The Centers for Medicare & Medicaid Services (CMS) recently announced two developments related to the Two Midnight Rule. The Two Midnight Rule was included in the hospital inpatient prospective payment system rules for fiscal year 2014, and provides that surgical procedures, diagnostic tests and other treatments generally qualify for inpatient admission and reimbursement under Medicare Part A if the physician admits the beneficiary to the hospital based upon the expectation that the beneficiary requires a stay that crosses two midnights. CMS on January 30, 2014 issued guidance on the physician order and certification requirements for hospital inpatient services, and the next day announced an extension of the inpatient hospital prepayment review “probe and educate” process until October 1, 2014.
Guidance on Hospital Inpatient Admission Order and Certification Requirements
CMS’ new guidance addresses several issues related to the hospital inpatient admission order and certification requirements. With respect to the inpatient order, the guidance contains information on the content, qualifications of the ordering/admitting practitioner, knowledge of the patient’s hospital course, timing, and specificity of the order. For instance, the guidance addresses admissions decisions made by non-physician practitioners, residents and physicians without admitting privileges. CMS indicates that if a practitioner is qualified to write an order, he or she can write an order on behalf of someone who has admitting privileges as long as the order is reviewed and countersigned by a person with admitting privileges.
The guidance also provides information on how to satisfy the physician certification requirements, including the required content, timing, authorization to sign the certification and the format. For example, CMS indicates in the guidance that the certification begins with the order at admission and must be completed prior to discharge. If it is made at discharge, a provider can cite the medical record to justify that the length of stay is appropriate.
Extension of the “Probe and Educate” Period
CMS initially planned for a three-month “probe and educate” period (from October 1, 2013 through December 31, 2013) during which the Medicare Administrative Contractors (MACs) would select for prepayment review a small sample of claims (10 claims for most hospitals and 25 claims for large hospitals) with dates of admission on or after October 1, 2013. CMS instructed the MACs to conduct educational outreach efforts over this implementation period, during which they would deny claims that are noncompliant with the Two-Midnight Rule, outline the reasons for denial in a letter to the hospital, offer individualized phone calls to certain providers and conduct additional probe reviews on claims submitted by providers identified as having moderate/significant concerns or major concerns.
CMS first extended the probe and educate period through March 31, 2014, but on January 31, 2014 announced that it was extending the probe and educate period for an additional six months (through September 30, 2014). During the extended time frame, the MACs will continue to select claims for review with dates of admission between March 31, 2014 and September 30, 2014 and will continue to deny claims found not in compliance with the Two Midnight Rule. The MACs will do the same number of reviews; the extension merely provides the MACs with more time to conduct the reviews. Importantly, the MACs and Recovery Auditors will not conduct post-payment patient status reviews of inpatient hospital claims with dates of admission on or after October 1, 2013 through October 1, 2014.
Additional information on the inpatient hospital admissions policy can be found here.
The guidance, “Hospital Inpatient Admission Order and Certification” issued on January 30, is available here.