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MLN Matters Article #:SE1037

Guidance on Hospital Inpatient Admission Decisions

It is important that any staff involved with the clinical decision to admit the patientstay abreast of all CMS national inpatient hospital policy and National and Local Coverage Determinations. Additionally, make sure medical documentation submitted demonstrates evidence of the clinical need for the patient to be admitted to the inpatient facility and fully and accurately identifies any subsequent care that was provided during the inpatient stay.

Some hospitals have recently expressed concern about how the Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractors (RACs), MACs, FIs, and the Comprehensive Error Rate Testing Contractor (CERT) are utilizing screening criteria to analyze medical documentation and make a medical necessity determination on inpatient hospital claims.

There are several commercially available screening tools that Medicare contractors in specific jurisdictions may use to assist in the review of medical documentation to determine if a hospital admission is medically necessary. These include Interqual, Milliman, and other proprietary systems.

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