Crystal's MCW Coder HubTags: compliance medicare cms inpatient
Key Resources
Medicare Learning Network (MLN)
- Free educational resources
- URL: cms.gov/Outreach-and-Education
- Search: “Inpatient E/M Services”
Local Coverage Determinations (LCDs)
- Specific to your MAC jurisdiction
- URL: cms.gov/medicare-coverage-database
- Search by specialty or code
Two-Midnight Rule
Inpatient Admission Criteria
- Inpatient: Expected stay ≥2 midnights
- Observation: Expected stay <2 midnights
Exceptions
- Procedures on inpatient-only list
- Death before 2 midnights
- Transfer to another hospital
Inpatient-Only Procedures
| Category | Examples |
|---|---|
| Cardiac | CABG, valve replacement |
| Neuro | Craniotomy, spinal fusion |
| Ortho | Total joint replacement |
| General | Some laparoscopic procedures |
Status Verification
Always verify patient status before billing. Wrong status = denial.
Teaching Hospital Rules
| Setting | Rule |
|---|---|
| Teaching | Teaching physician guidelines |
| Non-Teaching | Standard Medicare rules |
| Rural | Some flexibility |
Split/Shared (2024+)
Substantive Portion
- More than half of total time, OR
- Most of the MDM
- Modifier FS required when physician bills
Critical Care Policies
| Requirement | Detail |
|---|---|
| Minimum Time | 30 minutes |
| Documentation | Total time required |
| Bundled Services | Cannot bill separately |
| Same Day E/M | Modifier 25 on E/M |
Appeals Process
- Redetermination (120 days)
- Reconsideration (180 days)
- ALJ Hearing (60 days)
- Medicare Appeals Council (60 days)
- Federal Court (60 days)
Stay Updated
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00 Inpatient ProFee Coding MOC Medical Necessity for Inpatient Teaching Physician Rules