MOON Review a Week after the New Moon – on Monday

MOON Review a Week after the New Moon – on Monday

I have to admit, I am still upset at David Glaser for hiding the fact that last week was a new moon – and using a certain Duran Duran hit as his song for the week. It should have been abundantly clear to him that such an occurrence would have been the perfect time for me to make my segment about one of our favorite notices from the Centers for Medicare & Medicaid Services (CMS), the Medicare Outpatient Observation Notice (MOON).

So, let me provide a MOON refresher this week.

First, remember that the MOON is for Medicare and Medicare Advantage (MA) patients. If your state has its own rules about notifying observation patients, then be sure to check that your use of the MOON fulfills all the requirements. I have seen states that require every patient receiving observation to get a written observation notice, regardless of the duration, and every patient, regardless of their insurance.

Of course, the information on the MOON about coverage is specific to fee-for-service Medicare, so you may need to have a different form for different payers. I will also note that even for Medicare Advantage, most of the information on the MOON does not apply to them, with no three-day inpatient stay requirement to access a covered skilled nursing facility (SNF) stay, and different patient liabilities for the care they receive.

The MOON is only for patients who are receiving observation services, and should not be given to patients when observation is not ordered. For instance, outpatient surgery patients who will be spending a night in routine recovery should not get a MOON, since that is not observation care.

The MOON is only required for patients who receive at least 24 hours of observation, but it can be given prior to hour 24. I find it most convenient for it to be given when observation is first ordered. That order can trigger a task for registration to complete the form and present it to the patient. If the patient subsequently has questions, the registration clerk can find a case manager to assist.

It is crucial to note that the MOON must be completed to indicate the patient-specific reason why observation is ordered. CMS tells us it must be related to their presentation, such as chest pain or shortness of breath. It is insufficient to say “because the doctor ordered it” or “because inpatient criteria are not met.”

The MOON must also be explained to the patient verbally. While CMS always expects us to explain any form presented to the patient, the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, the law that established the MOON requirement, specifically requires that explanation. If you are struggling with that, remember, I have a video posted on my web page,, that can be shown to the patient to meet that requirement.

Now, the confusing parts of the MOON.

First, what do you do if you missed one? Delivery of patient notices is a condition of participation for Medicare, but it is not a condition of payment. If you miss one or two, figure out why, fix that, but go ahead and bill the stay. Should you mail it to the patient? It is not a requirement, and since the patient is already home, do they need to know that their stay did not qualify them for a stay in a SNF? And if you choose to mail it, do you then have to get a return receipt to indicate they received it? It seems better to not send it, but do everything possible to ensure it does not recur.

What about the MOON with Condition Code 44?

Well, the rules require you to notify the patient in writing that their status has changed from inpatient to outpatient. Can you use the MOON? Well, first, it is rare for such a patient to spend 24 hours after the status change, so the MOON is not required. Then the MOON never states that the status has changed, so such a statement has to be added to the form to be compliant. In addition, why use a form that needs completion, signature, and copying when a generic notice would suffice? Don’t make more work for yourself.

Finally, here is a scenario that was recently presented to me. A Medicare Advantage patient was admitted as an inpatient and went home a day later. The payer told the facility they could bill observation, and the hospital utilization review (UR) staff agreed, but compliance refused because the patient did not get a MOON. That’s just wrong. There is no requirement that a MOON be provided since the patient never received observation services.

The patient received inpatient care that is being billed as observation. It’s different. If the payer is trying to pay you, take the money.

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

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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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