One Day Stays for Chest Pain

Summary of Evidence Analysis of Evidence General Information Associated Information Sources of Information Bibliography Revision History Information Associated Documents Attachments Related Local Coverage Documents Related National Coverage Documents Public Versions Keywords Local Coverage Determination (LCD) One Day Stays for Chest Pain L34551 Expand All | Collapse All  Email Document  Download  Add to basket Contractor Information Contractor Name Contract Type Contract Number Jurisdiction States LCD Information Document Information LCD ID L34551 LCD Title One Day Stays for Chest Pain Proposed LCD in Comment Period N/A Source Proposed LCD N/A Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 07/10/2025 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date N/A Notice Period End Date N/A CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the American Medical Association. Current Dental Terminology © 2025 American Dental Association. All rights reserved. Copyright © 2025, the American Hospital Association, Chicago,

Background and Rationale: The goal of this policy is to decrease the frequency of denials and improper Medicare payments for one-day acute inpatient hospital admissions (one-day stays) for chest pain. This goal will be accomplished by utilizing the concepts contained in the American College of Cardiology Foundation/American Heart Association (ACC/AHA) guidelines for unstable angina/non-ST elevation myocardial infarction (NSTEMI) as a framework to communicate reasonable and necessary acute inpatient admissions for chest pain. The ACC/AHA evaluation & management algorithm of patients suspected of having acute coronary syndrome (ACS) algorithm provides a reliable, evidence-based structure for documenting the complex decision-making process required of hospitals submitting claims for one-day stays. The patient’s history, physical examination, diagnostic test results, together with observed changes over time (including responsiveness/non-responsiveness to treatment) are used by physicians to synthesize the clinical rationale for an acute inpatient admission. This cognitive process, however, is often incompletely transcribed into the healthcare record to support the resultant acute inpatient admission for chest pain. This incomplete transcription often results in Medicare one-day stay denials for failing to meet the “reasonable and necessary” standards established in the Medicare Benefit Policy Manual. While the Medicare coverage requirements for acute inpatient admissions have been in effect and disseminated by the Centers for Medicare & Medicaid Services (CMS) for many years, they have not been consistently adopted and implemented by acute care hospitals. This variation led to pre-payment record reviews by this A/B MAC and post-payment record reviews by the Comprehensive Error-Rate Testing Contractor (CERT) and the Recovery Audit Contractors (RACs). These record reviews have identified many instances of improper payments for one-day stays for chest pain. Relevant Concepts: The ACS algorithm contains evidence-based clinical diagnostic pathways that are also aligned with existing Medicare coverage and reimbursement policy. According to the ACC/AHA guidelines, a patient’s history, physical examination, 12-lead electrocardiogram (ECG) and initial cardiac biomarker tests should be used to select the most appropriate evidenced-based treatment and setting, acute inpatient admission, outpatient observation or outpatient follow-up. Proposed Solution: The ACC/AHA guidelines for unstable angina and NSTEMI provide a documentation framework for successfully communicating the complex decision-making processes required of physicians and hospitals caring for patients presenting with signs and symptoms of ACS. The resultant structured information could be used to improve both clinical and administrative communication. The adoption and implementation of these evidence-based guidelines for ACS will require a collaborative effort among physicians, nurses, hospitals and healthcare payers. The communication of patient-specific information via the health record should be the goal of both physicians and hospitals. Hospitals experiencing one-day stays for chest pain are encouraged to use the ACC/AHA evidence-based workflows to help improve their clinical documentation processes and strengthen the healthcare records supporting one-day stays for chest pain. This approach will improve communication between hospitals and this A/B MAC and thus decrease Medicare denials and improper payments for one-day stays for chest pain. This A/B MAC proposes to use the ACC/AHA framework in its reviews of one-day stays for chest pain in an effort to improve its communication with acute care hospitals experiencing denials for such claims. Education will be provided within the context of the ACS algorithm to help communicate opportunities for process improvements in documentation.