Short Inpatient Hospital Stay (PDF) Form

Medical necessity criteria for day one and day two of an inpatient hospital stay, excluding behavioral health and obstetrical delivery admissions. Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.3 Policy/Criteria
I. It is the policy of health plans affiliated with Centene Corporation® that day one and day two (if applicable) of an inpatient hospital stay (vs. observation) are medically necessary for one of the following indications: A. Admission is for a procedure on the CMS 2022 Inpatient Only List, (addendum E found here); B. Admission to an intermediate or intensive care unit level of care (including neonatal intensive care unit (NICU) considered medically necessary per a nationally-recognized clinical decision support tool; C. Admission to acute hospital care at home;7 D. Unexpected death during the admission; E. Departure against medical advice from a medically necessary (per a nationally- recognized clinical decision support tool) inpatient stay; F. Transferred from another facility, with a medically necessary (per a nationally- recognized clinical decision support tool) total length of stay greater than 2 days; G. Election of hospice care in lieu of continued treatment in hospital. II. It is the policy of health plans affiliated with Centene Corporation that inpatient hospital stays on day three and beyond are medically necessary when supported by nationally-recognized clinical decision support tools. Background
Expectation of time and the determination of the underlying need for medical care at the hospital are supported by complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk (probability) of an adverse event occurring during the time period for which hospitalization is considered.1 Observation services are commonly ordered for patients who present to the emergency department and who then require a significant period of treatment or monitoring in order to make a decision concerning their admission or discharge. The decision whether to discharge a patient from the hospital following resolution of the reason for the observation care, or to admit the Page 1 of 5

CLINICAL POLICY Short inpatient hospital stay patient as an inpatient, can be made in less than 2 days and usually in less than 24 hours. In only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 2 days.3 Centers for Medicare and Medicaid Services (CMS)- Inpatient Only List The inpatient only list was established by CMS and identifies 1,700 procedures for which Medicare will pay only when performed in a hospital inpatient setting. Inpatient only services are generally, but not always, surgical services that require inpatient care because of the complexity of the procedure, the underlying physical condition of patients who require the service or the need for at least 24 hours of postoperative recovery time or monitoring before the patient can be safely discharged. There is no payment under the Outpatient Prospective Payment Systems (OPPS) for procedures that CMS designates to be “inpatient-only” services. The designation of services to be “inpatient-only” is open to public comment each year as part of the annual rulemaking process and many procedures have been added and removed over the years.6 Centers for Medicare and Medicaid Services (CMS)- Acute Hospital Care at Home In November 2020, CMS announced the Acute Hospital Care at Home program to allow eligible hospitals expanded flexibility to care for patients in their homes. Hospital at home is designed to provide certain acute-level services in the home that patients would normally receive in the hospital setting. In-person physician evaluation is required prior to starting hospital at home care and patients may only be admitted from emergency departments and inpatient hospital beds. Acute Hospital Care at Home is for patients who require acute inpatient admission to a hospital and who require at least daily rounding by a physician and a medical team monitoring their care needs on an ongoing basis.7, 8 Coding Implications
This clinical policy references Current Procedural Terminology (CPT®). CPT® is a registered trademark of the American Medical Association. All CPT codes and descriptions are copyrighted 2020, American Medical Association. All rights reserved. CPT codes and CPT descriptions are from the current manuals and those included herein are not intended to be all-inclusive and are included for informational purposes only. Codes referenced in this clinical policy are for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage.
Providers should reference the most up-to-date sources of professional coding guidance prior to the submission of claims for reimbursement of covered services.

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ICD-10-CM Diagnosis Codes that Support Coverage Criteria

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  CLINICAL POLICY Short inpatient hospital stay

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  Reviews, Revisions, and Approvals Policy developed Added to the description that “medical necessity criteria for day one and day two of an inpatient hospital stay, excluding behavioral health and obstetrical delivery admissions.” Clarified that the medical necessity statement in I. applies to the first and second days of an inpatient stay. Added section II, stating that days 3 and beyond are medically necessary per nationally-recognized clinical decision support tools. Replaced all instances of member with member/enrollee. References reviewed and updated. I.A. updated to specify “2020” Inpatient Only List. Background updated to include heading for CMS and information related to the Inpatient Only List and CY 2021 OPPS/ASC Final Rule. In III, clarified that the statement refers to medically necessary stays supported by clinical decision support tools, vs. according to clinical decision support tools. Changed “Review Date” in the header to “Date of Last Revision,” and “Date” in the revision log header to “Revision Date.” Annual review. References reviewed and updated. Replaced 2020 inpatient only list with 2022 inpatient only list in I.A. and updated references accordingly. Annual review. Added I.C. “Acute hospital care at home.” Background updated with no clinical significance. References reviewed and updated. Revision Date 02/20 10/20 Approval Date 03/20 11/20 02/21 03/21 08/21 11/21 12/21 11/21 12/21 11/22 11/22