Awareness : Newsletter Articles

Patient Admission Orders

It is important to always keep in mind what constitutes as an inpatient admission under Medicare Part A. Title 42 Part 412 indicates that an individual is considered an inpatient if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner. The physician order must be present in the medical record and supported by the physician admission and progress notes, in order for the hospital to be paid for hospital inpatient services under Medicare Part A.

The order must be furnished by a qualified and licensed practitioner who has admitting privileges at the hospital as permitted by State law, and who is knowledgeable about the patient’s hospital course, medical plan of care, and current condition. The practitioner may not delegate the decision to another individual who is not authorized by the State to admit patients, or has not been granted admitting privileges applicable to that patient by the hospital’s medical record staff.  The physician order must be furnished at or before the time of the inpatient admission.

An inpatient admission is generally appropriate for payment under Medicare Part A when the admitting physician expects the patient to require hospital care that crosses two mid-nights. The expectation of the physician should be based on such complex medical factors as patient history and commodities, the severity of signs and symptoms, current medical needs, and the risk of adverse event. The factors that lead to a particular clinical expectation must be documented in the medical record in order to be granted consideration.

If an unforeseen circumstance, such as a beneficiary’s death or transfer, results in a shorter beneficiary stay than the physician’s expectation of at least two mid-nights, the patient may be considered to be appropriately treated on an inpatient basis, and payment for an inpatient hospital stay may be made under Medicare Part A.

An inpatient admission for a surgical procedure specified by Medicare as inpatient only is generally appropriate for payment under Medicare Part A. It is imperative to check the inpatient only list as some changes may have been made.