**Background and Rationale:**  
  
The goal of this policy is to decrease the frequency of denials and improper
Medicare payments for one-day acute inpatient hospital admissions (one-day
stays) for chest pain. This goal will be accomplished by utilizing the
concepts contained in the American College of Cardiology Foundation/American
Heart Association (ACC/AHA) guidelines for unstable angina/non-ST elevation
myocardial infarction (NSTEMI) as a framework to communicate reasonable and
necessary acute inpatient admissions for chest pain. The ACC/AHA evaluation &
management algorithm of patients suspected of having acute coronary syndrome
(ACS) algorithm provides a reliable, evidence-based structure for documenting
the complex decision-making process required of hospitals submitting claims
for one-day stays.  
  
The patients history, physical examination, diagnostic test results, together
with observed changes over time (including responsiveness/non-responsiveness
to treatment) are used by physicians to synthesize the clinical rationale for
an acute inpatient admission. This cognitive process, however, is often
incompletely transcribed into the healthcare record to support the resultant
acute inpatient admission for chest pain. This incomplete transcription often
results in Medicare one-day stay denials for failing to meet the reasonable
and necessary standards established in the Medicare Benefit Policy Manual.  
  
While the Medicare coverage requirements for acute inpatient admissions have
been in effect and disseminated by the Centers for Medicare & Medicaid
Services (CMS) for many years, they have not been consistently adopted and
implemented by acute care hospitals. This variation led to pre-payment record
reviews by this A/B MAC and post-payment record reviews by the Comprehensive
Error-Rate Testing Contractor (CERT) and the Recovery Audit Contractors
(RACs). These record reviews have identified many instances of improper
payments for one-day stays for chest pain.  
  
**Relevant Concepts:**  
  
The ACS algorithm contains evidence-based clinical diagnostic pathways that
are also aligned with existing Medicare coverage and reimbursement policy.
According to the ACC/AHA guidelines, a patients history, physical
examination, 12-lead ECG and initial cardiac biomarker tests should be used to
select the most appropriate evidenced-based treatment and setting, acute
inpatient admission, outpatient observation or outpatient follow-up.  
  
**Proposed Solution:**  
  
The ACC/AHA guidelines for unstable angina and NSTEMI provide a documentation
framework for successfully communicating the complex decision-making processes
required of physicians and hospitals caring for patients presenting with signs
and symptoms of ACS. The resultant structured information could be used to
improve both clinical and administrative communication. The adoption and
implementation of these evidence-based guidelines for ACS will require a
collaborative effort among physicians, nurses, hospitals and healthcare
payers.  
  
The communication of patient-specific information via the health record should
be the goal of both physicians and hospitals. Hospitals experiencing one-day
stays for chest pain are encouraged to use the ACC/AHA evidence-based
workflows to help improve their clinical documentation processes and
strengthen the healthcare records supporting one-day stays for chest pain.
This approach will improve communication between hospitals and this A/B MAC
and thus decrease Medicare denials and improper payments for one-day stays for
chest pain.  
  
This A/B MAC proposes to use the ACC/AHA framework in its reviews of one-day
stays for chest pain in an effort to improve its communication with acute care
hospitals experiencing denials for such claims. Education will be provided
within the context of the ACS algorithm to help communicate opportunities for
process improvements in documentation.