(Medicare Benefit Policy Manual)

 The severity of the signs and symptoms exhibited by the patient;   The medical predictability of something adverse happening to the patient;   The need for diagnostic studies that appropriately are outpatient services (i.e., their performance does not ordinaril y require the patient to remain at the hospital for 24 hours or more) to assist in assessing whether the patient should be admitted; and    The availability of diagnostic procedures at the time when and at the location where the patient presents.   Admissions of particular patients are not covered or noncovered solely on the basis of the length of time the patient actually spends in the hospital.  In certain specific situations coverage of services on an inpatient or outpatient basis is determined by  the following rules:   Minor Surgery or Other Treatment  - When patients with known diagnoses enter a hospital for a specific minor surgical procedure or other treatment that is expected to keep them in the hospital for only a few hours (less than 24), they  are considered outpatients  for coverage purposes regardless of: the hour they came to the hospital, whether they used a bed, and whether they remained in the hospital past midnight.  Renal Dialysis  - Renal dialysis treatments are usually covered only as o utpatient services but may under certain circumstances be covered as inpatient services depending on the patient's condition.  Patients staying at home, who are ambulatory, whose conditions are stable and who come to the hospital for routine chronic dialys is treatments, and not for a diagnostic workup or a change in therapy, are considered outpatients.  On the other hand, patients undergoing short -term dialysis until their kidneys recover from an acute illness (acute dialysis), or persons with borderline re nal failure who develop acute renal failure every time they have an illness and require dialysis (episodic dialysis) are usually inpatients.  A patient may begin dialysis as an inpatient and then progress to an outpatient status.   Under original Medicare, the Quality Improvement Organization (QIO), for each hospital is responsible for deciding, during review of inpatient admissions on a case- by-case basis, whether the admission was medically necessary.  Medicare law authorizes the QIO to make these judgment s, and the judgments are binding for purposes of Medicare coverage.  In making these judgments, however, QIOs consider only the medical evidence which was available to the physician at the time an admission decision had to be made.  They do not take into account other information (e.g., test results) which became available only after admission, except in cases where considering the post -admission information would support a finding that an admission was medically necessary.  Refer to chapters 4 and 7 of Pub. 100-10, Quality Improvement Organization Manual with regard to initial determinations for these services.  The QIO will review the swing bed services in these PPS hospitals as well.   NOTE:   When patients requiring extended care services are admitted to beds in a hospital, they are considered inpatients of the hospital.  In such cases, the services furnished in the hospital will not be considered extended care services, and payment may not be made under the program for such services unless the services are extended care services furnished pursuant to a swing bed agreement granted to the hospital by the Secretary of Health and Human Services.   10.1 - Bed and Board (Rev. 1, 10-01-03) A3-3101.1, HO-210.1  10.1.1 - Accommodations - General  (Rev. 1, 10-01-03) A3-3101.1.A, HO-210.1.A  The program will pay the same amount for routine accommodations services whether the patient has a private room not medically necessary, a private room medically necessary (Medicare does not pay for deluxe accommodations in any case), a semiprivate room (2-, 3-, or 4-bed accommodations), or ward accommodations, if its ward accommodations are consistent with program purposes (see 10.1.6 below).  A provider having both private and semiprivate accommodations may nevertheless charge the patient a differential for a private room if:    The private room is not medically necessary; and    The patient (or relative or other person acting on their behalf) has requested the private room, and the provider informs them of the amount of charge at the time of the request.   The private room differential may not exceed the difference between the customary charge for the accommodations furnished and the most prevalent semiprivate accommodation rate at the time of the patient's admission.   Where the provider bills for a private room as a covered service, i.e., shows the charge for the room as a covered charge on the Form CMS -1450, the A/B MAC (A) will deem the private room to be medically necessary.  Where the provider, on the other hand, shows a private differential as a noncovered charge, the A/B MAC (A) will assume that the private room is not medically necessary.   If the beneficiary (or their representative) protests a charge for the private room on the grounds that the privacy was medically necessary, such protest will, if not in written form, be reduced to writing and forwarded to the A/B MAC (A).  The A/B MAC (A) will then develop the facts and make a specific determination regarding the medical necessity of the private room.  (If an A/B MAC (A) receives many protests of this kind, the provider may need guidance on what constitutes medical necessity for privacy).  If the protest is received after the claim is processed, it will be treated as a request for reconsideration.  If at any time in the course of development (or thereafter within the period when the determination is not administratively final), the provider acknowledges that the private room was medically necessary; the A/B MAC (A) will make an immediate finding to this effect.   Where it is necessary to develop the medical necessity of a private room, the guidelines in subsections 10.1.2 and 10.1.3 below will apply.   10.1.2 - Medical Necessity - Need for Isolation  (Rev. 1, 10-01-03) A3-3101.1.B, HO-210.1.B  A private room is medically necessary where isolation of a beneficiary is required to avoid jeopardizing their health or recovery, or that of other patients who are likely to be alarmed or disturbed by the beneficiary's symptoms or treatment or subjected to infection by the beneficiary's communicable disease.  For example, communicable diseases, heart attacks, cerebra-vascular accidents, and psychotic episodes may require isolation of the patient for certain periods.  (See 10.1.3 below concerning medical necessity not based on need for isolation).  In establishing the medical necessity for isolation, the date of the physician's written statement is not controlling, nor is the presence of a written statement.  The c rucial question is whether a private room was ordered by the physician because it is necessary for the health of the patient himself or herself or of other patients.  