Utilization Management

Navigating the process for hospital level of care approval and denials.

A Step-by-Step Guide.

To assist you in navigating the process of receiving approval or denial for the level of care you request for admission to a hospital, long-term acute care facilities, rehabilitation facilities and skilled nursing facilities, we created this Step-by-Step Guide.

CMS Removes Inpatient Only List Starting in 2021 

Medicare Only – Allwell and MyCare

CMS has announced the finalization of their rule to end the inpatient-only list. This transition will occur over a three-year period and begins by eliminating about 300 services, mostly musculoskeletal-related in nature (including joint replacements).

  • The changes intend to give patients more freedom of choice in their health care options and save them money.
  • They also allow Medicare to pay for inpatient and outpatient services in the case that each is relevant.
  • Eliminated procedures may be subject to review, including the 2-midnight rule. This means the presumption of the need for Part A payment if an inpatient hospital stay lasts two or more midnights post-admission. CMS is exempting certain 2-minute rule reviews of newly removed procedures for two years.

Services Removed from the Inpatient Only List (IPO) for CY 2021

CMS has provided a table that includes services removed from the inpatient-only list for CY 2021. The list includes long descriptors and CPT/HCPCS codes and status indicators. You can find the list of removed services starting on page 709 of the CMS-1736 PDF.