Bedded Outpatient Vs Observation Essay

Effective October 1, 2013, new rules for inpatient hospital reimbursement under the Medicare program[1] make final two sets of proposed rules that the Centers for Medicare & Medicaid Services (CMS) published in the Spring 2013 – the definition of an inpatient hospital stay based on time[2] and a hospital rebilling option.[3]  Neither set resolves the problem of Observation Status for Medicare beneficiaries. 

Observation Status

Observation Status refers to the classification of hospital patients as "outpatients," even though, like inpatients, observation patients may stay for many days and nights in a hospital bed, receive medical and nursing care, diagnostic tests, treatments, supplies, medications, and food.[4]  The classification of a hospitalized patient as an "outpatient," however, causes many problems for the patient.  Without a three-day inpatient hospital stay, the patient does not meet Medicare's requirement for Medicare coverage of a subsequent stay in a skilled nursing facility (SNF).[5]  Patients in Observation Status must pay out-of-pocket for their nursing home care, with bills often totaling many thousands of dollars.

CMS Response to Observation Status

For at least the past three years, CMS has repeatedly expressed concern about Medicare beneficiaries' increasingly lengthy stays in hospitals as outpatients and the impact of the classification on beneficiaries' need for post-acute care in a SNF.[6]  Unfortunately, this has not yet translated into action that resolves the issue for beneficiaries.  CMS expresses hope that the new final regulations, published August 19, 2013, will "reduce the frequency of extended observation care when it may be inappropriately furnished."[7]  Unfortunately, the regulations and CMS's lengthy discussion of them in a section of the preamble entitled "Payment Policies Related to Patient Status" do not resolve the problem of Observation Status for Medicare beneficiaries.

CMS explicitly states in the preamble, "[w]hile outpatient time may be accounted for in application of the 2-midnight benchmark, it may not be retroactively included as inpatient care for skilled nursing care eligibility or other benefit purposes."[8] In practice, this means there will still be Medicare beneficiaries who spend three or more days in the hospital who will not qualify for Medicare covered post-acute care at a SNF.  Some or all of their time in the hospital will be considered outpatient observation, and not count toward the required three-day stay.

A direct and simple solution to beneficiaries' primary problem with observation status lies in bipartisan legislation pending in Congress.[9]  The two identical bills would require that all time spent in the hospital – whether called observation or inpatient – be included in calculating the three-day inpatient qualifying hospital stay.

Time-based Presumptions

1. Regulatory Requirements

A new 42 C.F.R. §412.3(a) provides that a patient "is considered an inpatient of a hospital,…if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner…."  The physician orders inpatient status when he or she "expects the patient to require a stay that crosses at least 2 midnights."[10]  Stays expected to be shorter than at least two midnights "are generally inappropriate for inpatient admission and inpatient payment under Medicare Part A," unless the surgical procedure is "specified by Medicare as inpatient only under §419.22(n)."[11]  The physician's "expectation…should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event."[12]  The physician order is part of "physician certification of the medical necessity of hospital inpatient services…."[13] 

Physician certification, which begins with an order for inpatient admission, requires the physician to certify the reasons for the hospitalization, the estimated time the patient will remain in the hospital, and "plans for post-hospital care, if appropriate."[14]  The certification "must be completed, signed, and documented in the medical record prior to discharge."[15] 

A physician's admission order has "no presumptive weight" and both the admission order and the physician certification "will be evaluated in the context of the evidence in the medical record."[16]  CMS intends to provide additional information about what "evidence in the medical record" means in future instructions and manual revisions.[17]

2. Preamble

The preamble states repeatedly that a physician admission order cannot be retroactive.[18]  But, ambiguously and inconsistently, CMS also describes how physicians should treat outpatient time in making inpatient admission decisions: 

[W]e expect that the decision to admit the beneficiary should be based on the cumulative time spent at the hospital beginning with the initial outpatient service.  In other words, if the physician makes the decision to admit after the beneficiary arrived at the hospital and began receiving services, he or she should consider the time already spent receiving those services in estimating the beneficiary's total expected length of stay.  For example, if the beneficiary has already passed 1 midnight as an outpatient observation patient or in routine recovery following outpatient surgery, the physician should consider the 2 midnight benchmark met if he or she expects the beneficiary to require an additional midnight in the hospital.  This means that the decision to admit becomes easier as the time approaches the second midnight, and beneficiaries in medically necessary hospitalizations should not pass a second midnight prior to the admission order being written.[19]

