Under what circumstances would outpatient observation be appropriate for a patient presenting to the emergency department (ED) with chest pain?
Observation is usually appropriate for patients following ED treatment for chest pain when the:
1. Cardiac enzymes are negative
2. EKG is negative (or shows non-diagnostic change)
3. Chest pain has resolved (either spontaneously or with administration of sublingual nitroglycerine)
These "3 negatives" can be used as a quick rule of thumb in identifying patients appropriate for observation.
Does a procedure have to be on the Medicare (CMS) Inpatient-Only List to be done as an inpatient? What if it is on the InterQual inpatient list?
If a physician determines that a patient should be admitted inpatient for a procedure that is not included in the CMS Inpatient-Only List, documentation in the medical record is required to substantiate the medical necessity for the inpatient care. For the Medicare population, inclusion in the InterQual Inpatient List does NOT automatically satisfy criteria for inpatient admission for a procedure.
Procedures included in the CMS Inpatient-Only List are reimbursable by Medicare ONLY if the patient is registered as an inpatient at the time the procedure is performed. Criteria are automatically met for inpatient admission for procedures in this list.
The InterQual Inpatient List is provided as a guide to assist hospitals that do not have an inpatient list for a patient population. For the Medicare population, the CMS Medicare Inpatient-Only List ALWAYS takes precedence over the InterQual Inpatient list.
A link to the CMS Inpatient-Only List is available through the TMF Web site at:
http://hpmp.tmf.org/pr/15/730a6.htm
If a patient requires an outpatient observation stay following outpatient surgery, is the hospital
reimbursed for observation?
The Centers for Medicare & Medicaid Services (CMS) policy states that postoperative monitoring during a standard recovery period (e.g. 4-6 hrs) should be billed as recovery room service (Manual Pub 100-02, MC Benefit Policy Transmittal 19, 09/10/04, change request 3444, 70.4D) and that outpatient observation is inappropriate during this time. If the patient requires additional observation following the recovery period, physician documentation is required to substantiate the medical necessity of the outpatient observation.
However, most outpatient surgeries (hysterectomy, thyroidectomy, spinal fusion, laparoscopic cholecystectomy, TURP, ICD/pacemaker insertion, etc.) are classified by CMS as T-status procedures. According to Medicare, no procedure with a T-status indicator can be reported on the same day that observation care is provided. This means that the hospital does not receive any additional payment for observation, even if the patient is admitted to outpatient observation following the outpatient surgery (per CMS Transmittal A-02-026, March 28, 2002, sect XII). According to CMS, the additional time is considered extended outpatient care.
Can the physician write an order to place an outpatient surgery patient in observation status prior to the surgery or during the normal postoperative recovery period?No. Observation status is appropriate for outpatient surgery patients who develop a complication requiringadditional treatment or monitoring. Observation status is not appropriate for normal postoperative recovery timefollowing surgery or routine stays following late surgery. The clinical condition of the patient at the end of thepostoperative recovery time determines whether outpatient observation status is required.
A physician writes pre-op orders for a patient having outpatient surgery. The orders include the request to make the patient a full inpatient admission after the surgery. Is this acceptable?
No. If it is known the patient will require an inpatient admission following surgery, the physician should admit the patient as an inpatient to begin with. If the patient suffers a complication of an outpatient surgery and subsequently requires an inpatient admission, an inpatient admission order can be written at that time.
If a hospital is not certified as an End Stage Renal Disease (ESRD) facility, can hemodialysis be performed and billed as an outpatient service?
Yes, unscheduled hemodyialysis can be performed as an outpatient service if the patient cannot obtain a regularly scheduled dialysis treatment at a certified ESRD facility and:
- dialysis is performed following or in connection with a vascular access procedure, or
- dialysis is performed following treatment for an unrelated medical emergency.
Emergency hemodialysis can be performed as an outpatient service for ESRD patients who would otherwise have to be admitted as inpatients in order for the hospital to receive payment.
In these situations, non-ESRD certified hospital outpatient facilities are to bill Medicare using HCPCS code GO257, “Unscheduled or emergency treatment for dialysis for ESRD patients in the outpatient department of a hospital that does not have a certified ESRD facility.”
Does a copy of the hospital-issued notice of non-coverage (HINN) need to be submitted along with the medical record submitted to TMF Health Quality Institute?
When submitting a medical record to TMF (the quality improvement organization or QIO for Texas) for a retrospective review for HINN, a copy of the notice should be submitted as part of the record.
When the QIO requests medical records from a long-term, acute care (LTAC) hospital, what must be included?
When the QIO requests medical records from an LTAC hospital, the hospital must send the complete record plus documentation to support any billed procedure performed outside its facility (i.e. the Operative Report).
When should a patient be assigned a status of outpatient versus outpatient observation?
There must be medical necessity of observation services documented in the medical record for a patient to be assigned a status of outpatient observation. Some stays are considered outpatient and do not qualify for outpatient observation status. These include:
- Routine stays following late surgery
- Diagnostic testing
- Outpatient therapy/procedures (unless there is documentation that the patient's condition is unstable)
- Normal postoperative recovery time following surgery
- Stays for the convenience of patient, family or doctor
- Stays prior to an outpatient surgery procedure
Does an ASA classification of 3, 4 or 5 alone satisfy criteria for a patient to have a procedure performed as an inpatient that would otherwise be considered an outpatient procedure?
While an ASA classification identifies patients at risk for complications of anesthesia, it does not indicate that an individual patient has had (or will have) a complication that would warrant admission to the hospital. If a patient were scheduled for a procedure that is considered outpatient by Medicare (not on Medicare inpatient only list), Medicare would require documentation of the medical necessity of inpatient admission based on the patient’s clinical picture. The ASA classification alone would not suffice.