LCD L34551: One Day Stays for Chest Pain

Background and Rationale:

The goal of this policy is to decrease the frequency of denials and improper Medicare payments for one-day acute inpatient hospital admissions (one-day stays) for chest pain. This goal will be accomplished by utilizing the concepts contained in the American College of Cardiology Foundation/American Heart Association (ACC/AHA) guidelines for unstable angina/non-ST elevation myocardial infarction (NSTEMI) as a framework to communicate reasonable and necessary acute inpatient admissions for chest pain. The ACC/AHA evaluation & management algorithm of patients suspected of having acute coronary syndrome (ACS) algorithm provides a reliable, evidence-based structure for documenting the complex decision-making process required of hospitals submitting claims for one-day stays.

The patient’s history, physical examination, diagnostic test results, together with observed changes over time (including responsiveness/non-responsiveness to treatment) are used by physicians to synthesize the clinical rationale for an acute inpatient admission. This cognitive process, however, is often incompletely transcribed into the healthcare record to support the resultant acute inpatient admission for chest pain. This incomplete transcription often results in Medicare one-day stay denials for failing to meet the “reasonable and necessary” standards established in the Medicare Benefit Policy Manual.

While the Medicare coverage requirements for acute inpatient admissions have been in effect and disseminated by the Centers for Medicare & Medicaid Services (CMS) for many years, they have not been consistently adopted and implemented by acute care hospitals. This variation led to pre-payment record reviews by this A/B MAC and post-payment record reviews by the Comprehensive Error-Rate Testing Contractor (CERT) and the Recovery Audit Contractors (RACs). These record reviews have identified many instances of improper payments for one-day stays for chest pain.

Relevant Concepts:

The ACS algorithm contains evidence-based clinical diagnostic pathways that are also aligned with existing Medicare coverage and reimbursement policy. According to the ACC/AHA guidelines, a patient’s history, physical examination, 12-lead electrocardiogram (ECG) and initial cardiac biomarker tests should be used to select the most appropriate evidenced-based treatment and setting, acute inpatient admission, outpatient observation or outpatient follow-up.

Proposed Solution:

The ACC/AHA guidelines for unstable angina and NSTEMI provide a documentation framework for successfully communicating the complex decision-making processes required of physicians and hospitals caring for patients presenting with signs and symptoms of ACS. The resultant structured information could be used to improve both clinical and administrative communication. The adoption and implementation of these evidence-based guidelines for ACS will require a collaborative effort among physicians, nurses, hospitals and healthcare payers.

The communication of patient-specific information via the health record should be the goal of both physicians and hospitals. Hospitals experiencing one-day stays for chest pain are encouraged to use the ACC/AHA evidence-based workflows to help improve their clinical documentation processes and strengthen the healthcare records supporting one-day stays for chest pain. This approach will improve communication between hospitals and this A/B MAC and thus decrease Medicare denials and improper payments for one-day stays for chest pain.

This A/B MAC proposes to use the ACC/AHA framework in its reviews of one-day stays for chest pain in an effort to improve its communication with acute care hospitals experiencing denials for such claims. Education will be provided within the context of the ACS algorithm to help communicate opportunities for process improvements in documentation.

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