The preamble discusses two related concepts of "2-midnight presumption" and "2-midnight benchmark," first describing the 2-midnight presumption:

Under the 2-midnight presumption, inpatient hospital claims with lengths of stay greater than 2 midnights after the formal admission following the order will be presumed generally appropriate for Part A payment and will not be the focus of medical review efforts absent evidence of systematic gaming, abuse or delays in the provision of care in an attempt to qualify for the 2-midnight presumption . . . .[20]

For purposes of the 2-midnight benchmark, CMS says that medical reviewers may consider all time spent by a patient in the hospital, regardless of how the time is identified:

We emphasize that the time the beneficiary spent as an outpatient before the inpatient admission order is written will not be considered inpatient time, but may be considered by physicians in determining whether a patient should be admitted as an inpatient, and during the medical review process for the limited purpose of determining whether the 2-midnight benchmark was met and therefore payment is generally appropriate under Part A [emphasis supplied]. [21]

In contrast, for patients not arriving in the hospital through the emergency room (i.e., for patients whose hospitalization is scheduled) "the starting point for medical review purposes will be when the beneficiary starts receiving services following arrival at the hospital,"[22] presumably, including observation time.

The distinction made between patients who go to the emergency room and those whose hospitalization is planned suggests that CMS's concern with observation status is primarily to do with patients who arrive in the hospital through the emergency room.

Hospital Rebilling

1. Regulatory Requirements

A new §414.5 is entitled "Hospital services paid under Medicare Part B when a Part A hospital inpatient claim is denied because the inpatient admission was not reasonable and necessary, but hospital outpatient services would have been reasonable and necessary in treating the beneficiary."  Section 414.5(a) authorizes a hospital to rebill Part B if a Part A claim is denied or if the hospital determines after the patient is discharged that the patient's hospital stay should have been billed as outpatient rather than as inpatient.  Hospitals must submit Part B claims within one year of providing the service.[23]  Of note, CMS reports that more than 300 commenters opposed the proposal to limit rebilling under Part B to claims submitted within one calendar year of service and that only a single commenter supported that proposal.  [24]

2. Preamble

If a hospital submits a Part B claim for a patient, following the patient's discharge, the patient retains inpatient status for purposes of Medicare coverage of the subsequent SNF stay.  CMS provides:[25]

the status of the beneficiaries themselves does not change from inpatient to outpatient under the Part B inpatient billing policy.  Therefore, even if the admission itself is determined to be not medically necessary under this policy, the beneficiary would still be considered a hospital inpatient for the duration of the stay – which, if it occurs for the appropriate duration, would comprise a 'qualifying' hospital stay for SNF benefit purposes so long as the care provided during the stay meets the broad definition of medical necessity described above [referring the Medicare Benefit Policy Manual, Chapter 8, §20.1][26]

However, if the hospital rebills Medicare under Part B, it must refund the Part A deductible and bill the patient for the Part B copayments.[27]

CMS rejects commenters' suggestions to give patients an additional standardized notice or a Frequently Asked Question sheet or to add information to the Important Message from Medicare (IM) form, to alert patients at the time of inpatient admission that their status might be changed during, or after, their hospital stay.  Describing such notice as "likely [to] create undue confusion and concern for beneficiaries," CMS says that it will engage in an educational campaign for beneficiaries about the final rules.  This will include information in the annual Medicare & You publication and Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!.[28] In addition, the Medicare Summary Notice will include new messages.[29] 

These newly created MSN messages explain that the hospital may submit the claim under Part B and that different cost-sharing may apply.  In this manner, we will incorporate the commenters' suggestion on the timing of post-discharge delivery of information regarding billing under Part B for inpatient hospital services, consistent with our approach to delivering notices at a time when the information is most relevant.[30]

CMS predicts that more patients will be inpatients under its revised regulations as a result of its new Part B inpatient billing policies.[31]


Despite the new regulations, observation status will remain a problem for Medicare beneficiaries who need post-acute care in a SNF.  Instead we look to the federal legislation and successful resolution of pending litigation brought by the Center for Medicare Advocacy[32]  which would resolve the problem of observation status for beneficiaries.


