CurrentCurativePolicy CHP-OP-2026-110

Acute Inpatient Hospital Facility Admission and Stay

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Establishes medical-necessity criteria for acute inpatient hospital admission, continued stay, discharge, and transition for medical and surgical conditions in acute care hospitals for members of all ages.

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CurrentCurativePolicy CHP-OP-2026-110

Acute Inpatient Hospital Facility Admission and Stay

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Policy Summary

PayerCurative

PolicyAcute Inpatient Hospital Facility Admission and Stay

Policy CodePolicy CHP-OP-2026-110

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a practitioner inpatient admission order with supporting physician documentation of the clinical basis for hospital-level care.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All agesApplicable population

4Admission requirement groups

NEWS2 ≥5Adult severity threshold

NEWS2 ≥7Emergency-response threshold

8Documentation checklist

Acute Inpatient Coverage Criteria

Acute inpatient admission

Covered when all of the following are met.

Hospital-level need: At least one Section B severity finding persists after initial emergency department or observation treatment, at least one Section C intensity-of-service requirement is present, or a planned or performed procedure meets Section D.
Safe site-of-care determination: The required care cannot be safely provided in observation status, an outpatient setting, or at a lower level of care.
The admitting practitioner must document this determination.
Practitioner basis and order: The admitting practitioner documents history and comorbidity, severity of signs and symptoms, current medical needs, and risk of an adverse event, and an inpatient admission order is present.
An expected stay crossing two midnights and the CMS inpatient-only list are not required; a procedure on the inpatient-only list supports approval.

Objective severity-of-illness findings

Any one objective severity finding supports hospital-level care when it persists after initial treatment or represents an acute change from the member’s documented baseline.

Objective severity of illness: At least one of the following is present: adult NEWS2 aggregate score of 5 or more, or a score of 3 in any single parameter, unresolved after initial treatment; systolic blood pressure of 90 mmHg or less or mean arterial pressure below 65 mmHg not corrected by initial fluids, or any vasopressor requirement; suspected or confirmed infection with at least 2 qSOFA criteria or serum lactate greater than 2 mmol/L; oxygen saturation of 91% or less on room air, oxygen saturation of 83% or less in a member with documented chronic hypercapnic respiratory failure using the NEWS2 SpO2 scale 2, a new or increased oxygen requirement above baseline, or respiratory rate of 25 or more per minute; severe community-acquired pneumonia; pulse of 40 or less or 131 or more per minute or a new symptomatic arrhythmia requiring continuous monitoring and treatment; new confusion or decreased level of consciousness without a rapidly reversible cause; or core temperature of 35.0 C or less.

Findings must persist after initial treatment or represent an acute change from documented baseline.

Intensity-of-service requirements

Any one ordered and actually furnished intensity-of-service requirement supports acute hospital care.

Intensity of service: Invasive or noninvasive mechanical ventilation or high-flow oxygen requiring titration; intravenous vasoactive medication or continuous intravenous medication requiring titration to physiologic targets; vital-sign monitoring at least hourly or continuous monitoring because of clinical risk; intravenous therapy with serial clinical and laboratory reassessment that cannot safely be delivered in observation or through outpatient or home infusion; or a procedure or postoperative course requiring inpatient-level monitoring beyond a standard recovery period.

The service must be ordered and actually furnished.

Surgical and procedural admissions

A surgical or procedural inpatient admission is medically necessary when any one of the following is met in addition to the inpatient order requirement.

Surgical and procedural admissions: The procedure is on the CMS inpatient-only list in effect on the date of service; or the procedure is not on that list but the record documents that the procedure, the member’s comorbidities, anesthesia risk, or expected postoperative needs require hospital-level care; or an outpatient procedure results in a complication or clinical course meeting the objective severity-of-illness or intensity-of-service criteria.

The inpatient-only list supports approval but is never required, and the Medicare two-midnight benchmark is not applied.

Relationship to inpatient condition policies

The matching inpatient condition policy governs when one applies; otherwise this policy supplies the admission criteria.

Applicable approval pathway: The admission meets the matching inpatient condition policy, or it meets the severity-of-illness and intensity-of-service criteria in the applicable acute inpatient sections. A request meeting neither pathway is referred to a physician reviewer.

