CMS Inpatient Two-Midnight Rule 2014 Final Rule. Linda Corley, MBA, CPC Vice President – Compliance, Quality Assurance and Associate Development 706 577-2256 [email protected] Reimbursement “environment” strategy! Importance of Two-Midnight Rule
Importance of Two-Midnight Rule
What’s happening with Medicare inpatient payments?
What is the new inpatient admission “benchmark” for medical necessity?
Why all this focus on Case Management / Utilization Review to ensure “revenue integrity”?
Finalizing Proposed CMS Rules1455 and 1599
Impact on hospital Revenue Cycle collaboration
Preparation and actions to consider for effective reimbursementAgenda
Effective: October 1, 2013 (Q1 CMS fiscal year)
546 total pages in Federal Register, August 2nd publication release was 2,255 pages
Most of the language from the proposed rules remained unchanged
Key pages Federal Register: 50506-50954
Document includes updates on a wide range of topics – today’s focus will be on Two Midnight Rule and its affect on inpatient reimbursementOverview of IPPS Final Rule
Reimbursement operations practices:
4. Rate your “patient care management” (CM, UR, DC Planning) program on a 1 (poor) to 5 (excellent) scale.
Time for honest and in-depth evaluation of the “results” of these staff members!
Noted as the “only” identified Revenue Cycle Department whose performance either substantially increases or decreases CASH!
5. What $$ amount was written-off at your facility last month (and YTD) due to services provided in the “wrong setting,” “not medically necessary,” or “short-stay denied when billed as inpatient care”?
Track, Set improvement goals, communicate, reward!
Past challenge for hospitals has been dichotomy of clinical “care plans” and/or “protocols” for patient care, versus Medicare “coverage, coding and billing” requirements.
The two are not the same – but they do overlap!
The overlap is where “pay-for-performance” and value-based purchasing of medical services will be resolved.
The two requirements must be merged!
Each hospital / facility location is different –
Must perform “risk” analysis to identify specific strengths and weaknesses for collaboration of clinical and revenue cycle staff members.
Financial results such as denials, medical necessity write-offs, bundling of services, re-admission data, and quality benchmarks must be shared.Pay for Performance Dichotomy
… We (CMS) provided hospital inpatient admission guidance specifying that a physician, or other qualified practitioner (herein we will refer to the physician, with the understanding that this can also pertain to another qualified practitioner)
should order inpatient admission if he or she expects that the beneficiary’s length of stay will exceed a 2-midnight benchmark or if the beneficiary requires a procedure specified as “inpatient-only” under § 419.22.
Page 50944, IPPS Rule2-Midnight Inpatient Benchmark
Our (CMS) proposed 2-midnight benchmark, which we now finalize, simply modifies our previous guidance to specify that the relevant 24 hours are those encompassed by 2 midnights.
Page 50945, IPPS Rule
The benchmark used in determining the expectation of a stay of at least 2-midnights begins when the beneficiary starts receiving services in the hospital.
We (CMS) do not believe beneficiaries treated in an intensive care unit should be an exception to this standard, as our 2-midnight benchmark policy is not contingent on the level of care required, or the placement of the beneficiary within the hospital.
Page 50946, IPPS Rule2-Midnight Benchmark (con’t)
“Benchmark of 2 midnights” finalize, simply modifies our previous guidance to specify that
The decision to admit the beneficiary should be based on the cumulative time spent at the hospital beginning with the initial outpatient service.
In other words, if the physician makes the decision to admit after the beneficiary arrived at the hospital and began receiving services, he or she should consider the time already spent receiving those services in estimating the beneficiary’s total expected length of stay.
Page 50946, IPPS Rule
The time a beneficiary spends as an outpatient before the formal
Inpatient admission does not count as Inpatient time, but may be
considered by the physician when determining if the expectation
of a stay lasting at least 2-midnights in the hospital is reasonable
and generally appropriate for inpatient admission.Benchmark vs. Presumption
Important Note! finalize, simply modifies our previous guidance to specify that
CMS has responded to a question regarding when a patient is admitted for Observation for one day, and on the second or even third day, the patient’s condition deteriorates; and then the patient is admitted as an Inpatient who is discharged one day after admission. The RACs previously would review this as a 1-day stay – even though the patient was actually in the hospital for three days. How would this scenario be reviewed under the new 2-Midnight Rule?
