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CMS issues FAQs on new admission and medical review criteria policy

September 26, 2013

The Centers for Medicare & Medicaid Services today issued new guidance in the form of several frequently asked questions on the admission and review criteria it adopted in the fiscal year 2014 hospital inpatient prospective payment system final rule. The agency reiterated that Medicare Administrative Contractors and Recovery Audit Contractors are not to review claims spanning more than two midnights after admission for a determination of whether the inpatient hospital admission was appropriate. CMS also announced that, for a period of 90 days, it will not permit RACs to review inpatient admissions of one midnight or less that begin on or after Oct. 1, 2013. In addition, the agency stated that MACs and RACs will not review any claims from critical access hospitals during this period. However, CMS will allow the MACs to review small samples of inpatient hospital claims with admission dates of Oct. 1 through Dec. 31, 2013 that span less than two midnights to determine whether the inpatient hospital admission was appropriate. If the MAC determines that the admissions were appropriate, it will cease further reviews for that hospital from Oct. 1 through Dec. 31, 2013, unless there are significant changes in billing patterns for admissions. “Today, CMS tried but failed to provide the hospital field with much needed information on the two-midnight policy,” said AHA President and CEO Rich Umbdenstock. “Unfortunately, the agency’s guidance only raises new questions and lacks clarity. Hospitals do not support the implementation of this regulation under these circumstances – too many aspects are fundamentally flawed. We believe that the only workable approach is to suspend this rule and immediately start dialog on a new policy direction that includes consideration of a payment option.”