News Alert: CMS MOON Shot Fizzles During Open Door Forum

With the March 8 deadline to implement the Centers for Medicare & Medicaid Services (CMS) Medicare Outpatient Observation Notice (MOON) bearing down on providers, Wednesday’s CMS open door forum generated few answers, but many more questions.

That vagueness has created a dilemma for hospitals, especially those that have already printed MOONs using checkboxes that do not include space for clinical reasons for service.

“Trying to predict how a surveying agency will interpret this vague guidance is also impossible, and that is obviously the key, since the surveyors are the ones who will show up to review MOON processes and determine compliance with the regulations,” said Ronald Hirsch, MD. “In online forums, some have even suggested sticking with wording that solely addresses the expected length of stay without any clinical details specific to the patient.”

Most significantly, CMS addressed the need for a clinical rationale for the decision to order observation, stating that it expects one “that is specific to each beneficiary’s circumstances.” CMS officials also stated that if checkboxes are used, there must be an option for “other.” 

“This requirement for a ‘specific clinical reason’ caught many, including myself, off guard, as CMS had never previously indicated that such detail is needed,” Hirsch told RACmonitor. “Despite my personal plea and the questions of others, CMS refused during the call to provide an example of acceptable wording for the clinical reason and stated that they would not suggest any wording, endorse any wording, or review any submitted examples for appropriateness of the wording.” 

“As many know, I have recommended the use of checkboxes on the MOON. With this new guidance, my previous recommendation appears to have become non-compliant,” Hirsch continued. “Based on the information on the call, I would now recommend that the first choice on the form be modified to include a fill-in-the-blank space to allow a clinical reason for the choice of observation. For example, that could be ‘You require hospital care for evaluation and/or treatment of (blank). It is expected that you will need hospital care for less than a total of two days.’”

Hirsch, vice president of physician advisory services at Chicago-based R1, said that he has posted a modified version of the form on his website, These blanks, Hirsch explained, can be filled in based on the diagnosis the physician provides when ordering observation.

“This, in my opinion, meets the new guidance requiring a reason specific to the patient, but still allows the MOON to be completed without direct physician input,” Hirsch said. “The other two checkbox reasons appear to remain compliant, as the surgery option would apply specifically to such a patient and the Medicare Advantage option does accurately reflect that the decision was not at all clinical, but dictated by the payer.” 

Hirsch said that during the call, CMS also was unable to answer his question about the formatting requirements if the MOON is translated into other languages and the counting of observation hours if the patient is transferred from another facility where they received observation. This was especially disappointing to Hirsch, as he noted that both of his questions were submitted in writing to the MOON mailbox, so CMS had sufficient time to research the matter and formulate a response.

CMS also dodged another question that was of interest to all hospitals, according to Hirsch. Asked if the approval of a one-day inpatient admission by the Quality Improvement Organization (QIO) in an audit, in which the patient was admitted as inpatient despite the expectation of a stay of fewer than two midnights, would allow hospitals to use that as precedent and consider all other patients with a similar clinical presentation to be eligible for inpatient admission, CMS failed to respond. 

“This example could also apply to a patient presenting with complete heart block who is going immediately to have a permanent pacemaker placed and is expected to be discharged the next day,” Hirsch explained. “Once again, CMS provided a non-answer, deviating into a discussion about the use of criteria to determine status.”

The recording of the forum will be available for two days at 1-855-859-2056, with conference ID No. 56386914 – and it is hoped, but not confirmed, that the recording will be posted to the new podcast page at If you do listen, prepare to be frustrated, as were most of the listeners on the call. If there are more updates, you’ll get them from RACmonitor and Monitor Mondays, so stay tuned.


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