The Inpatient-Only List & The Role Utilization Review Can Play

The Inpatient-Only List & The Role Utilization Review Can Play

EDITOR’S NOTE:
While there have been attempts to phase out the IPO List, the reality is that it continues to be a significant factor in healthcare reimbursement. This article will delve into the complexities of the IPO List, its impact on revenue, and the importance of accurate coding and utilization review in ensuring proper billing.

The Inpatient-Only (IPO) List is comprised of services, primarily surgical, that are designated as requiring inpatient care due to the nature of the procedure, the patient’s underlying physical condition, or the need for extended post-operative recovery time.

This designation is critical, as Medicare and other payers reimburse and/or deny these procedures differently, depending on their recognition of the IPO List. Although it is clear where Medicare stands on the subject, it was not until April 2023, when the Centers for Medicare & Medicaid Services (CMS) released CMS 4201-F, commonly known as the “Medicare Advantage (MA) Final Rule,” that MA plans were also required to adhere to the IPO List.

However, this is not necessarily the case for commercial and managed Medicaid plans, which still have autonomy, per their provider guidelines and hospital contracts, to dictate their stance on the IPO List, unless state-mandated otherwise. Regardless of the payers, getting it wrong can be significant to a hospital’s bottom line, as payers will often deny in full an incorrect authorization, such as completing an inpatient-only procedure in an outpatient setting of the hospital and billing the claim under an outpatient designation. This is where utilization review (UR) can collaborate with clinical documentation integrity (CDI), coding, and the rest of the revenue cycle to ensure that the status is correct up front. 

Sometimes this is when fallouts occur because an accountability owner and hardwired process do not exist, as the surgical process passes through so many departments. Regardless of the owner, however, there are some clear steps that need to occur to ensure the successful capture of IPO procedures.

Utilization review should be participating in access management by reviewing scheduled surgeries 2-3 days prior and collaborating with the scheduling and authorization team to make sure that each IPO procedure receives not only a pre-scheduled inpatient-only order in the medical record but also that the payer authorization matches the appropriate level of care.

Understanding that plans change in the operating room, documentation should be reviewed either by UR and/or the CDI team to evaluate for any changes that may have adjusted an outpatient procedure to an inpatient, requiring an updated level-of-care order to be obtained.

Even though education is important, providers should also partner with surgeons’ offices to ensure that they are aware of their potential missed opportunities for accuracy with IPO procedures and the authorization process. It is also important to understand that the pre-authorization function is typically completed by medical assistants and/or surgery schedulers, thus consideration should be given to maximize technology and hardwire the process – such as by adding hard stops in the electronic medical record (EMR) for when a procedural code is entered for surgery, via an alert when the appropriate level of care opens, notifying the user that this is an IPO procedure.

Some hospitals are still using fax and paper to schedule procedures, so consider giving custom forms to your top surgeon offices that identify very clearly which surgeries they perform that appear on the IPO List to avoid confusion leading to denials.

Finally, review your denials data with your revenue cycle and billing team. Which IPO procedures were missed? Break down what happened in each case and determine what procedure it was, along with which group was performing the procedure. This will provide key details in payers practices and lead the team upstream to work out any missteps that occurred in the process.

Accurate coding, diligent utilization review, and a clear understanding of the IPO List are vital components of revenue cycle management for healthcare organizations. The financial implications of IPO procedures are significant, underscoring the importance of precise billing and adherence to regulatory requirements.

Staying informed about the ever-evolving healthcare landscape is crucial, as political and regulatory changes can impact reimbursement policies and ultimately affect a hospital’s bottom line.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Tiffany Ferguson, LMSW, CMAC, ACM

Tiffany Ferguson is CEO of Phoenix Medical Management, Inc., the care management company. Tiffany serves on the ACPA Observation Subcommittee. Tiffany is a contributor to RACmonitor, Case Management Monthly, and commentator for Finally Friday. After practicing as a hospital social worker, she went on to serve as Director of Case Management and quickly assumed responsibilities in system level leadership roles for Health and Care Management and c-level responsibility for a large employed medical group. Tiffany received her MSW at UCLA. She is a licensed social worker, ACM, and CMAC certified.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
Mastering Medicare Notices: Your Essential Guide to the MOON and Beyond

Mastering Medicare Notices: Your Essential Guide to the MOON and Beyond

Hospital staff continue to grapple with the complexities of Medicare notices.  In this webcast, Tiffany Ferguson, LMSW, CMAC, ACM, will present the latest requirements for preparation and delivery of CMS-mandated forms, including the Advance Beneficiary Notice (ABN), Hospital-Issued Notices of Noncoverage (HINNs), Important Message from Medicare (IMM) and Medicare Outpatient Observation Notice (MOON), and practical solutions through foolproof workflows and compliance auditing.

January 25, 2024
OBGYN ICD-10-CM/PCS Coding: Mastering Complex Guidelines and Compliance

OBGYN ICD-10-CM/PCS Coding: Mastering Complex Guidelines and Compliance

Dive into the complexities of Obstetrics and Gynecology coding, addressing challenges from antepartum to postpartum care. Learn to decode intricate guidelines, tackle claim denials, and safeguard your practice’s financial health. Uncover the secrets to compliant coding, reducing errors, and optimizing reimbursement. With practical exercises and expert insights, this webcast empowers coders, auditors, and healthcare professionals to elevate their OBGYN coding prowess.

February 28, 2024
Unlocking Clinical Documentation Excellence: Empowering CDISs & Coders

Unlocking Clinical Documentation Excellence: How to Engage the Provider

Uncover effective techniques to foster provider understanding of CDI, empower CDISs and coders to customize their queries for enhanced effectiveness, and learn to engage adult learners, leveraging their experiences for superior learning outcomes. Elevate your CDI expertise, leading to fewer coding errors, reduced claim denials, and minimized audit issues.

December 14, 2023
Coding for Spinal Procedures: A 2-Part Webcast Series

Coding for Spinal Procedures: A 2-Part Webcast Series

This exclusive ICD10monitor webcast series will help you acquire the critical knowledge you need to completely and accurately assign ICD-10-PCS and CPT® codes for spinal fusion and other common spinal procedures.

October 26, 2023

Trending News

It’s Heart Month! Use code HEART24 at checkout to receive 20% off your cardiology products. Click here to view our suite of Cardiology products!