An admission is never denied solely because no condition-specific policy exists.

Continuation and re-authorization

Continued acute inpatient stay is medically necessary when any one of the following is documented on daily or event-driven review.

Continued stay: A severity-of-illness finding persists or develops; an intensity-of-service requirement continues; a complication or new diagnosis requires hospital-level evaluation or treatment; or treatment response is not yet adequate for safe transition, including unresolved vital-sign abnormalities, inability to eat, or abnormal mentation.

Does not meet criteria

The following scenarios do not meet this policy’s acute inpatient medical-necessity criteria and require physician review.

Does not meet criteria: Care can be safely managed in observation or outpatient care without documented hospital-level need; admission is based only on bed location, telemetry, unit placement, diagnosis, or a single intervention without overall severity and intensity; minor surgery or other treatment is expected to require fewer than 24 hours in a member with a known diagnosis and no complication; acute criteria have resolved; or admission is for convenience of the member, family, or practitioner, transportation, social reasons, or routine preoperative preparation that can be completed as an outpatient.

These scenarios are referred for physician review and are not denied by an automated system or non-physician reviewer.

Pneumonia hospitalization and clinical stability

Pneumonia hospitalization and higher-intensity care should be determined using prognostic assessment and clinical judgment.

Pneumonia site-of-care assessment

Higher-intensity care indicators: The patient requires vasopressors or mechanical ventilation, or meets relevant 2007 minor criteria for higher-intensity care.
Clinical stability for improvement assessment: Assess resolution of vital-sign abnormalities, ability to eat, and normal mentation.
These findings help judge improvement and readiness for ongoing lower-intensity care or discharge planning.

Procedures removed from inpatient-only list

For procedures removed from the inpatient-only list during the CY 2026 phase-out, apply the applicable inpatient admission standard.

Inpatient admission pathway: The inpatient decision follows either the two-midnight expectation or a case-by-case exception.

This applies to procedures removed from the inpatient-only list during the three-year phase-out.

This policy addresses facility medical-necessity criteria for acute inpatient admission, continued stay, and discharge or transition for medical and surgical conditions in acute care hospitals. Decisions involving observation status or observation-versus-inpatient status for short stays, emergency department services, maternity delivery stays, rehabilitation, skilled nursing, sick newborn care, transplant admissions, and inpatient mental health or substance use disorder care are governed by the applicable referenced policy or standard.

Admission is not medically necessary at the inpatient level when the condition can be safely managed in observation or outpatient care and the record does not document a clinical basis for hospital-level care. Observation remains the appropriate covered status when the member requires short-term treatment and reassessment but does not meet acute inpatient criteria.

Inpatient status must be supported by the member’s overall clinical needs. Bed location, telemetry, unit placement, diagnosis, or a single intervention alone does not establish medical necessity without documented severity of illness and intensity of services.

Minor surgery or other treatment expected to require fewer than 24 hours of hospital care in a member with a known diagnosis and no complication is considered an outpatient service and does not meet acute inpatient criteria.

A continued inpatient stay is not supported after the acute criteria have resolved. Once the member no longer requires hospital-level care, the stay should proceed toward a safe transition to the appropriate lower level of care.

Admission for the convenience of the member, family, or practitioner, for transportation or social reasons, or for routine preoperative preparation that can be completed as an outpatient is not medically necessary at the inpatient level.

Coding and Clinical Thresholds

Inpatient room and board revenue codesRevenue

0111	Inpatient room and board, private room
0112	Inpatient room and board, private room
0113	Inpatient room and board, private room
0114	Inpatient room and board, private room
0115	Inpatient room and board, private room
0116	Inpatient room and board, private room
0117	Inpatient room and board, private room
0118	Inpatient room and board, private room

Leave of absence revenue codeRevenueNot Covered

0181	Leave of absence (bed hold; noncovered days)

Adult NEWS2 aggregate

Aggregate thresholdAdult NEWS2 score of 5 or more qualifies.

Single-parameter thresholdA score of 3 in any single NEWS2 parameter qualifies.

Response to treatmentThe finding must remain unresolved after initial treatment.

