Fillable Checklist: Inpatient admission documentation (Medicare & Medicaid)

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Checklist: Inpatient admission documentation (Medicare & Medicaid)

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04/09/2020
On August 2, 2013, the Centers for Medicare & Medicaid Services, (CMS) issued Fiscal Year 2014 Inpatient Prospective
Payment System (IPPS) final rule (CMS-1599-F), which modifies and clarifies CMS‘s longstanding policy on how Medicare
contractors review inpatient hospital admissions for payment purposes.
The two-midnight presumption outlined in CMS-1599-F specifies hospital stays spanning two or more midnights after the beneficiary is
formally admitted as an inpatient will be presumed to be reasonable and necessary for the inpatient status as long as the hospital stay
is medically necessary. Inpatient stays spanning less than two midnights after the beneficiary is formally admitted as an inpatient are
not subject to the presumption and may be selected for medical review. However, if total time in the hospital receiving medically
necessary care (including pre-admission outpatient time from the time care is initiated in the hospital) spans two or more midnights,
the two-midnight benchmark for inpatient admission will be met and payment supported upon medical review.
This checklist was created as a tool to assist hospital personnel when responding to medical record documentation requests. The
provider of service must ensure correct submission of documentation to the Medicare contractor within the specified calendar days
outlined in the request.
The documentation submitted for review should include, if applicable, but is not limited to the following:
Name of beneficiary and date of service in all documentation
Inpatient certification
Signed and dated by a physician prior to discharge
Reason for inpatient admission
Estimated and/or actual hospital time
Progress notes support the reason for admission and explain current treatment plans
Post-hospital care plans
Valid inpatient admission order
Admission order
Includes specific language such as “admit to inpatient,” “admit to inpatient services,” or similar
Written order
Verbal order
Includes specific language such as “admit to inpatient,” “admit to inpatient services,” or similar
Identity of the ordering physician/practitioner
Countersigned and dated by a physician/practitioner
Written at or before the time of the inpatient admission
Authenticated prior to discharge
Checklist: Inpatient admission documentation
Two-midnight rule
04/09/2020
Two-midnight benchmark
Include all outpatient services time
Observation
Emergency department
Operating room
Other treatment areas
Note: Do not include time in pre-hospital services such as simple triage and time in ambulance.
Exceptions or unforeseen circumstances
Patient’s death
Patient transferred to another facility
Patient left against medical advice (AMA)
Unexpected recovery is clearly documented in medical record
Other:
Signed, timed and dated physician orders for each day of care/service
History and physical
Legible physician progress notes
All diagnostic and laboratory reports, as applicable
Surgical procedure reports
Anesthesia reports
Medication administration record
Nurses' notes
Ambulance run sheet
Discharge summary
Signature log or physician’s attestation for any missing signatures
Signed ABN/HINN
Any other clinical records that support the medical necessity of the service billed
Any other documentation a provider deems necessary to support medical necessity of services billed, as well as
documentation specifically requested in the Additional Documentation Request (ADR) letter
Providers should refer to the CMS inpatient hospital review information at https://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html for additional
information on the two-midnight rule. Official documentation and coverage guidelines can be found at https://
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf and https://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads/clm104c12.pdf.
Disclaimer: This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the
documentation requirements published in national or local coverage determinations, or the CMS’s documentation guidelines. It is
the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.
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Completed 10 January 2021

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