The Centers for Medicare and Medicaid Services (CMS) has released final rule CMS-5519-F "Advancing Care Coordination through Episode Payment Models (EPMs)". This rule establishes bundled payments for 90-day episodes of care for acute MI (AMI), coronary artery bypass grafting (CABG), and surgical hip/femur fracture treatment (SHFFT).
Readers are aware that in recent years many AMIs have been treated as outpatient in observation, but the EPM program applies only to inpatient stays. This has lead to discussion of whether AMI has now become a diagnosis that justifies admission, though the rule is explicit that it does not do this.
CMS-5519-F states, "The AMI model does not change Medicare's current payment policy for classifying Medicare beneficiaries as outpatients or inpatients, including beneficiaries with AMI. Therefore, AMI model participants should continue to follow all existing Medicare rules that apply to classifying beneficiaries as inpatients or outpatients for beneficiaries with AMI who could potentially initiate AMI episodes if they were admitted to the AMI model participant."
But CMS does not seem to realize how many AMIs are treated in observation:
"As we stated in the proposed rule (81 FR 50829) patients experiencing an AMI are almost uniformly admitted to the hospital for further evaluation and management based on clinical guidelines for the treatment of beneficiaries with AMI."
I don’t think this statement is accurate at many hospitals where NSTEMIs (non-ST-elevation MIs) may go rapidly from the ED to the cath lab, perhaps have a stent placed, and be released the next day – all from observation. These cases would not be included in the bundled payment program even though they may be clinically identical to inpatient cases.
So AMI is not being designated as a diagnosis that warrants admission. Rather, only those cases that are admitted will be considered for bundled payment. This is likely to encourage hospitals to keep their AMIs in observation longer but CMS will be watching for a change in admission patterns.
The new case-by-case pseudo-exception to the 2-midnight LOS expectation based on physician judgment notwithstanding, how can a hospital justify the need for "inpatient level of care" - regardless of diagnosis, severity of illness, or risk of an adverse outcome - when CMS has explicitly stated that there is no such thing?
The 2014 IPPS Final Rule (CMS-1599-F) states, “We also expect that physicians will apply the revised benchmark as they have previously applied the existing benchmark, providing any medically necessary services in an inpatient status whenever the benchmark is met and in all other instances providing identical services to patients staying at the hospital in a day or overnight outpatient status.”
“The beneficiary’s required “level of care” is not part of the guidance regarding hospital inpatient admission decisions.”
And “contrary to the commenters’ suggestion, we do not refer to “level of care” in guidance regarding hospital inpatient admission decisions…there are no prohibitions against a patient receiving any individual service as either an inpatient or an outpatient, except for those services designated by the Outpatient Prospective Payment System (OPPS) Inpatient-Only list as inpatient-only services.”
Bottom line: I would not recommend that a hospital implement a diagnosis-based admission for AMI or any other diagnosis until CMS says it's OK. It's just asking for denials - and perhaps worse.