Know When to Give Hospital Patients the MOON
Shed light on the new Medicare form and its effect on midnight madness.
Every Medicare patient who receives observation care in the hospital for more than 24 hours must receive a Medicare Outpatient Observation Notice (MOON), form CMS-10611. The Federal Notice of Observation Treatment and Implication for Care Eligibility Act (NOTICE Act) requires all hospitals and critical access hospitals to provide a written and oral notification to patients who are placed in observation status. The notice informs the patient of specific details about their status, and educates them regarding what Medicare typically covers.
Time Factors into MOON Rules
The MOON does not need to be delivered to every Medicare patient who receives outpatient services — only those receiving at least 24 hours of observation services. Per the Centers for Medicare & Medicaid Services (CMS), the observation clock begins when “observation services are initiated (furnished to the patient), as documented in the patient’s medical record, in accordance with a physician’s order.” Some hospitals affected are Prospective Payment System hospitals, critical access hospitals, and psychiatric hospitals.
Patients must receive the MOON no later than 36 hours after the start of observation services, and the patient or representative must acknowledge receipt by signing and dating the form. The form may be printed or electronically signed, and the patient must receive a hardcopy of the signed form.
If the patient refuses to sign the MOON form, the refusal must be signed. For example:
I, Jane Doe, RN, care manager, certify that this notice was presented and explained to patient John Smith on 4/30/17 at 10:30 pm and the patient refused to sign the notice.
Jane Doe, RN
4/30/17 10:31 pm
Why the MOON Is Necessary
The MOON was created because of inconsistency in status assignment and ongoing patient confusion. The purpose of the MOON is to tell patients up front about potential out-of-pocket expenses. The MOON informs patients:
- Part A does not cover outpatient services.
- Part B requires a copayment for certain hospital and provider services after meeting the deductible.
Patients will most likely be charged extra for any self-administered drugs they are taking for chronic conditions.
Observation services are not counted toward the three-day inpatient stay required for Part A post-discharge skilled nursing facility services.
Because patients may have questions, Medicare advises hospitals to have pricing information available for patients to review as they read the MOON form.
CMS says a patient must be cared for in the most appropriate setting; if a patient does not need inpatient care, they must be cared for as an outpatient. Only a provider can decide whether a patient requires inpatient care or observation care. Determining the status of the patient’s stay (acute inpatient, observation outpatient) affects how much Medicare patients pay for hospital services.
Have a Process for Non-cooperative Patients
Be aware that the MOON conversation may raise questions and complaints from patients, who may decide to leave the hospital against medical advice. In the conversation with the patient, explain that the provider determines observation status, not the hospital. Establish a follow-up process for patients who leave against medical advice, so they (at minimum) visit their primary care physician after leaving the hospital.
Other MOON Requirements
The MOON is a standard CMS form with blanks for:
- Patient name and number
- Attending physician name
- Date and time observation services begin
- A description of why the patient is being placed in outpatient observation status
- Additional patient-specific information, which may be added by the hospital
- The original signed form must be filed in the patient’s medical record.
Auditors will look for properly executed MOON forms for all applicable observation cases, so compliance is important.
Assign Responsibility and Finalize Details
It can be a challenge to decide who in your organization is responsible to speak with the patient regarding the MOON. Common options are care manager/case manager, financial counselor, patient access staff, or social worker.
You’ll also want to hammer out a few details to be sure your processes are effective:
Emergency department — If observation patients are held in the emergency department, who will watch the clock to ensure timely delivery of the notice?
Providers — Healthcare professionals must know what information is being given to their observation patients.
Health information management — Educate staff to look for the notice, and check that it was provided on time before coding.
There are also several important, unanswered questions that CMS has not yet addressed. For example:
What if there is an observation case that requires a MOON, and it isn’t delivered?
Can this case be billed? Is the patient responsible for the charges?
What is the process to manage cases missing the required notice?
There’s No Appealing the MOON
All other Medicare notices of coverage determination give patients an opportunity to appeal to Medicare. Only the MOON defines the coverage issue as non-appealable. Medicare advocacy groups contend that just as patients can challenge a premature discharge or contest a host of other coverage determinations in the Medicare program, they should be able to appeal their placement in observation status.
Will the MOON Eclipse “Midnight Madness?”
The two-midnight rule, implemented by CMS in 2014 (also known as midnight madness), will stay in place. The purpose of this rule is to decrease both short inpatient stays and prolonged outpatient observation stays. OIG findings in December 2016 suggest it has not been overwhelmingly successful:
- Short inpatient stays are down 10 percent
- Long observation stays are down 3 percent
- Ongoing variation regarding how encounter statuses are determined remains in hospitals
The MOON is not intended to replace the two-midnight rule, but to help further the goal of efficiency and clarity for patients and staff.
To access the necessary forms (CMS 10611-MOON), or for questions regarding the MOON, go to www.cms.gov/Medicare/Medicare-General-Information/BNI or call: 1-800-MEDICARE. For alternate formats, email: AltFormatRequest@cms.hhs.gov.
Robin Ingalls-Fitzgerald, CPC, CEDC, CEMC, CCS, FCS, is company founder, CEO, and president of Medical Management and Reimbursement Specialists, LLC. She has been in the healthcare industry for over 30 years and a coder for 20 years, with expertise in E/M coding in both the facility and practice settings. Ingalls-Fitzgerald’s knowledge of Medicare coding and billing guidelines, NCDs, LCDs, and NCCI edits is a resource to facility and practice billing departments. She is a member of the Manchester, N.H., local chapter.
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