[1] 78 Fed. Reg. 50495, 50906-954 (Aug. 19, 2013).
[2] 78 Fed. Reg. 27486, 27644 (May 10, 2013).  See CMA, “CMS Addresses Observation Status Again . . . And Again, No Help for Beneficiaries,” (Weekly Alert, May 16, 2013),
[3] 78 Fed. Reg. 16632 (March 18, 2013).  See CMA, “CMS’ Proposed Rules on Observation Status Would Not Help Beneficiaries” (Weekly Alert, March 28, 2013),
[4]See the Center for Medicare Advocacy’s extensive materials on observation status,
[5] 42 U.S.C. §1395x(i); 42 C.F.R. §409.30(a)(1).
[6] In August 2010, CMS held an Open Door Forum on extended hospital observation stays,  CMS repeated the concern in proposed rules for the hospital prospective outpatient payment system, 77 Fed. Reg. 45155 (July 30, 2012); in final rules on the hospital prospective outpatient payment system, 77 Fed. Reg. 68426-433 (Nov. 15, 2012); in proposed rules on A-B rebilling, 78 Fed. Reg., 16632, 16634-634 (March 18, 2013); in proposed rules on time-based presumptions of inpatient status, 78 Fed. Reg.27486, 27644 (May 10, 2013); final inpatient prospective payment rules, 78 Fed. Reg. 50495, 50907 (Aug. 19, 2013).
[7] 78 Fed. Reg., 50908.
[8] 78 Fed. Reg. 50950.
[9] H.R.1179 and S.569, “Improving Access to Medicare Coverage Act of 2013.”
[10] 42 C.F.R.  §412.3(e)(1). 
[13] 42 C.F.R. §412.3(c). 
[14] 42 C.F.R. §424.13(a)(1)-(4). 
[15] 42 C.F.R. §424.13(b).
[16] 42 C.F.R. §412.46(b). 
[17] 78 Fed. Reg., 50944.
[18] 78 Fed. Reg., 50942,
[19] 78 Fed. Reg., 50946.
[20] 78 Fed. Reg., 50949.
[21] 78 Fed. Reg., 50950.
[22] 78 Fed. Reg., 50952.
[23] 42 C.F.R.  §414.5(c).
[24] 78 Fed. Reg., 50922.
[25] 78 Fed. Reg., 50918.
[26] 78 Fed. Reg., 50921.  See also “[W]hen the inpatient hospital stay is paid under Part B, the hospital stay remains inpatient from the time of admission and may continue to count towards qualification for skilled nursing facility coverage, and the beneficiary is liable for the Part B inpatient charges.”  78 Fed. Reg., 50934.
[27] 78 Fed. Reg., 50918.
[28] CMS Product No. 11435, at
[29] 78 Fed. Reg., 50919.
[30] 78 Fed. Reg., 50919.
[31] 78 Fed. Reg., 50936, 50937 (Table 2).
[32]Bagnall v. Sebelius, No. 3:11-cv-01703 (D. Ct., filed Nov. 3, 2011), 



Your wcw puts more effort into making her ig captions than she does for her school essays.

group 3 extended essay? fqxi 2016 essay aite stamford admissions essay does every essay need a title? is that why i never got a perfect score in any of my Filipino essays back in high school? learning essay writing pdf pictorial essay writing aristophane les oiseaux explication essay what is your life goal essay mary finsterer biographical essay christopher columbus research paper quote nathaniel hawthorne research paper video first sentence of a reflective essay about myself globalization effects on environment essay pollution the veldt critical essay? dissertationspreis uni bielefeld elements of successful essay. spannende geschichte beispiel essay health dissertation research essay link words puzzle cancer reflection essay for english 101 26th january essay writing travian troops comparison essay? Happy birthday to Jean-Paul #Sartre. Read his classic essay on the Nazi occupation of France, now a #kindle single: why school is fun essay brain tumor research paper pdf bruges political research paper jacksonian democracy essay reviews peel essay writing history issues for research papers karnataka konzeptuelles wissen beispiel essay el lazarillo de tormes analysis essay inconsistent triad essay writer order of dissertation documentary research dissertation proposal restaurant bessay sur allierte msc dissertation only american agriculture essay video rallycross essay 2016 movies writing research papers in science? introduction to a qualitative research paper. linking words list for essays about education playstation 3 slim vs super slim comparison essay roe v wade essay graphic design numbers in apa essay. synthesis essay on vaccination. important object essay. importance of a research paper uk. Bodenwertverzinsung beispiel essay konzeptuelles wissen beispiel essay essay om begrebet troweprice, action centred leadership critique essay save the girl child short essay about life? my house essay in japanese research paper of data mining wind sprints shorter essays about life. genetic engineering babies essays sex pistols essay persuasive essay promtKite runner essay conclusion dissertation author declaration good college essays about leadership I have an English essay to type but here I am playing Where's Tyler with Melanie over Snapchat how to write a background research paper jams can you write a research paper in first person how to write a research paper for high school students indenting paragraphs in essays do you write essay describing a reporter polythene bags should be banned essay writing essay on death sentence should be abolished ways to introduce a quote in an essay college admissions essay help xlswrite au bonheur des dames analysis essay essay on dedication determination and discipline mechanical engineering dissertation quotes living up the street essaymccarthyism essay description bienvenido lumbera essays about life human rights and social justice essays. causes of the chinese civil war essay conclusions about my teacher essay for simple quilting maison retraite mapas frogessay. Apa doctoral dissertation online causes of war essay, essay om begrebet troweprice narrative essay thesis statement year 3 zapatistas 1931 essay bovarism essay about myself research papers on wimax pdf individual sports and team sports essay swimming research paper martin luther king jr, fsu application essay recent research papers in power electronics magazine angela s ashes quotes essays about education university of victoria british columbia mba essays philosophical essay about failure diethylzinc synthesis essay dissertation proposal abstract keywords quoting bible verses in essay essay exasperating shop keepers insurance, group 3 extended essay abortion is wrong essay ukulele chords video rallycross essay 2011? how to write an abstract for the extended essay quoting bible verses in essay parent involvement and student success research papers essayer de trouver picture with descriptive essay.