Blood pressure

Systolic blood pressure90 mmHg or less.

Mean arterial pressureBelow 65 mmHg, not corrected by initial fluid resuscitation.

Vasopressor requirement

Authorization and Documentation Requirements

Prior Authorization

Inpatient Admission Authorization

Obtain and submit a practitioner order for acute inpatient admission, with physician documentation supporting the decision. Admission requires hospital-level care based on documented severity-of-illness findings, intensity-of-service requirements, or a qualifying procedure, and the care cannot be safely provided in observation, outpatient, or another lower-acuity setting.

A practitioner inpatient admission order must be present in the record.
Physician documentation must support the admission decision and the requested level of care.

Prior Authorization

Continued-Stay Authorization

Continued acute inpatient authorization requires documentation on daily or event-driven review showing that hospital-level care remains medically necessary.

A severity-of-illness finding persists or a new one develops.
An intensity-of-service requirement continues.
A complication or new diagnosis requires hospital-level evaluation or treatment.

Policy Background

Acute inpatient care is appropriate when the member’s severity of illness and intensity of services cannot be safely managed in observation, outpatient care, or a post-acute setting. The determination considers physiologic instability, risk of adverse events, current medical needs, required monitoring and treatment, and the availability of hospital services.

Definitions and Policy Terms

Severity of illness

DefinitionSeverity of illness consists of objective clinical findings indicating the degree of physiologic instability or risk of an adverse outcome.

Vital-sign findingsRelevant findings may include vital signs and examination results.

Diagnostic findingsLaboratory and imaging results are also objective clinical findings.

Intensity of service

DefinitionIntensity of service consists of the diagnostic and therapeutic services the member requires and the frequency of monitoring and reassessment.

Acute-hospital requirementThe required services can only be provided in an acute hospital.

Policy Summary

PayerCurative

PolicyAcute Inpatient Hospital Facility Admission and Stay

Policy CodePolicy CHP-OP-2026-110

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a practitioner inpatient admission order with supporting physician documentation of the clinical basis for hospital-level care.

SourceLink

On This Page

Any requirement for vasopressors also qualifies.

qSOFA

Required criteriaAt least 2 qSOFA criteria must be present.

Respiratory rate22 or more per minute.

Other criteriaAltered mentation or systolic blood pressure of 100 mmHg or less.

Serum lactate

Qualifying lactateSerum lactate greater than 2 mmol/L.

Clinical contextThe threshold appears among objective severity findings for suspected or confirmed infection.

Care implicationA qualifying lactate supports acute hospital care when the applicable severity-of-illness standard is met.

Oxygenation and respiratory rate

Room-air oxygen saturation91% or less on room air.

Chronic hypercapnic respiratory failure83% or less with documented chronic hypercapnic respiratory failure scored on the NEWS2 SpO2 scale 2.

Additional respiratory thresholdsNew or increased supplemental oxygen above baseline, or respiratory rate of 25 or more per minute.

Severe community-acquired pneumonia

Qualifying patternOne major criterion or three or more minor criteria for severe community-acquired pneumonia.

Respiratory and oxygenation examplesMinor criteria include respiratory rate of 30 or more and PaO2/FiO2 ratio of 250 or less.

Additional examplesMultilobar infiltrates, new confusion, BUN of 20 mg/dL or more, WBC below 4,000/microliter, platelets below 100,000/microliter, core temperature below 36 C, or hypotension requiring aggressive fluid resuscitation.

Pulse

Low pulse40 or less per minute.

High pulse131 or more per minute.

Related findingA new symptomatic arrhythmia requiring continuous monitoring and treatment also qualifies as an objective severity finding.

Core temperature

Core-temperature threshold35.0 C or less.

Clinical significanceThis is an objective severity-of-illness finding supporting acute hospital care.

Persistence standardThe finding must persist after initial treatment or represent an acute change from the documented baseline.

Septic shock mean arterial pressure

Mean arterial pressureAt or above 65 mm Hg must be maintained.

Support requiredThe septic shock state is identified by a vasopressor requirement to maintain the pressure threshold.

Related lactate criterionSerum lactate must be greater than 2 mmol/L in the absence of hypovolemia.

