decisionhealth Newsletters, Part B News - 2014 Issue 2 (February)
4 ways to bolster documentation of inpatient stays, hospital relationships
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Article Overview
This piece discusses hospital inpatient admission documentation in the context of CMS guidance on the two-midnight rule. It is aimed at physicians, hospital administrators, and coding/billing professionals who need to understand how admission orders, certification, and progress-note documentation may affect inpatient status review and hospital reimbursement. The article covers the timing of CMS’s rule changes, the compliance concerns driving hospital attention, and practical documentation themes relevant to admissions and contractor review.
Why This Topic Matters
Hospitals and physicians may face payment and status-review consequences if inpatient stays are not documented clearly enough under CMS’s rules. Strong documentation also helps preserve hospital relationships and supports accurate handling of admission status.
Article Sections
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Background on the two-midnight rule
Introduces CMS’s inpatient stay policy changes and the hospital payment concerns that prompted attention to admission documentation. It also describes the broader context for review of inpatient versus outpatient status.
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Documentation tips to support admissions
Summarizes documentation themes intended to help support inpatient admission records and related hospital processes. The section focuses on broad communication and charting practices rather than coding specifics.
What You Will Learn
- How CMS’s inpatient stay policy affects documentation expectations
- Why clear admission records matter for hospital review processes
- Which broad documentation themes are emphasized for inpatient stays
- How admission orders and certification relate to hospital documentation
- Why hospital and physician stakeholders are paying close attention to inpatient status reviews
Who Should Read This
- Physicians with hospital admitting privileges
- Hospital administrators
- Coding and billing staff
- Compliance professionals
- Physician payment and revenue cycle staff
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