(Medicare Benefit Policy Manual)

With regard to the time of discharge, a Medicare beneficiary is considered a patient of the hospital until the effectuation of activities typically specified by the ordering practitioner as havi ng to occur prior to discharge (e.g., discharge after supper or discharge after voids).  Thus, discharge itself can but does not always coincide exactly with the time that the discharge order is written, rather it occurs when the ordering practitioner s order for discharge is effectuated.   1. Content:  The ordering practitioners order contains the instruction that the beneficiary should be formally admitted for hospital inpatient care.  The order must specify admission for inpatient services.  Inpatient rehabilitation facilities (IRFs) must adhere to th e admission requirements specified in 42 CFR 412.622 .  The two midnight benchmark does not apply in IRFs.   2. Qualifications of the ordering/admitting practitioner:  The order must be furnished by a physician or other practitioner (ordering practitioner) who is:  (a) licensed by the state to admit inpatients to hospitals, (b) granted privileges by the hospital to admit inpatients to that specific facility, and (c) knowledgeable about the patients hospital course, medical plan of care, and current condition at the time of admission.  See section (B)(3) for a discussion of the requirements to be knowledgeable about the patients hospital course.  The ordering practitioner makes the determination of medical necessity for inpatient care and renders the admission decision.  The ordering practitioner is not required to write the order but must authenticate (sign, or in t he case of an initial order (under (B)(2)(a)) or a verbal order (under (B)(2)(b)), countersign) the order reflecting that he or she has made the decision to admit the patient for inpatient services.   The admission decision (order) may not be delegated to a nother individual who is not authorized by the state to admit patients, or has not been granted admitting privileges by the hospital's medical staff.  However, a medical resident, physician assistant, nurse practitioner, or other non- physician practitioner  may act as a proxy for the ordering practitioner provided they are authorized under state law to admit patients and the requirements outlined below are met ( FY 14 IPPS Final Rule  and 42 CFR 412.3(b)).  a. Residents and non- physician practitioners authorized to make initial admission decisions -  Certain non- physician practitioners and residents working within their residency program are authorized by the state in which the hospital is located to admit inpatients, and are allowed by hospital by -laws or policies to do the same.  The ordering practitioner ma y allow these individuals to write inpatient admission orders on his or her behalf, if the ordering practitioner approves and accepts responsibility for the admission decision by authenticating (countersigning) the order prior to discharge.  (See (A)(2) fo r guidance regarding the definition of discharge time and (B)(3) for more guidance regarding knowledge of a patients hospital course).  In authenticating (countersigning) the order, the ordering practitioner approves and accepts responsibility for the adm ission decision.  This process may also be used for practitioners (such as emergency department physicians) who do not have admitting privileges but are authorized by the hospital to issue temporary or bridge inpatient admission orders.   b. Verbal orders - At some hospitals, individuals who lack the authority to admit inpatients under state laws and hospital by laws (such as a registered nurse) may nonetheless enter the inpatient admission order as a verbal order.  In these cases, the ordering practitioner  directly communicates the inpatient admission order to staff as a verbal (not standing) order, and the ordering practitioner need not separately record the order to admit.  Following discussion with and at the direction of the ordering practitioner, a ver bal order for inpatient admission may be documented by an individual who is not qualified to admit patients in his or her own right, as long as that documentation (transcription) of the order for inpatient admission is in accordance with state law includin g; scope ofpractice laws, hospital policies, and medical staff bylaws, rules, and regulations.  In this case, the staff receiving the verbal order must document the verbal order in the medical record at the time it is received.  The order must identify the ordering practitioner and must be authenticated (countersigned) by the ordering practitioner promptly and prior to discharge.  Example:  Admit to inpatient per Dr. Smith would be considered an acceptable method of identifying the ordering practitioner and would meet the verbal order requirement if the verbal order (1) is appropriately documented in the medical record by the individual receiving the verbal order when the order is received; and (2) is authenticated (countersigned) by Dr. Smith promptly, prior to discharge.   c. Standing orders and protocols -  The inpatient admission order cannot be a standing order.  While Medicares rules do not prohibit use of a protocol or algorithm that is part of a protocol, only the ordering practitioner, or a residen t or other practitioner acting on his or her behalf under section (B)(2)(a) can make and take responsibility for the inpatient admission decision.  d. Commencement of inpatient status -  Inpatient status begins at the time of formal admission by the hospita l pursuant to the order, including an initial order (under (B)(2)(a)) or a verbal order (under (B)(2)(b)) that is authenticated (countersigned) timely, by authorized individuals, as required in this section.  If the practitioner responsible for authenticat ing (countersigning) an initial order or verbal order does not agree that inpatient admission was appropriate or valid (including an unauthorized verbal order), he or she should not authenticate (countersign) the order and the beneficiary is not considered  to be an inpatient.  The hospital stay may be billed to Part B as a hospital outpatient encounter.  3. Knowledge of the patients hospital course: CMS considers only the following practitioners to have sufficient knowledge about the beneficiarys hospital  course, medical plan of care, and current condition to serve as the ordering practitioner: the admitting physician of record (attending) or a physician on call for him or her, primary or covering hospitalists caring for the patient in the hospital, the beneficiarys primary care practitioner or a physician on call for the primary care practitioner, a surgeon responsible for a major surgical procedure on the beneficiary or a surgeon on call for him or her, emergency or clinic practitioners caring for the beneficiary at the point of inpatient admission, and other practitioners qualified to admit inpatients and actively treating the beneficiary at the point of the inpatient admission decision.  