Health Reform Connect

Two cases have been settled to resolve allegations that the hospital billed Medicare for admissions for Gamma Knife treatment that could have been performed on an outpatient basis. Gamma Knife treatment, formerly known as stereotactic radiosurgery, uses focused radiation to treat tumors, vascular deficiencies and other neurological conditions without damaging outlying tissue and is often performed on an outpatient basis without general anesthesia.  Patients that stay overnight for a procedure are not necessarily considered inpatients.  The Medicare Benefit Policy Manual (Chapter 1, Section 10) specifically states that patients undergoing minor procedures who are expected to require fewer than 24 hours of care often should be considered outpatients even if they spend the night in the hospital.  This is often referred to as “outpatients in a bed” and APC payments under the outpatient prospective payment system include reimbursement for postoperative care up to 24 hours, including routine postoperative observation and monitoring.  When determining whether a patient requires admission, the factors to consider on a case-by-case basis are: whether the procedure is on the Medicare inpatient-only list, whether the patient is expected to require more than 24 hours of care and whether the patient has increased risk or comorbidities that would require care in the inpatient setting.  Because RAC auditor decisions are typically limited to what a chart supports, sufficiently-documented charts are key.  Even when inpatient admissions may be justified, insufficient charted evidence will require denial.  Therefore physicians should include all details, such as frequency of necessary vital signs or neuro checks, and distinguish between the term “admit” for observation versus “admit” for inpatient bed.  If you have any further questions please contact Meghan Linvill McNab at 317-808-5863 or Kristen L. Gentry at 317-238-6288.