Septic shock serum lactate

Lactate thresholdGreater than 2 mmol/L.

Equivalent valueGreater than 18 mg/dL.

Septic shock contextThe threshold applies with a vasopressor requirement to maintain mean arterial pressure at or above 65 mm Hg, in the absence of hypovolemia.

Treatment response is not yet adequate for safe transition, such as unresolved vital-sign abnormalities, inability to eat, or abnormal mentation.

Documentation Required

Required Clinical Documentation

Submit the clinical record needed to validate the admission, ongoing treatment, and level-of-care decision.

Admission history and physical and emergency department record.
Vital signs, including NEWS2 or an equivalent adult score, plus laboratory and imaging results supporting the severity findings relied on.
Treatments ordered and furnished, with monitoring frequency.
Practitioner inpatient order with date and time.
Admitting practitioner's clinical basis for inpatient care, including history and comorbidity, severity of signs and symptoms, current medical needs, risk of an adverse event, expected duration when known, and any inpatient-only procedure.
Daily progress notes documenting ongoing severity, intensity, and response to treatment.
Early discharge-planning evaluation, discharge criteria, and barriers.
Certification documentation for long-stay or cost-outlier cases when required.

Documentation Required

Admission Rationale and Order

Document why inpatient care is required for this member and why a lower level of care is unsafe. The admitting practitioner must record the clinical basis for hospital-level care; an expected stay crossing two midnights and the CMS inpatient-only list are not required, although an inpatient-only procedure supports approval.

Address history and comorbidity, severity of signs and symptoms, current medical needs, and risk of an adverse event.
Document that the required care cannot be safely provided in observation, an outpatient setting, or another lower level of care.
Include a practitioner order for inpatient admission with physician support.
Include the planned or performed qualifying procedure when the procedure itself requires inpatient care.

Billing Rule

Support the Requested Scope

The submitted documentation must support the full quantity, units, and duration requested. When the clinical record supports only part of the request, approve the supported portion and subject only the unsupported increment to review.

Document the requested scope and the clinical facts supporting each quantity, unit, and duration.
A physician review applies to any unsupported quantity, unit, or duration rather than automatically to the entire request.

Documentation Required

Pneumonia Site-of-Care Documentation

For pneumonia, document the validated prognostic rule used for the site-of-care decision—preferably the Pneumonia Severity Index (PSI)—together with clinical judgment. Document the factors supporting ward versus intensive care and the patient's response to treatment.

Use a validated prognostic rule, preferentially PSI, plus clinical judgment for hospitalization.
Document vasopressor or ventilator needs supporting ICU admission and applicable 2007 minor criteria for higher-intensity care.
For stability and transition decisions, document resolution of vital-sign abnormalities, ability to eat, and normal mentation.

Denial Risk

Scenarios That Do Not Meet Criteria

The following scenarios do not meet acute inpatient medical-necessity criteria under this policy and are referred for physician review rather than denied by an automated system or non-physician reviewer.

A condition can be safely managed in observation or outpatient care, without documented hospital-level need; observation Policy 112 is the appropriate covered status.
Admission is based only on bed location, telemetry, unit placement, diagnosis, or a single intervention without overall severity and intensity; status depends on clinical needs, not location.
Minor surgery or other treatment is expected to require fewer than 24 hours in a member with a known diagnosis and no complication; this is outpatient care by definition.
Continued stay occurs after acute criteria resolve; manage at the appropriate lower level of care.
Admission is for convenience of the member, family, or practitioner, transportation or social reasons, or routine preoperative preparation that can be completed outpatient.

Note

Condition-Specific Policy and Physician Review

Apply a matching inpatient condition-specific policy when one governs the principal diagnosis or procedure. That policy controls admission criteria, expected length-of-stay benchmark, level of care, and discharge; this acute inpatient policy supplies the framework for conversion from observation, continued stay, discharge or transition, and admissions without a matching condition policy.

