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The changes will become effective in about three months, giving providers time to modify processes.

The staff at the Centers for Medicare & Medicaid Services (CMS) have been working overtime for the last two years. I have noted before their amazing efforts during the COVID-19 public health emergency (PHE), revising and nuancing the regulations to allow medical care to continue to be provided to patients. But at the same time, these same devoted staff have had to continue with the routine regulatory review and revision that is required by law. And one of these revisions, an update to the Medicare Manual provisions for the Important Message from Medicare (IMM), has been released.

Rather than copying the 17 pages of instructions, allow me to summarize the changes and clarifications I found worthy of mention.

  • The changes have an effective date of April 21, 2022, providing three months to modify any of your processes that may be no longer compliant.
  • The current section of Chapter 30 of the Medicare Claims Processing Manual is 24 pages, although that iteration included standard versions of the IMM and Detailed Notice of Discharge (DND).
  • The revisions to the expedited appeal process are applicable to patients with original Medicare, with processes applicable to Medicare health plans outlined in a separate manual, although on a practical basis, most of the same procedures should be followed.
  • CMS has added as a formal exception to the issuance of the IMM any patient who elects the hospice benefit. This would mean that the patient being admitted to an inpatient hospice bed should not get an IMM, nor should the inpatient who elects to cease curative care and enroll in hospice receive the follow-up copy of the IMM.
  • CMS has added a notation that patients whose status is changed from inpatient to outpatient via the Condition Code 44 process do not have expedited appeal rights. It should be noted that a case pending in federal court (previously known as Alexander v. Azar, but now known as Bagnall v. Becerra) involves petitioners attempting to require patients whose status has changed from inpatient to outpatient to be permitted to appeal their status change.
  • CMS now formally prohibits providing an IMM to a patient who has not been formally admitted as inpatient, or whose inpatient admission is pending, specifically noting that the IMM “should not be given ‘just in case,’ such as a hospital delivering (such notices) to all Medicare patients being treated in a hospital emergency room.” I have heard anecdotes of hospitals where every Medicare patient who registers is given an IMM, and in some cases, a Medicare Outpatient Observation Notice (MOON).
  • The IMM may be presented and signed on an electronic screen, but the patient must be given a paper copy of the completed IMM.
  •  The follow-up copy of the IMM may be a new IMM, which must be signed and dated by the patient, or a copy of the initial IMM. The guidelines do note that the date of delivery should be indicated on the IMM, but I am seeking clarification from CMS on whether that means a copy of this dated follow-up copy must be retained by the hospital. There is some ambiguity here that warrants clarification.
  • CMS states that the follow-up IMM must be given “no later than four hours prior to discharge.” In previous non-manual correspondence, CMS has clarified that a patient is not required to stay the full four hours if they have no objections to discharge, but this manual revision is silent on that.
  • If the IMM must be delivered to a representative who is not present, it should be explained verbally by phone, and a copy sent with a method that allows signature verification of delivery.  Fax and email can only be used if that method meets HIPAA privacy and security requirements.
  • CMS once again states that a timely expedited discharge appeal must be requested from the Beneficiary Family Centered Care-Quality Improvement Organization (BFCC-QIO) by midnight on the day of discharge, before leaving the hospital.
  • A discharge appeal may be requested after midnight, but it will be considered not timely, and financial liability is not waived, although CMS does not delineate when patient financial liability begins.
  • Patients continue to have the option to appeal an unfavorable BFCC-QIO decision to an independent review entity by noon the day after the BFCC-QIO’s determination, although, as before, the patient will incur financial liability during this reconsideration. This appeal process is outlined in Section 300 of this manual chapter, which was not updated.

I have submitted a few questions to CMS on the changes, and will update RACmonitor and ICD10monitor readers if I get responses.

Editor’s Note: For an important and timely follow-up article on this topic by Ronald Hirsch, MD, be sure to read “Answers to Important Questions,” also by Dr. Hirsch.


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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