CMS Requirement for IP Level of Care

Does CMS have guidelines on selecting level of care/accommodation codes?  Patient presented and was admitted to a Tele unit.  The patient went south and was transferred to ICU but the physician didn't enter the transfer order for ICU until Day 2.   The clinical documentation supports ICU care.  Is it ok to charge for ICU on Day 1 even though the order wasn't entered until Day 2?  Does the physician need to add an addendum to his Day 1 progress note or is the clinical documentation of going south sufficient?

Comments

  • Just as the IP admission time is based on the physician order, the ICU time is also based on physician order and has a clinical validaton requirement of sorts in that the ICU level of service must be medically necessary based on the documentation in the record.

  • At our facility, once the patient is admitted to Inpatient status, the nursing accommodation code policy dictates the correct daily level of care assignment based on ordered services and care provided.  In the case above, we would assign the accommodation code prior to midnight for the level that the patient was in the majority of the day.  The accom code entered by nursing staff then determines the r/b charge that will drop.  Our accommodation policy in addition to the patient's documented status and care provided would be used to support the r/b charge if audited.

  • In the final IPPS rule for FY 2019 (https://www.govinfo.gov/content/pkg/FR-2018-08-17/pdf/2018-16766.pdf) CMS stated "We acknowledged that in the extremely rare circumstance the order to admit is missing or defective, yet the intent, decision, and recommendation of the ordering physician or other qualified practitioner to admit the beneficiary as an inpatient can clearly be derived from the medical record, medical review contractors are provided with discretion to determine that this information constructively satisfies the requirement that a written hospital inpatient admission order be present in the medical record." If the patient went south, there should be physician documentation that a transfer to ICU was required due to the patient's condition change. You do have an inpatient order, but it is the next day. My thought would be that you can support the ICU room charge from the day before the order based on the physician documentation in the record regarding the events that necessitated the transfer.  

  • I should also clarify in my previous response that we would have a valid and signed MD/physician order for the initial IP admission.  thx!

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