A utilization review committee physician functioning in that role does not have direct responsibility for the care of the patient and is therefore not considered to be sufficiently knowledgeable to order the inpatient admission.  The order must be written by one of the above practitioners directly involved with the car e of the beneficiary, and a utilization committee physician may only write the order to admit if he or she is not acting in a utilization review capacity and fulfills one of the direct patient care roles, such as the attending physician.  Utilization revie w may not be conducted by any individual who was professionally involved in the care of the patient whose case is being reviewed ( 42 CFR 482.30(d)(3)).  4. Timing:  The order must be furnished at or before the time of the inpatient admission.  The order can be written in advance of the formal admission (e.g., for a pre scheduled surgery), but the inpatient admission does not occur until hospital care services are provided to the beneficiary.  Conversely, in the unusual case in which a patient is admitted as an inpatient prior to an order to admit and there is no documented verbal order, the inpatient stay should not be considered to commence until the inpatient admission order is documented.  CMS does not permit retroactive orders.  Authentication by the ordering practitioner of the order (either by signature or, in the case of an initial order under (B)(2)(a) or a verbal order under (B)(2)(b), countersignature) is required prior to discharge for all inpatient cases.   5. Specificity of the Order:  The regulations at 42 CFR 412.3 require that, as a condition of payment, an order for inpatient admission must be present in the medical record.  The preamble of the FY 2014 IPPS Final Rule  at 78 FR 50942 states, the order must specify the admitting practitioners recommendation to admit to inpatient, as an inpatient, for inpatient services, or similar language specifying his or her recommendation for inpatient care.  While CMS does not  require specific language to be used on the inpatient admission order, it is in the interest of the hospital that the ordering practitioner use language that clearly expresses intent to admit the patient as inpatient that will be commonly understood by an y individual who could potentially review documentation of the inpatient stay.  CMS does not recommend using language that may have specific meaning only to individuals that work in a particular hospital (e.g., admit to 7W) that will not be commonly unde rstood by others outside of the hospital.  If admission order language used to specify inpatient or outpatient status is ambiguous, the best course of action would be to obtain and document clarification from the ordering practitioner before initial Medicare billing (ideally before the beneficiary is discharged).  Under this policy, CMS will continue to treat orders that specify a typically outpatient or other limited service (e.g., admit to ER, to Observation, to Recovery, to Outpatient Surger y, to Day Surgery, or to Short Stay Surgery) as defining a non inpatient service, and such orders will not be treated as meeting the inpatient admission requirements.   The admission order is evidence of the decision by the ordering practitioner to admit the beneficiary to inpatient status.  In extremely rare circumstances, the order to admit may be missing or defective (that is, illegible, or incomplete, for example inpatient is not specified), yet the intent, decision, and recommendation of the orde ring practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record.  In these extremely rare situations, contractors have been provided with discretion to determine that this information constructively satisfies the r equirement that the hospital inpatient admission order be present in the medical record.  However, in order for the documentation to provide acceptable evidence to support the hospital inpatient admission, thus satisfying the requirement for the order, the re can be no uncertainty regarding the intent, decision, and recommendation by the ordering practitioner to admit the beneficiary as an inpatient, and no reasonable possibility that the care could have been adequately provided in an outpatient setting.   This narrow and limited alternative method of satisfying the requirement for documentation of the inpatient admission order in the medical record should be extremely rare, and may only be applied at the discretion of the contractor.  20 - Nursing and Other S ervices  (Rev. 1, 10-01-03) A3-3101.2, HO-210.2  Nursing and other related services, use of hospital facilities, and medical social services ordinarily furnished by the hospital for the care and treatment of inpatients are covered under hospital insurance and included in the Prospective Payment system payment.  NOTE:  The services of a private-duty nurse or other private- duty attendant are not covered.  Private-duty nurses or private- duty attendants are registered nurses, licensed practical nurses, or any other trained attendant whose services ordinarily are rendered to, and restricted to, a particular patient by arrangement between the patient and the private-duty nurse or attendant.  Such persons are engaged or paid by an individual patient or by someone act ing on their behalf, including a hospital that initially incurs the costs and looks to the patient for reimbursement for such noncovered services.  Where the hospital acts on behalf of a patient, the services of the private -duty nurse or other attendant under such an arrangement are not inpatient hospital services regardless of the control which the hospital may exercise with respect to the services rendered by such private-duty nurse or attendant.  20.1 - Anesthetist Services  (Rev. 1, 10-01-03) A3-3101.2.A, HO-210.2.A  If the hospital engages the services of a nurse anesthetist or other nonphysician anesthetist (either on a salary or fee- for-service basis) under arrangements which provide for billing to be made by the hospital, the cost of the service when provided to an inpatient could be covered under Part A.  (See the Medicare Claims Processing Manual for more information.)  20.2 - Medical Social Services to Meet the Patient's Medically Related Social Needs  (Rev. 1, 10-01-03) A3-3101.2.B, HO-210.2.B  Medical social services are services which contribute meaningfully to the treatment of a patient's condition.  Such services include, but are not limited to:   Assessment of the social and emotional factors related to the patient's illness, need for care, r esponse to treatment, and adjustment to care in the facility;    Appropriate action to obtain case work services to assist in resolving problems in these areas; and    Assessment of the relationship of the patient's medical and nursing requirements to their h ome situation, financial resources, and the community resources available to them in making the decision regarding their discharge.  30 - Drugs and Biologicals  (Rev. 1, 10-01-03) A3-3101.3, HO-210.3