An admission is approved when it meets the matching condition policy or the severity-of-illness and intensity-of-service criteria in Sections A through D.
If no condition-specific policy fits, the request is evaluated under this policy; an admission is never denied solely because no condition-specific policy exists.
Review under the applicable facility policy for maternity delivery (Policy 98), inpatient mental health or substance use disorder care (MH01-MH21), post-acute care (H001-H004), sick newborn care (Policy 116), or transplant admissions (Policy 120).
For pregnancy, Policy 98 governs the delivery stay; pregnancy complications before or after delivery are reviewed under the applicable inpatient condition policy.
A request meeting neither the applicable condition policy nor Sections A through D is referred to a physician reviewer.

Denial Risk

Adverse Determination Authority

Only a licensed physician of the same or similar specialty may issue an adverse determination, after offering the requesting provider a peer-to-peer discussion. The reviewing physician must also meet applicable plan and situs-state licensure, specialty, and medical-director requirements.

Automated systems and non-physician clinical reviewers may approve a request in full or in part but may never issue an adverse determination.
Adverse determinations must apply the plan's medical-necessity standards and applicable state utilization-review requirements.
The absence of a criterion addressing a service is not by itself a basis for adverse determination; a physician applies generally accepted standards of medical practice.
Coverage remains subject to the member's benefit plan and applicable federal and state law, including MHPAEA and 42 CFR Part 2 where applicable.

Denial Risk

Criteria Not Met: Physician Review

When the submitted record does not establish that acute inpatient criteria are met, refer the request to physician review. Automated systems and non-physician reviewers may approve but may not deny; the physician reviewer determines whether the request satisfies the applicable policy and medical-necessity standards.

Offer the requesting provider a peer-to-peer discussion before an adverse determination.
Do not issue an adverse determination solely because a service is not specifically addressed by a criterion.
Apply the matching condition-specific policy when one exists, or this policy's severity-of-illness and intensity-of-service framework when none exists.

Denial Risk

Unsupported Quantity or Duration

When the service meets medical-necessity criteria but the requested quantity, units, or duration exceed what the documentation supports, approve the supported portion and review only the unsupported increment.

Document the clinical support for the approved portion and identify the unsupported quantity, units, or duration.
The unsupported increment is subject to physician review and peer discussion when an adverse determination is being considered.

Service componentsThe assessment includes both treatment needs and the monitoring and reassessment frequency required.

NEWS2

DefinitionNEWS2 is the National Early Warning Score 2, an aggregate score used to assess physiologic deterioration.

Component measuresRespiratory rate, oxygen saturation, supplemental oxygen, systolic blood pressure, pulse, level of consciousness, and temperature.

Response thresholdsA total score of 5 to 6 is the key threshold for urgent response; 7 or more is the emergency-response threshold; a score of 3 in any single parameter prompts urgent clinical review.

Two-midnight benchmark

DefinitionThe two-midnight benchmark is the expectation, documented at the time of the inpatient order, that the member will require medically necessary hospital care crossing two midnights.

TimingThe expectation is formed and documented when the inpatient order is placed.

Counted hospital timeMedically necessary hospital time before the inpatient order, including observation and emergency department time, counts toward the benchmark.

Inpatient-only procedure

DefinitionAn inpatient-only procedure is designated by CMS in the annual Outpatient Prospective Payment System rule as payable only on an inpatient basis.

Designating authorityCMS designates the procedure in the annual Outpatient Prospective Payment System rule.

Policy useThe CMS list is used here as a reference list.

Septic shock

Vasopressor requirementA vasopressor is required to maintain mean arterial pressure at or above 65 mm Hg.

Lactate requirementSerum lactate is greater than 2 mmol/L, or greater than 18 mg/dL.

Additional conditionThe definition applies in the absence of hypovolemia.

Observation

DefinitionObservation is a covered outpatient service used for short-term treatment and reassessment.

Care purposeThe service supports short-term treatment and reassessment.

Status changeChanging a patient from inpatient to observation status is not a refusal of care.

Inpatient-only list

DefinitionThe inpatient-only list is the Medicare list of procedures historically designated as inpatient-only.

CY 2026 phase-outThe CY 2026 OPPS final rule begins a three-year elimination of the inpatient-only list.

Procedures removed from the listFor procedures removed during the phase-out, the inpatient decision follows the two-midnight expectation or a case-by-case exception.