Patient Status Training Toolkit for Medicare Utilization Review, Second Edition

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Patient Status Training Toolkit for Medicare Utilization Review, Second Edition

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Patient Status Training Toolkit for Medicare Utilization Review, Second Edition

Hospitals continue to struggle with applying CMS’ patient status guidelines and 2-midnight rule requirements in real-world—and often high-pressure—situations. While CMS has issued clarifications to the 2-midnight rule and changes to ease inpatient order requirements, confusion still exists. This uncertainty can leave hospitals vulnerable to audits or lead to overly conservative patient status determinations, which can inappropriately delay reimbursement and even impact patients’ financial responsibility.

Utilization review (UR) committee members are tasked with conducting patient status reviews to help identify patients who may have been assigned to the incorrect status, but even these professionals may find it difficult to navigate Medicare regulations and provide support to physicians.

The Patient Status Training Toolkit for Medicare Utilization Review, Second Edition, serves as a quick reference guide for UR committee members. The pocket card portion uses a flow chart and helpful tips to step through the process of verifying patient status determinations. If the committee member determines the patient’s status must be changed, the pocket card provides guidance on next steps. The handbook portion of the toolkit provides clear, concise information on the applicable Medicare regulations, including provision of notices and billing rules, that can be used to help support UR committee members’ patient status recommendations. In addition to an overview of regulatory requirements, the toolkit offers access to downloadable case studies and Medicare resources that will help guide committee members through real-world cases.

This book will help readers:

  • Ensure correct patient status determinations in fast-paced environments
  • Quickly identify the necessary steps to change a patient’s status
  • Stay up to date on CMS’ latest patient status guidelines, including the 2-midnight benchmark and recent changes to inpatient order requirements
  • Avoid audit and reimbursement implications due to incorrect patient status determinations


Published: October 2019

Pages: 60 (Handbook), plus a laminated card
Dimensions: 5 x 8.5/Pocket card: 4.25 x 8
ISBN: 978-1-64535-024-8

About the Authors

Kimberly Anderwood Hoy Baker, JD, CPC, is the director of Medicare and compliance for HCPro, a Simplify Compliance brand. She is a lead regulatory specialist for HCPro's Revenue Cycle Institute and is the lead instructor for HCPro's Medicare Boot Camp®—Hospital Version and Medicare Boot Camp®—Utilization Review Version. She is also an instructor for HCPro’s Medicare Boot Camp®—Critical Access Hospital Version. She is a former hospital compliance officer and in-house legal counsel, and has 10 years of experience teaching, speaking, and writing about Medicare coverage, payment, and coding regulations and requirements.

Table of Contents

  • Chapter 1: Medicare Requirements for Observation        
    • Observation Services     
    • Supplement: Payment for Observation Services
  • Chapter 2: Medicare Requirements for Inpatient Admission        
    • Inpatient Admission       
    • Transfers            
    • Delays in Care and Convenience Care     
    • Circumstances  
    • Inpatient-Only Procedures
    • Admission on a Case-by-Case Basis
    • Documentation
    • The Role of Screening Criteria    
    • Certification for Inpatient Care  
  • Chapter 3: Utilization Review Requirements and Processes
    • Conditions of Participation for Utilization Review
    • Utilization Review Determinations
    • Condition Code 44
    • Postdischarge Review   
  • Chapter 4: Notices for Care Not Covered by Medicare
    • Medicare’s Financial Liability Protections
    • Outpatient Advance Beneficiary Notice 
    • Inpatient Hospital-Issued Notice of Noncoverage
    • Important Message From Medicare
    • Detailed Notice of Discharge      
  • Downloadable Materials
    • Case Studies
    • Medicare Resources