evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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)).
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
 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  Drugs and biologicals for use in the hospital, which are ordinarily furnished by the hospital for the care and treatment of inpatients, are covered.  Three basic requirements must be met for a drug or biological furnished by a hospital to be a covered hospital service:   1. The drug or biological must represent a c ost to the institution in rendering services to the beneficiary;   2. The drug or biological must meet the statutory definition.  Under the statute, payment may be made for a drug or biological only where it is included, or approved for inclusion, in the latest official edition of the United States Pharmacopoeia -National Formulary (USP -NF), the United States Pharmacopoeia Drug Information (USP DI), or the American Dental Association (ADA) Guide to Dental Therapeutics, except for those drugs and biologicals unfavorably evaluated in the ADA Guide to Dental Therapeutics.  Combination drugs are also included in the definition of drugs if the combination itself or all of the therapeutic ingredients of the combination are included, or approved for inclusion, in a ny of the above drug compendia.  Drugs and biologicals are considered approved for inclusion in a compendium if approved under the established procedure by the professional organization responsible for revision of the compendium; or be approved by the phar macy and drug therapeutics or equivalent committee of the medical staff of the hospital for use in the hospital; and   3. Use of the drug or biological must be safe and effective and otherwise reasonable and necessary as specified in the Medicare Benefit Polic y Manual, Chapter 15, Covered Medical and Other Health Services, 50.   Drugs or biologicals approved for marketing by the Food and Drug Administration (FDA) are considered safe and effective for purposes of this last requirement when used for indications specified in the labeling.  Therefore, use of an FDA -approved drug or biological is covered if:   It was administered on or after the date of the FDA's approval;   It is reasonable and necessary for the individual patient; and    All other applicable coverag e requirements are met.
(Medicare Benefit Policy Manual)
 It was administered on or after the date of the FDA's approval;   It is reasonable and necessary for the individual patient; and    All other applicable coverag e requirements are met.   Drugs and biologicals, which have not received final marketing approval by the FDA, are not covered unless CMS instructs the A/B MAC (A) to the contrary.  However, FDA-approved drugs are used for indications other than those specified on the labeling.  As long as the FDA has not specified such use as nonapproved, coverage is determined taking into consideration the generally accepted medical practice in the community.  For example, the labeling of certain chemotherapeutic drugs indicates their use in the therapy of specified types of cancer.  However, based on experience and empirical evidence, physicians may prescribe these drugs for a wider range of cancer treatments than what is indicated in the labeling.  Local medical review policy may or may not grant coverage, depending on the circumstances.  Determinations as to whether use of a drug or biological is reasonable and necessary for an individual patient are the responsibility of the Quality Improvement Organization (QIO), if this  is part of the review for a PPS acute care admission.  However, if this is an excluded service claim being reviewed by the A/B MAC (A), the A/B MAC (A) reviews and makes a determination, unless it cannot and needs to refer it to the QIO for an initial determination.   A hospital stay solely for the purpose of use of a drug or biological that is determined not reasonable and necessary is not covered.  30.1 - Drugs Included in the Drug Compendia  (Rev. 1, 10-01-03) A3-3101.2.A, HO-210.3.A
(Medicare Benefit Policy Manual)
Medicare covers only  those drugs and biologicals included, or approved for inclusion, in the latest official edition or revision of the compendia as previously listed.  Where a drug is excluded from coverage because it is unfavorably evaluated in either the AMA Drug Evaluatio ns or Accepted Dental Therapeutics, the exclusion applies to all uses for which the drug or biological was so unfavorably evaluated.  Drugs and biologicals are considered "approved for inclusion" in a compendium if approved under the procedure established by the professional organization responsible for revision of the compendium.  30.2 - Approval by Pharmacy and Drug Therapeutics Committee  (Rev. 1, 10-01-03) A3-3101.3.B, HO-210.3.B  A pharmacy and drug therapeutics or equivalent committee is a medical staff committee that confers with the hospital pharmacist in the formulation of policies pertaining to drugs.  Drugs and biologicals approved for use in the hospital by such a committee are covered only if the committee develops and maintains a formulary or li st of drugs accepted for use in the hospital.  The committee need not function exclusively as a pharmacy and drug therapeutics committee but may also carry on other medical staff functions.  Drugs and biologicals are considered approved for use in the hospital if selected for inclusion in the hospital drug list of formulary under the procedure of the committee established for that purpose.  Express approval is required; the fact that a drug or biological has not been specifically determined to be unacceptab le for use in the hospital does not constitute approval.  Drugs and biologicals are covered if approved for general use in the hospital, or if approved for use by a particular patient or group of patients.  Approval by a pharmacy and drug therapeutics comm ittee is an alternative to approval for inclusion of the drug or biological in an approved drug compendium (see 30.1 above); such approval does not preclude the need for a determination of medical necessity.  An investigat ional drug is not considered to meet the reasonable and necessary test since its efficacy has not yet been established.