In the absence of such an order, a patient who requested the room with knowledge of the amount of the charge may be charged appropriately, even though a physician subsequently submits a statement that the room was medically necessary.  There may be cases in which the physician's written statement of medical necessity, though dated after admiss ion or even after discharge, merely confirms an order made informally at or before the time the beneficiary was admitted to the private room (e.g., the physician made arrangements by phone for the patient's admission, gave the diagnosis, and stated the beneficiary would need a private room).  In such cases, assuming that the private room was medically necessary, the lack of a written statement by the physician, or the fact that the written statement was prepared after discharge, would not be controlling.  T he patient may not be charged.   10.1.3 - Medical Necessity - Admission Required and Only Private Rooms Available  (Rev. 1, 10-01-03) A3-3101.1.C, HO-210.1.C  A private room is considered to be medically necessary even though the beneficiary's condition does not require isolation if he/she needs immediate hospitalization (i.e., the beneficiary's medical condition is such that hospitalization cannot be deferred) and the hospital has no semiprivate or ward accommodations available at the time of admission.   It need not be considered whether semiprivate or ward accommodations were available in some other accessible hospital.  Where medical necessity exists, the provider may not charge the beneficiary a private room differential until semiprivate or ward accommodations become available.  Thereafter the provider may transfer the patient to the nonprivate accommodations, or allow them to continue occupancy of the private room, subject to an appropriate differential charge (described in 10.1.1 above) if they request the private room with knowledge of the amount of the charge.  If the admission could be deferred until semiprivate or ward accommodations become available, the beneficiary should be informed of the amount of the differential he/she must pay for a private room if he/she wishes to be admitted immediately.  The beneficiary may be charged the specified differential if he/she has been admitted to the private room at their request (or at the request of their representat ive) with knowledge of the amount of the charge.  10.1.4 - Charges for Deluxe Private Room  (Rev. 1, 10-01-03) A3-3101.1.D, HO-210.1.D  Beneficiaries found to need a private room (either because they need isolation for medical reasons or because they need i mmediate admission when no other accommodations are available) may be assigned to any of the provider's private rooms.  They do not have the right to insist on the private room of their choice, but their preferences should be given the same consideration as if they were paying all provider charges themselves.  The program does not, under any circumstances, pay for personal comfort items.  Thus, the program does not pay for deluxe accommodations and/or services.  These would include a suite, or a room substa ntially more spacious than is required for treatment, or specially equipped or decorated, or serviced for the comfort and convenience of persons willing to pay a differential for such amenities.  If the beneficiary (or representative) requests such deluxe accommodations, the provider should advise that there will be a charge, not covered by Medicare, of a specified amount per day (not exceeding the differential defined in the next sentence); and may charge the beneficiary that amount for each day he/she occupies the deluxe accommodations.  The maximum amount the provider may charge the beneficiary for such accommodations is the differential between the most prevalent private room rate at the time of admission and the customary charge for the room occupied.  Beneficiaries may not be charged this differential if they (or their representative) do not request the deluxe accommodations.  The beneficiary may not be charged such a differential in private room rates if that differential is based on factors other than personal comfort items.  Such factors might include differences between older and newer wings, proximity to lounge, elevators or nursing stations, desirable view, etc.  Such rooms are standard 1-bed units and not deluxe rooms for purposes of these instructions, even though the provider may call them deluxe and have a higher customary charge for them.  No additional charge may be imposed upon the beneficiary who is assigned to a room that may be somewhat more desirable because of these factors.   10.1.5 - All Private Room Providers (Rev. 1, 10-01-03) A3-3101.E, HO-210.1.E  If the patient is admitted to a provider which has only private accommodations, and no semiprivate or ward accommodations, medical necessity will be deemed to exist for the accommodations f urnished.  Beneficiaries may not be subjected to an extra charge for a private room in an all-private room provider.  10.1.6 - Wards  (Rev. 1, 10-01-03) A3-3101.1.F, HO-210.1.F  The law contemplates that Medicare patients should not be assigned to ward accommodations except at the patient's request or for a reason consistent with the purposes of the health insurance program.  When ward accommodations are furnished at the patient's request or for a reason determined to be consistent with the program's purposes, payment will be based on the average per diem cost of routine services (see 10.1.1 above).  Where ward accommodations are assigned for other reasons, the law provides what may be a substantial penalty.  (See 10.1.6.2  below).  Any request by the patient (or relative or other person responsible for his or her affairs) for ward accommodations must be obtained by the provider in writing and kept in its files.   10.1.6.1 - Assignment Co nsistent With Program Purposes  (Rev. 1, 10-01-03) A3-3101.1.F.1, HO-210.1.F.1  It is considered to be consistent with the program's purposes to assign the patient to ward accommodations if all semiprivate accommodations are occupied, or the facility has no semiprivate accommodations.  However, the patient must be moved to semiprivate accommodations if they become available during the stay.   Some hospitals have a policy of placing in wards all patients who do not have private physicians.  Such a practice may  be consistent with the purposes of the program if the A/B MAC (A) determines that the ward assignment inures to the benefit of the patient.  In making this determination, the principal consideration is whether the assignment is likely to result in better medical treatment of the patient (e.g., it facilitates necessary medical and nursing supervision and treatment).  The A/B MAC (A) should ask a provider having this policy to submit a statement describing how the assignments are made, their purpose, and the effect on the care of patients so assigned.