Inpatient orders wouldn’t be required anymore for Medicare Part A payments as long as hospitals have other evidence to support the admissions, according to the proposed 2019 inpatient prospective payment system (IPPS) regulation, which was released April 24. But there may be less to this proposal than meets the eye because of CMS guidance to the contrary and because the regulation reiterates that inpatients are “formally” admitted when there’s an order for admission. The change, however, is expected to reduce claim denials, and that was welcomed by compliance officers.

CMS presented the proposal, which is not a done deal unless it makes it into the final regulation, as proof it’s keeping its promise to reduce the administrative burden on health care organizations (RMC 4/23/18, p. 1). “We are proposing to revise the inpatient admission order policy to no longer require a written inpatient admission order to be present in the medical record as a specific condition of Medicare Part A payment. Hospitals and physicians are already required to document relevant orders in the medical record to substantiate medical necessity requirements,” the proposed rule stated. CMS said it doesn’t believe orders are necessary if other documentation, including progress notes and physician certification, are available to support the medical necessity of the admission and coverage criteria.

On its face it sounds great, but without corresponding changes to subregulatory guidance on orders, this may be sound and fury signifying nothing, says Edward Hu, president of the American College of Physician Advisors. “I’m not sure this alone changes a lot,” he says. “It’s a good first step, but it opens a lot more questions that CMS has to clarify.” CMS elaborated on its expectations for orders and certifications in Sept. 5, 2013, and Jan. 30, 2014, subregulatory guidance on the two-midnight rule, and they stand. For example, the latter guidance states that “if the physician or other practitioner responsible for countersigning an initial order or verbal order does not agree that inpatient admission was appropriate or valid (including an unauthorized verbal order), he or she should not countersign the order and the beneficiary is not considered to be an inpatient.”