CMS Releases Additional 2014 IPPS Implementation Guidance


CMS Releases Additional 2014 IPPS Implementation Guidance – In early November, CMS released additional guidance regarding implementation of provisions of the 2014 Inpatient Prospective Payment System (IPPS) Final Rule that apply to inpatient admissions. For more background regarding the IPPS Final Rule, please see the August 5, 2013 Health Headline, CMS Releases FY 2014 Hospital IPPS Final Rule.

In the new guidance documents, CMS provides additional detail regarding its “Probe and Educate” implementation period. Initially, CMS stated that the Probe and Educate period would apply to claims for inpatient admissions between October 1, 2013 and December 31, 2013. In the new guidance, CMS extended the Probe and Educate period to inpatient admissions occurring between October 1, 2013 and March 31, 2014. During this period, Recovery Audit Contractors are not permitted to review inpatient admissions to assess patient status. Initially, CMS will instruct Medicare Administrative Contractors (MACs) to conduct a prepayment review of a sample of 10 or 25 claims for inpatient stays spanning less than 2 midnights, depending on hospital size. MACs are instructed to use the initial probe reviews as educational tools. Depending on the number of denials in the initial probe sample, hospitals may receive additional reviews of claims with dates of admission between January 1, 2014 and March 31, 2014. However, MACs will not review Part A claims spanning 2 or more midnights after formal inpatient admission for appropriateness of the inpatient admission during the Probe and Educate period. Notably, Critical Access Hospitals are specifically excluded from patient status reviews during this 6-month timeframe.

Because the probe reviews will be conducted on a prepayment basis, hospitals may rebill for medically necessary Part B inpatient services provided during Part A inpatient hospital stays that are found not to be reasonable and necessary.

In addition, CMS offers additional clarification regarding the application of the inpatient admission two-midnight presumption and benchmark policies.

To visit the CMS Inpatient Hospital Review webpage, click here. To view the CMS Questions and Answers Relating to Patient Status Reviews, click here. CMS guidance regarding selection of hospital claims for patient status reviews may be found here. CMS guidance for reviews of hospital claims for patient status may be found here.

Reporter, Lauren Slive, Atlanta, +1 404 572 3592,

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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