Industry News

CMS Provides Instructions for Post Payment Patient Status Reviews.

Lisa Shuman | November 2013

The Centers for Medicare & Medicaid Services (CMS) released instructions relating to the time period that contractors should begin “patient status” reviews.  The Final Rule CMS-1599-F, which updated fiscal year 2014 Medicare payment policies and rates, requires contractors to perform “patient status” reviews according the 2-Midnight inpatient admission and medical review guidelines.  

According to the current CMS instructions,  Medicare Administrative Contractors, Recovery Auditors, and the Supplemental Medical Review Contractor must not conduct postpayment status reviews for inpatient claims with dates of admission from October 1, 2013 through December 31, 2013.  However, CMS notes that claims with evidence of systematic gaming, abuse, or delays in the provision of care in effort to exceed the 2 midnight presumption may warrant medical review at any time.  Contractors are currently allowed to conduct other inpatient hospital reviews that are not “patient status” reviews.

The CMS instructions are effective as of October 1, 2013, and will be implemented on December 2, 2013. Transmittal 1315 is available at:

Centers for Medicare & Medicaid Services.  “Immediate Suspension of Postpayment Patient Status Reviews of Inpatient Hospital Admissions 10/1/13-12/31/13.”  Transmittal 1315.  15 Nov. 2013. 

*The dates for the restriction of post-payment patient status reviews conflict with information from the Website, which states that CMS will not conduct post-payment patient status reviews for claims with dates of admission October 1, 2013 through March 31, 2014.

About the Author

Ms. Shuman assists health care organizations to develop, implement and evaluate their compliance programs and HIPAA privacy programs. Ms. Shuman specializes in our firm’s HIPAA Privacy services, including leading privacy investigations, breach risk assessments, breach notification letters, breach reporting to the Office for Civil Rights and corrective actions plans. She specializes in serving as Interim Privacy Officer for large health care systems, managed care organizations, comprehensive cancer center and health care business associate.