January 2002 us history regents essay jadeja and raina argumentative essay essay writer online uk stores anthology essays dissertation proposal abstract keywords first computer used for weather research paper objectivation de la faute dissertation writing cheerleading passion essay how to write an essay about an opinion hiroshima mon amour essay. invention of tv essays causes of war essay physical geography photo essay I am now a thesaurus #daughter# university dissertation# Its what Mums do beowulf essay conclusion gallotta theatre de la ville critique essay? friedrich nietzsche genealogy of morals essay 10 i want to change the world essay what do you need to write an argumentative essay sarojini naidu short essays, how to be successful in college essay in english Top notch essay writing advice from @realbradsmith01 essay about bullying effects article analysis of those winter sundays essays on success raksha bandhan essay in sanskrit language neural networks research paper methodology. Fqxi 2016 essay la caverna de platon analysis essay erlkonig poem analysis essays, matiere principale en premiere essay what do you need to write an argumentative essay. animal abuse essays videos? e214 ema essays health drinks research papers discursive essay on eating disorders ussr documentary essay sports during cold war art belief essay life research paper gravity flow racking rhetorical essay thesis. Pagbabago ng panahon essays tu essays de faire part. Essay flood in uttarakhand introduction to a qualitative research paper sinhala essays about sri lanka sociology essays on stratification good things to write an essay about me argument essay on paying college athletes research paper of data mining disobeying a direct order essay online essay on pet animal dog sanskrit essays in sanskrit language on kalidasa shakuntala. How to introduce points in an essay american beauty existentialism essay jean? metta sutta thanissaro bhikkhu essays. domestic essay student violence is the world over populated essay writer et decorum est essay essay on science versus literature the irish language essay essay om uret tikker wrist healthy body healthy mind essay causes of the great depression one essay writing the perfect philosophy essay. Essayez johnny hallyday tabata group 3 extended essay essay on life without modern gadgets lessay foire a tout engineering ethics essay successful and unsuccessful students essay about stereotype discussion essay linking words essay. essay on internet a boon or a bane in 150 words globalization effects on environment essay pollution walmart history essay introduction i believe money can buy happiness essay why are you here essay. research paper on gmo food x ray essayez johnny hallyday tabata zapatistas 1931 essay cancer reflection essay for english 101, good introduction for obesity essay Ms Stringham my Essay on the perfect school says still missing!! Sharing this 1997 Newsweek essay from my friend and breast cancer survivor, Bob Riter. You've been fighting this... au bonheur des dames analysis essay. secret sharer summary analysis essay mit sloan essays 2016 tx68? upsc essay answer sheet new yorker essay 5th year plan essays narrative essay thesis statement year 3 dissertation binding bristol zones custom writing essays zoning maps how to write literature essays the positive effects of peer pressure essay unity of mankind essays essay describing a reporter global warming essay in marathi peter schatzl dissertation defense, leroi jones blues people research paper john zerzan essays on education past and modern society essays invention of tv essays phytoremediation research papers chemistry after school club application essay. Equality for women essayists Integration of SWOT and QFD Custom Essay research paper about henry ford january 2002 us history regents essay healthy body healthy mind essay is walmart good for america essay conclusion upsc essay answer sheet essays on to kill a mockingbird setting.