(Medicare Benefit Policy Manual)
above); such approval does not preclude the need for a determination of medical necessity.  An investigat ional drug is not considered to meet the reasonable and necessary test since its efficacy has not yet been established.   The decision of individual hospitals should not transcend the determinations of the Food and Drug Administration and Public Health Service in respect to the safety and effectiveness of drugs.  Therefore, even if approved by an appropriate hospital committee, the reasonable cost of an investigational or other nonapproved drug or biological (e.g., Laetrile) cannot be reimbursed.  This exclusion from payment applies whether or not the drug or biological is administered during the course of an otherwise covered hospital stay, since payment may not be made for items and services that are not reasonable and necessary.  A hospital stay solely for the purpose of administering a drug or biological that is not reasonable and necessary, including an investigational drug or biological, is not covered and the drug or biological itself is not covered.  30.3 - Combination Drugs  (Rev. 1, 10-01-03) A3-3101.3.C, HO-210-3.C  Combination drugs are covered if the combination itself or all of the therapeutic ingredients of the combination are included, or approved for inclusion, in any of the designated drug compendia.  Any combination drug approved for use in the hospital by the pharmacy and drug therapeutics or equivalent committee is covered.   30.4 - Drugs Specially Ordered for Inpatients  (Rev. 1, 10-01-03) A3-3101.3.D, HO-210.3.D
(Medicare Benefit Policy Manual)
30.4 - Drugs Specially Ordered for Inpatients  (Rev. 1, 10-01-03) A3-3101.3.D, HO-210.3.D  Coverage is not limited to drugs and biologicals routinely stocked by the hospital; a drug or biological not stocked by the hospital, which the hospital obtains for the patient from an outside source, such as a community pharmacy, can also be covered.  Drugs and biologicals not included in the drug list or formulary maintained b y the hospital's pharmacy and drug therapeutics committee may be covered if the hospital has a policy which permits such drugs to be furnished to a patient at the special request of a physician.  However, in order to be covered, such drugs and biologicals must be included, or approved for inclusion, in one of the designated drug compendia.  (In addition, a combination drug, or all of its therapeutic ingredients, would have to be included or approved for inclusion in one of the compendia.)  30.5 - Drugs for Use Outside the Hospital  (Rev. 1, 10-01-03) A3-3101.3.E, HO-210.3.E  Drugs and biologicals furnished by a hospital to an inpatient for use outside the hospital are, in general, not covered as inpatient hospital services.  However, if the drug or biological is deemed medically necessary to permit or facilitate the patient's departure from the hospital, and a limited supply is required until the patient can obtain a continuing supply, the limited supply of the drug or biological is covered as an inpatient hospital service.   40 - Supplies, Appliances, and Equipment  (Rev. 1, 10-01-03) A3-3101.4, HO-210.4  Supplies, appliances, and equipment, which are ordinarily furnished by the hospital for the care and treatment of the beneficiary solely during the inpatient h ospital stay, are covered inpatient hospital services.
(Medicare Benefit Policy Manual)
Supplies, appliances, and equipment, which are ordinarily furnished by the hospital for the care and treatment of the beneficiary solely during the inpatient h ospital stay, are covered inpatient hospital services.   Under certain circumstances, supplies, appliances, and equipment used during the beneficiary's inpatient stay are covered under Part A even though the supplies, appliances and equipment leave the hospital with the patient upon discharge.  These are circumstances in which it would be unreasonable or impossible from a medical standpoint to limit the patient's use of the item to the periods during which the individual is an inpatient.  Examples of items c overed under this rule are:   Items permanently installed in or attached to the patient's body while an inpatient, such as cardiac valves, cardiac pacemakers, and artificial limbs; and    Items which are temporarily installed in or attached to the patient's body while an inpatient, and which are also necessary to permit or facilitate the patient's release from the hospital, such as tracheotomy or drainage tubes.  Hospital admission packs containing primarily toilet articles, such as soap, toothbrushes, toothpaste, and combs, are covered under Part A if routinely furnished by the hospital to all its inpatients.  If not routinely furnished to all patients, the packs are not covered.  In that situation, the hospital may charge beneficiaries for the pack, but only if they request it with knowledge of what they are requesting and what the charge to them will be.   Supplies, appliances, and equipment furnished to an inpatient for use only outside the hospital are not, in general, covered as inpatient hospital services.  However, a temporary or disposable item, which is medically necessary to permit or facilitate the patient's departure from the hospital and is required until the patient can obtain a continuing supply, is covered as an inpatient hospital service.  Oxygen furnished to hospital inpatients is covered under Part A as an inpatient supply.  50 - Other Diagnostic or Therapeutic Items or Services  (Rev. 1, 10-01-03) A3-3101.5, HO-210.5