News to Note – April 2025

• The presentation at the American College of Physician Advisors Town Hall on Observation highlighted that high-risk patients are not limited to medical patients or only emergent surgery; it can be applied whenever the patient is at higher risk due to the severity of their signs and symptoms, or the increased risk of an adverse event. Now of course you need documentation to support that decision; since the physician is making the determination based on that individual case, the notes must support the decision to admit as inpatient. 
• CMS from the 2018 OPPS Final Rule: if a surgical patient requires SNF, and you should know this as part of a pre-op assessment, then you can admit as inpatient for surgery. That starts the 3 inpatient day clock ticking for SNF on the day of surgery. Just to be clear, this applies to any Medicare patient having surgery who will have a legitimate need for SNF. CMS has opened the door a bit for cases where we, the hospital, do something like surgery that reduces the patient’s ability to remain independent. 
• CMS expanded their list to include not only SNF and Home Care options but also inpatient rehab facilities and long-term acute care hospitals. But that is misleading because the regulation also states, “We expect discharge planning to facilitate patient choice in any post hospital extended care services.” If the patient requires dialysis, are you offering choice? If the patient is electing hospice care, are you offering choice?
• The next choice issue relates to which providers must be included. If the patient needs a nursing home, must you list every nursing home in the area? The answer is no. CMS has indicated that you are only required to list the facilities that can provide the care required by the patient. For example, if they have a complex wound, you can limit the choice to facilities that have wound care staff. But most importantly you are only required to indicate providers that have capacity to accept the patient. Many nursing homes, especially the higher rated ones, rarely have an open bed so listing a facility with no open bed would simply set the patient up for disappointment. CMS says to omit those providers from your list.
• It is also important to note that an increasing number of hospitals are participating in bundled payment programs where they have partnerships with post-acute providers. You cannot limit your list to just those providers.