crosswalk

Crosswalk Document for Changes to the CMS 10611-MOON

Medicare Outpatient Observation Notice

Summary of Changes to the MOON:

The following changes have been made to the MOON as a result of comments received during the 60 day notice and comment period.

• The “Time”, “Date”, and “Physician” blanks in the header have been removed.

• The order of information illustrated in the notice has been changed to improve readability and clarity.

• We’ve removed the language stating the date and time observation services began.

• In place of generic language to explain observation services, we’ve added the section “You’re a hospital outpatient and not an inpatient because:” for the hospital to provide the specific reason behind the beneficiary’s outpatient status.

• In the section “Being an outpatient may affect what you pay in a hospital”, the language has been simplified to include only the cost sharing implications of Medicare Part B.

• Under the heading “Observation services may affect coverage and payment of your care after you leave”, the skilled nursing facility requirements are restated to enhance clarity and beneficiary understanding of the qualifying stay implications.

• We have allowed more space for “Additional Information”, and indicated this as an “Optional” field on the revised notice.

• Information regarding filing a grievance with a Medicare Advantage or other health plan has been removed from the notice.

• The reference to the QIO, along with the blanks for contact information, has been removed from the notice, as has corresponding contact information for MA enrollees.

Summary of Changes to Instructions:

The following changes have been made to the instructions as a result of comments received during the 60 day notice and comment period and correspond to above noted changes in the MOON.

• Step one, instructing hospitals to display “Department of Health & Human Services, Centers for Medicare and Medicaid Services”, and the OMB number has been removed. Because the OMB number will be pre-printed on the standardized form, it is not necessary for the hospital to fill in a specified field.

• The instruction for the hospital to document the time in military time has been removed since the beneficiary will be the sole person documenting the date and time on the form.

• Instructions for the “Physician”, “Date”, and “Time” blanks have been removed.

• Language has been added to instruct hospitals how to fill out the new section “You’re a hospital outpatient and not an inpatient because:…”.

• Instructions for filling in the “Date”, “Time”, and “Hospital Name” in the body of the notice were removed.

• Under “Page 2 of the MOON”, the “Additional Information:” section has been simplified, with the removal of information regarding beneficiary refusals.

• We’ve removed the “QIO Name” and “QIO Phone Number” information, as well as the corresponding contact information for MA enrollees.