Important: Livanta Confirms Stance on One Day Inpatient Admissions

Important: Livanta Confirms Stance on One Day Inpatient Admissions

As I reported last week for RACmonitor, Livanta released a newsletter about short inpatient stays at the end of July. Their case examples were, to put it mildly, surprising. And as I discussed, I provided them some feedback – and they were kind enough to respond to me. I expected them to backtrack on some points, based on my experiences defending one-day inpatient admissions that had been denied in prior audits, but they stuck to their case examples.

Overall, their interpretation of the provisions of the Two-Midnight Rule seems much more liberal than previous communications from them and the Centers for Medicare & Medicaid Services (CMS).  

How so? First, they continue to insist that the Medicare patient presenting to the ED who requires a cholecystectomy or appendectomy can be admitted as an inpatient even if they are likely to go home the next day, and regardless of the patient’s comorbidities.

Now, they did make it clear that the patient’s condition should be emergent, meaning that if the doctor is using the ED to expedite the evaluation and treatment, it would not qualify for inpatient admission. I can see that happening with gallbladder disease, but rarely is a patient with acute appendicitis worked up as an outpatient. Once again, the documentation should support the emergent presentation. While patients with these acute surgical needs are significantly less common than patients with heart failure, the ability to admit these patients as inpatients will lead to an increase in compliant revenue by at least $6,000 – and potentially much more for teaching hospitals and hospitals in underserved areas.

Their apparent change in stance also applies to medical patients. If you recall, there was also a patient with angioedema and a patient with a GI bleed. In both those cases, the patient’s description was that of someone who was clinically stable. But Livanta stuck by their support of inpatient admission, stating that in both cases, the patient was at risk of a relapse and required close monitoring.

They seemed to differentiate between close monitoring and routine observation without any details about what separates their definitions, so that is an unanswered question.

They also stressed that the documentation must support the requirement for more than routine monitoring. As they said, “since we do not question inpatient orders that can be supported by the record, we would approve this case.” They also did not specify that the physician must explicitly state that they were admitting individuals as inpatients based on increased risk, despite an expectation of a stay of less than two midnights, but implied that the description of the patient’s condition would suffice to illustrate that increased risk.

Livanta and I also had an esoteric discussion about their contention that there are medications that “can only be given as inpatient.” With that, I disagreed. Their example was intraarterial thrombolytic agents, which can be given for stroke or pulmonary embolus. But my argument is that for most of these patients, the patient’s status at the moment of the infusion is actually outpatient, because patient care comes first, and the inpatient order usually does not get written until the patient is stabilized, which is almost always after the treatment.

The same, by the way, also applies to inpatient-only surgery. The reality is that many patients have inpatient-only surgery as outpatients, then are formally admitted as inpatients after completion of the surgery. Yes, it must be an inpatient Part A claim for the surgery to be paid, but the three-day payment window allows the surgery to appear on the claim even if the surgery was performed as outpatient.

The Medicare Benefit Policy Manual, Chapter 1, even allows an inpatient Part A claim if the whole stay was outpatient, in rare circumstances. (I warned you it was esoteric.) It’s long past time for the phrase “only as an inpatient” was removed from use, especially by those who should best know the regulations. This issue is surely less significant to all of you, but for the regulatory nerd that I am, it’s crucial that they understand the difference.

Now, what should you all do?

First, go get the Livanta newsletter. Save a copy of it for reference. Then arrange a meeting with your utilization review staff, your physician advisor, your compliance team, and your denials team, and decide what changes to your processes, if any, are appropriate. Especially be sure to use this document if your short stays get audited and they deny any cases.

I know from my experience that medical directors have generally not been as generous with approval of one-day inpatient stays. In one case, the Livanta medical director denied a one-day inpatient admission for an 80+-year-old patient with a first-time grand mal seizure and a post-ictal period, noting that “I routinely send these patients home directly from the ED.”

And it is important to remember that since Livanta is the designated CMS contractor for short-stay reviews, we can take their examples as also applicable to the Medicare Advantage plans in 2024, when they will be held to the Two-Midnight Rule, as established in CMS-4201-F and codified in 42 CFR 422.101.

Programming note: Listen to Dr. Ronald Hirsch as he makes his Monday Rounds on Monitor Mondays, 10 Eastern, with Chuck Buck and sponsored by R1-RCM.

Print Friendly, PDF & Email

Ronald Hirsch, MD, FACP, ACPA-C, 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, and the National Association of Healthcare Revenue Integrity, 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).

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 SDoH Update: Navigating Coding and Screening Assessment

2024 SDoH Update: Navigating Coding and Screening Assessment

Dive deep into the world of Social Determinants of Health (SDoH) coding with our comprehensive webcast. Explore the latest OPPS codes for 2024, understand SDoH assessments, and discover effective strategies for integrating coding seamlessly into healthcare practices. Gain invaluable insights and practical knowledge to navigate the complexities of SDoH coding confidently. Join us to unlock the potential of coding in promoting holistic patient care.

May 22, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

Happy National Doctor’s Day! Learn how to get a complimentary webcast on ‘Decoding Social Admissions’ as a token of our heartfelt appreciation! Click here to learn more →

Happy World Health Day! Our exclusive webcast, ‘2024 SDoH Update: Navigating Coding and Screening Assessment,’  is just $99 for a limited time! Use code WorldHealth24 at checkout.

SPRING INTO SAVINGS! Get 21% OFF during our exclusive two-day sale starting 3/21/2024. Use SPRING24 at checkout to claim this offer. Click here to learn more →