Tips for complying with CMS’ inpatient-only rule on cath lab cases

by Tina Rosier, MS, PT

I was thrilled to read in the 2021 Outpatient Prospective Payment System (OPPS) final rule that the notorious inpatient-only (IPO) rule would be phased out over three years. I was just as disappointed when I read in the 2022 OPPS final rule that CMS was reversing its decision and that the IPO list and surrounding regulations would continue. 

I have been involved in revenue integrity for over 15 years, and IPO has been a challenging rule to comply with. One record without an inpatient order can be well over $100,000 in gross charges sitting on an outpatient claim that we cannot bill. As such, even one case that we are forced to write off is a problem. For this reason, we have implemented Epic OpTime tools to prevent IPO write-offs in our surgical services area. However, until recently, we did not have the same Epic/Cupid tools in place for our cardiac catheterization lab (CCL). This article focuses on the education and Epic/Cupid tools we put in place to help prevent IPO write-offs in our CCL area.

First, we assembled a group of IT, clinical, revenue integrity, and compliance stakeholders and experts. We then looked at a list of the top cath lab IPO procedures that we perform at our hospitals. We looked at each of these IPO services for key supplies, devices, Current Procedural Terminology (CPT®) codes, and exam names so that we could build a best practice advisor (BPA) that would fire and alert the physician, nurse practitioner, or physician assistant that an IPO procedure had taken place. Finally, this BPA would fire every time the chart was opened by the provider until an inpatient order was entered into the system.

Additionally, our IT team created a daily schedule report. The schedule report is filtered to show any case for the current and next day that is scheduled with an IPO payer because other payers besides Medicare have IPO lists, such as TRICARE. It also indicates a green check if the account is an inpatient class or a red X if it is not. Each hospital’s cath lab department is responsible for running this report each day to look for potential IPO cases that are not inpatient class. They are then to communicate with the provider or utilization review nurse to ensure that an inpatient order is obtained. 

Since the implementation of our Epic/Cupid tools, the BPA has fired many times, and we can determine from an IT report when the BPA was canceled or acted upon. As a result, we have been able to supply the providers with good data on how our tools are working. In turn, the providers have developed a higher awareness regarding the IPO cases they complete. Finally, and even more importantly, we have not had an IPO write-off since the implementation of our tools on February 1. It’s still early, but we hope the trend continues!

About the Author

Rosier is the director of revenue integrity acute care services at Community Health Network in Indianapolis, Indiana.