Joseph Nitti, M.D. Medical Director/Physician Advisor Continuum of Care Dept. Morristown Medical Center 973-971-4004 CMS -1599F The 2 Midnight Rule Effective October 1, 2013
Determination of Inpatient vs. Outpatient- Now based on expectation and prediction of LOS Inpatient admission generally appropriate for: Hospitals stays where the physician expects the patient to require care that will cross 2 midnights Observation/Outpatient generally appropriate for: Hospital stays where the physician expects the patient to require care for less than 2 midnights However, the physician is permitted to consider all time a patient has already spent in the hospital as an outpatient receiving observation services or in the ER, operating room, or other treatment area in guiding their two midnight expectation. 2
Medical Necessity however is not going away in order for payment to be provided under Medicare Part A, the care must be reasonable and necessary. The factors that lead a physician to admit a particular beneficiary based on the physician s clinical expectation must be clearly and completely documented in the medical record. 3
2 Midnight Benchmark vs. Presumption Medicare review contractors will consider all time after the initiation of care* in applying the benchmark that inpatient status is generally appropriate for medically necessary stays crossing 2 midnights Reviewers will also adopt a presumption that a medically necessary stay surpassing 2 midnights after being admitted was appropriately provided as an inpatient. However, if a hospital is found to be abusing or gaming the 2 midnight presumption for non-medically necessary inpatient stays by prolonging the provision of care to surpass the 2 midnight timeframe, CMS review contractors would disregard the 2 midnight presumption. *initiation of care the time the patient starts receiving any services after arrival at the hospital 4
Continued Reviewers would generally presume that a stay spanning less than 2 midnights was appropriately provided as an outpatient Exceptions: 1. Inpatient leaves after 1 midnight or less but there is clear documentation supporting the physician s order and expectation that the patient would require care spanning 2 midnights (examples patient improved much more quickly than expected, or patient expired, left AMA, or was transferred to another facility) 2. Patient received services or procedures listed on CMS s Inpatient Only List Essentially all other procedures or surgeries spanning 1 midnight, barring complications, are outpatient stays 5
Short inpatient stays will be a potential source of denials CMS medical reviewers will focus on inpatient hospital admissions with lengths of stay crossing 1 midnight or less after admission. 6
Critical points in the physician decision process Though always very important, getting the patient into the correct status at the time of presentation is now even more critical The morning following a first midnight spent under observation/outpatient status 7
Not changed by the new rule 3 medically necessary nights under inpatient status are still necessary for short term SNF coverage The inpatient stay is still calculated from the time of the admission order Even though a midnight spent as an outpatient may factor into a physician s 2 midnight calculation and benchmark for inpatient status, it does not count as one of the medically necessary 3 inpatient nights to qualify for subacute rehab. 8
Inpatient order is critical under the new rule The rule emphasizes the need for a formal order CMS states that unless a treating physician has written an order to admit the patient as an inpatient, the patient is considered to be a hospital outpatient The order must specify the admitting practitioner s recommendation to admit to inpatient, as an inpatient, for inpatient services or similar language. The words admit and inpatient must appear The order must be furnished by a qualified and licensed practitioner who has admitting privileges at the hospital as permitted by State law. The practitioner may not delegate the decision to another individual who is not authorized by the State to admit patients, or has not been granted admitting privileges by the hospital 9
Certification and Recertification Must be signed by the attending physician responsible for the case or by another physician who has knowledge of the case and is authorized to do so by the attending physician or by a member of the medical staff with knowledge of the case There must be a separate signed statement for each certification or recertification Certification begins with the order for inpatient admission. This is a required component of the physician certification Must also certify that: 1. the services were provided in accordance with Article 412.3 (order) 2. the reason for hospitalization of the patient for inpatient treatment (diagnosis at a minimum) 3. the estimated time the patient will need to remain in the hospital 4. Plans for post-hospital care, if appropriate 10
Continued No requirement that the certification or recertification be entered in any specific form or handled in any specific way. May adopt any method that permits verification. If no specific form is utilized, there must be a signed statement as to where the information can be found in the medical record. No requirement that the certification needs to be done at the time of admission. It is only specified that it be done prior to discharge of the patient Certification or recertification of the need for continued hospitalization is necessary for patients remaining in the hospital who could be receiving proper treatment in a SNF but no bed is available. The physician is expected to continue efforts to place the patient in a participating SNF as soon as a bed becomes available. Recertification of the same elements otherwise only applies for day outliers or cost outliers. 11
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