Ask the Expert
Questions about MOON and CMS notification regulations
Learning objective
At the completion of this educational activity, the learner will be able to:
- Identify strategies to comply with the Medicare Outpatient Observation Notice (MOON) notification and understand rules related to navigating the skilled benefit for Medicare
One of the topics raising the most questions in case management today is related to the MOON notification requirement. Hospitals were struggling this summer to comply with the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act, which was signed by President Barack Obama August 6, requiring hospitals to provide a verbal and written notice of outpatient status to any patient in observation who has been in the hospital for more than 24 hours. Just prior to the August 6 implementation date, hospitals received word that the notification requirement would be delayed pending approval of modifications made to the government’s notification form. (See related story on p. 1.)
But despite the delay, case managers still have questions about MOON, which were answered this month by Ronald Hirsch, MD, FACP, CHCQM, vice president of the Regulations and Education Group at Accretive Health in Chicago. Janet L. Blondo, MSW, LCSW-C, LICSW, CMAC, ACM, CCM, C-ASWCM, ACSW, manager of case management at Washington Adventist Hospital in Takoma Park, Maryland, and Peggy Rossi, BSN, MPA, CCM, a consulting associate for the Center for Case Management in Wellesley, Massachusetts, also tackled a Medicare notification question this month.
Q: What is the consequence if we miss giving a patient who meets the MOON criteria the notice? Has there been an update if the observation hours will need a modifier or the claim a value or condition code to show that the notice was given?
Hirsch: CMS has not stated the consequence of not issuing a MOON. CMS will be updating its survey tools in the future and may address it there. CMS stated in the IPPS final rule that, "all monitoring and enforcement of the MOON will be consistent with our oversight procedures for other hospital delivered notices."
Q: Now that CMS has released a new version of the MOON form, how should my organization proceed?
Hirsch: CMS released a new version of the MOON August 1, but it must go through the public comment period. After that time, it will be issued an Office of Management and Budget number and then there will be a 90-day implementation period. Until that time, hospitals should follow any state regulations for notices to outpatients and patients receiving observation services.
Q: I read your article on navigating the skilled benefit for Medicare and I have a few related questions. My understanding is that you can only use a Hospital-Issued Notice of Noncoverage (HINN) for inpatient, so you could use it if less than a three-day stay. We have been giving Advance Beneficiary Notices (ABN) for our traditional Medicare patients that are observation when families are not timely on getting a skilled nursing facility secured to those patients that require it. Is this correct?
Rossi: The HINNs have varied uses, and if a HINN is used it should be the HINN1, as this is a letter used to deny any admission?it is a preadmission denial and is issued when it is known the stay will not be covered. Another letter to use will be an ABN, as the ABN is a letter designed by CMS to deny outpatient services, when it is known they will not be covered.
Blondo: HINN1 is known as a preadmission/admission HINN and can be given prior to a hospital stay when it is expected that the entire stay will be denied for coverage. So if a patient was brought to the hospital ED for the purpose of SNF placement and the physician is writing an order to admit to inpatient, many hospitals have their ED case manager intervene by giving the patient and family the HINN1. The physician does not have to agree with the issuance of the denial notice. Seeing the denial notice often convinces the patient and family to choose another plan of care for the patient, and no admission takes place.
For patients placed in observation, ABNs are used for Medicare Part B outpatient services when it is believed Medicare will no longer pay for the services it normally would cover. Some common reasons one would issue an ABN include when services are not reasonable and necessary or when the care is custodial. So if the family hasn’t moved fast enough to take that available SNF bed and the patient’s care is considered custodial, it is correct to issue the ABN.
For more information, see Medicare Advance Beneficiary Notices, October 2015, Medicare Learning Network, Department of Health and Human Services, Centers for Medicare & Medicaid Services at: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/abn_booklet_icn006266.pdf.
Got a question on any case management topic that you’d like to ask our experts? Email it to Kelly Bilodeau at Kelly@phbphoto.com.