How Eliminating the Inpatient-Only List Puts Documentation Back in The Spotlight
by XSOLIS Insights, on Jan 20, 2021 7:00:00 AM
January 1, 2021, marked the initial implementation of a new policy change by the Centers for Medicare and Medicaid Services (CMS) that will eventually end the inpatient-only list.
The initial phase of this three-year transition removes about 300 inpatient-only procedures from the list, mostly musculoskeletal. By 2024, 1,700 procedures in all will be removed, leaving the determination of inpatient or outpatient care to the physician, and expanding coverage options for patients and providers.
“Inpatient-only meant outpatient never,” says Dr. Alan Balick, Vice President of Medical Affairs at XSOLIS. “This new rule now brings clinical merit back to the forefront of healthcare, which is fundamental when providing the best care for patients.”
CMS says the new rule's goal is to “put more control back into patients’ and doctors’ hands.” As Dr. Balick said, if someone needed one of the 1,700 procedures done on the inpatient-only list, it had to be done in a hospital inpatient setting to be covered by Medicare. The new rule allows patients and doctors the freedom to determine a case as outpatient, and still be covered.
“It allows doctors and patients to make decisions about the most appropriate site of care, based on what makes the most sense for the course of treatment and the patient without micromanagement from Washington,” Seema Verma, administrator of CMS, said in a release.
The American Hospital Association and Healthcare Financial Management Association voiced concerns about the new rule. The main issue? Fear that the administrative burden would increase for care and coordinated services in hospitals as well as physicians. Instead of an inpatient-only automatic determination, patients will need further evaluation to determine the best recommendation for patients. That requires better documentation.
But Dr. Balick believes this rule will force doctors to go back to their basic responsibility of telling the patient’s most relevant clinical story. He feels this has been missing because the inpatient-only regulations allowed for abbreviated documentation. Little comprehensive documentation was necessary to determine the status; it was already decided for everyone.
“Physician documentation is always king, and this new rule puts that back in the spotlight,” he says. “It’s our job to justify the patient’s need for ongoing care in the hospital every day. An accurate narrative should justify both the clinical complexity and the reimbursement, but it cannot just be about how sick someone is and how intense the treatment is; it also has to include the concern of the treating physician for a case to truly align properly. Only by providing such documentation routinely will we be able to consistently demonstrate whether a patient’s two-midnight stay expectation is reasonable or not.”
XSOLIS’ CORTEX platform helps ease the administrative burden by providing non-biased patient status predictions in real time through artificial intelligence. “CORTEX continues to facilitate the navigation of hospital case reviews, bringing those most compelling and conflicting components to the surface for efficient adjudication as the patient’s hospital course progresses,” says Dr. Balick.
With all the regulatory changes that continue to evolve, Dr. Balick and his team continue to work with our clients from an educational perspective to show how we all best proceed in managing these evolving challenges.
See how the CORTEX platform can help reduce your administrative burden and prepare the right documentation needed for compliance by scheduling a demo today.