Case management should never write request to make pt an I/P unless they have the written order from the physician or their facilities policies and procedures are in place to empower them to do so. If they are writing the request solely on the policy and procedure set in place then I believe it is a billing issue. Did patient actually meet criteria per Medicare guidelines or because they were here longer than 24 hrs? The electronic billing software and clearinghouses that manage the program should have edits in place that are set up according to the payer assigned to a claim. Many times I have had our RN ask me what on earth would compel me to question her decision for I/P status.

And yes Virginia there is a Santa Claus and the big DRG's come about as often as he and the Easter Bunny!!

As for the CMS manual, I spoke with our local FI who could not give me specifics but directed me to the manual and told me to look through the observation section. I couldn't find it either. I asked another biller who has been billing for almost 20 years and she said it has been a set in stone rule for a very long time. She went back through the ancient HCFA scrolls and writings from decades past and could not find the coveted document anywhere!!

Anyway, have a great day and sorry I could not be more help!

Amy