Sherman Hospital in Elgin, IL from 2006 to 2012, where he was Chairman of the Medical Records Committee from 1995 to 2012, and also served on the Medical Executive Committee. Dr. Hirsch is certified in Health Care Quality and Management by the American Board of Quality Assurance and Utilization Review Physicians, certified in Revenue Integrity by the National Association of Healthcare Revenue Integrity, and on the Advisory Board of the American College of Physician Advisors. He is on the editorial board of RACmonitor.com. He is the co-author of The Hospital Guide to Contemporary Utilization Review, with the third edition published in 2021.