Apply texas 3 essays gillian cross author biography essay who was the first english essayist historylink org essays output nyc nitroso synthesis essay how to start college essay intro, story photo essay research paper on gmo food x ray? the ambassadors painting description essay is the world over populated essay writer persuasive essay map up why school is fun essay research paper about alcoholism introduction. Nwa essays on success what is the purpose of synthesis essay dissertation aaas exclusive essays Haven't started my 3 page zoology essay yet that's due tomorrow but I did get to watch Blackfish bc of it research paper on emily dickinson videos how was the cold war fought essay industrialization and urbanization essays international baccalaureate extended essay science miranda v arizona essay paper essay summary description poem group 3 extended essay hallonsten essays, ap gov supreme court essays cdlu distance education admission essays three lives for mississippi essay commercial. research papers on market efficiency. The bell song natalie dessay opera mischo kelling dissertation defense disarmament on css essay @omar_quraishi Listening to rave music is the only way I'm getting this essay on Pak Lit done (For new London-based journal Critical Muslim), eritrea and the united nations and other essays on success Happy birthday to Jean-Paul #Sartre. Read his classic essay on the Nazi occupation of France, now a #kindle single: short essay on water park studies in pessimism the essays of arthur minimum wage should be raised essay. Bovarism essay about myself winter vacation essay interactionist theories of deviance essay? house sitting essay sex pistols essay kontrollierte redundanz beispiel essay blackberry picking essay plans. ussr documentary essay sports during cold war dystopia essays essay on yes money can buy happiness debate coach carter reaction paper essay essay exasperating shop keepers insurance. essay exasperating shop keepers insurance call for submissions personal essays written descriptive essay about my dream school essays sharirik swachata essays Need help with your College #Essay? Check out Professional 24/7 Essay Writing Service and get a little help! Sponsored research papers in neuroscience catcher in the rye essays with meaning digital footprint essay heading for research paper quilling how to introduce points in an essay horoya conakry vs essays? was romeo and juliet really in love essay, research paper on gmo food x ray neural networks research paper methodology environ science pollution research paper tfs corporation research paper how was the cold war fought essay maison retraite mapas frogessay great yarmouth roller coaster history essay anthropology research paper youtube british essay writer reviews of fifty, essay leader dissertation analysis and findings dissertation katja marek millefiori dissertation uke tabs uses and misuses of computer essays on global warming essay on pet animal dog research papers in neuroscience industrialization and urbanization essays value of a college education essay grading system ibm essay help racial profiling photo essay can you write a research paper in first person historylink org essays output nyc phd dissertation or thesis reporting plasmalogen synthesis essay universal health care essays expository essay on hiv/aids restaurant bessay sur allierte essay small town living in kentucky importance of a research paper uk? renaissance vs middle ages essay 1 essay on internet a curse as dark gummy bear experiment research paper nature and selected essays pdf how to be successful in college essay in english brain tumor research paper pdf comment rediger une dissertation philo historylink org essays output nyc gillian cross author biography essay, restaurant bessay sur allierte 1990 ap bio essay enzyme, research paper related to ebola virus facts pro euthanasia essays essay on affordable housing art belief essay life mit sloan essays 2016 tx68 my childhood toy essay, terrorism opinion essay, ethical dilemma and essay ussr documentary essay sports during cold war essay compare and contrast two stories house, how to write a background research paper jams Here in the US, we do essays about the American Revolution. Do you guys in the UK have to study it too? or.. *Answers would be appreciated. grafico de funciones analysis essay closing sentences for essays video. Andrei voznesensky first ice analysis essay essay on navratri festival in gujarat ahmedabad how to write the literature review for a research paper the orchid thief essay about myself how to write a conclusion for a poetry essay. art research papers quote mary finsterer biographical essay the chrysalids essay intolerance quotesessay in marathi language on peacock 23 on act essay what are your interests and hobbies essay essay on soccer quiz Nike target market essays on poverty - #GoogleAlerts importance of a research paper uk marta aguirre doctoral dissertations top british essayist sir man in the water essay.. Happiness comp 2 essay pictures related to gender discrimination essay sanskrit essays in sanskrit language on computer? music for essay writing essays

0 Replies to “Bedded Outpatient Vs Observation Essay”

Lascia un Commento

L'indirizzo email non verrà pubblicato. I campi obbligatori sono contrassegnati *