… Per CMS, as soon as the physician believes that a second day of Observation will be needed, an Inpatient order should be written!
One CMS rep stated: “Under this application of the 2-Midnight Rule, there should be no Observation stays of more than 1 day!2-Midnight Benchmark
What about InterQual or Milliman “medical necessity” criteria for Inpatient admission?
… Per CMS, the 2-Midnight Rule will apply even if an admission failed InterQual or Milliman …
The only (medical review) question will be
…whether there was a medical reason that required the patient to be in the hospital for at least 2 midnights
…even if that reason is that the patient must remain under Observation for at least 2 days.
One CMS rep stated: “Under this application of the 2-Midnight Rule, there should be no Observation stays of more than 1 day!”2-Midnight Benchmark
“Presumption of 2 midnights” criteria for Inpatient admission?
Under the 2-midnight presumption, inpatient hospital claims with lengths of stay greater than 2 midnights, after formal admission following the order, will be “presumed” generally appropriate for Part A payment, and
will not be the focus of medical review efforts absent evidence of systematic gaming, abuse or delays in the provision of care…
Page 50949, IPPSBenchmark vs. Presumption
For payment of hospital inpatient services under Medicare Part A, the order must specify the admitting practitioner’s recommendation to admit “to inpatient,” “as an inpatient,” “for inpatient services,” or similar language specifying his or her recommendation for inpatient care
Page 50942, IPPS
“Admit to Med/Surg” or
“Admit to Dr. Smith”
are no longer acceptable
No longer acceptable “inferred” Inpatient admission order
Verbal order must be properly countersigned by the physician who gave the verbal order!Physician Order
…while the physician order and the physician certification are required for all inpatient hospital admissions in order for payment to be made under Part A,
the physician order and the physician certification are not considered by CMS to be conclusive evidence that an inpatient hospital admission or service was medically necessary.
The decision to admit is a complex medical judgment, and the 2-Midnight instruction does not override the clinical judgment of the physician …
Admission reviews will continue to play an important role in ensuring hospitals are compliant with CMS guidelines.
Rather, the physician order and physician certification are considered along with other documentation in the medical record.
Page 50940, IPPSPhysician Certification
“(c) The are required for all inpatient hospital admissions in order for payment to be made under Part A, physician order also constitutes a required component of physician certification of the medical necessity of hospital inpatient services under subpart B of Part 424 of this chapter.
(d) The physician order must be furnished at or before the time of the inpatient admission.”
Page 50965, IPPSOrder and Certification
What are the components of a valid Certification for Inpatient admission?
Physician order for inpatient admission
Medical reason for Inpatient hospital stay – Primary Diagnosis
The expected time the patient will remain in the hospital
Plan for inpatient care (services), any diagnostic test orders and findings, and progress notes
Plan for post-hospital care
See new requirements for “discharge planning” documentation
Physician Certification must be documented and signed in the medical record prior to patient discharge!
42 CFR SS 424Order and Certification
What is your facility’s PLAN? Inpatient admission?
Written procedures for
Patient Access (Registration) Reps
PFS Medicare Billers
Consider CM – Physician “team” for inpatient documentation!
Consider pre-bill edit to hold Medicare inpatient claims that are one-day stays.
Case Manager or Nurse Auditor Review prior to billing
Take specific deficiencies in documentation and LOS back to physician for review (ideally, back to CM – Phys team)2-Midnight Rule
“Use of Inpatient admission?Condition Code 44 or Part B inpatient billing pursuant to hospital self-audit is not intended to serve as a substitute for adequate staffing of utilization management personnel or for continued education of physicians and hospital staff about each hospital’s existing policies and admission protocols.”
Page 50914, IPPSNo substitute for UM Process
“Beneficiaries who are treated for extended periods of time as hospital outpatients receiving Observation services may incur greater financial liability than they would if they were admitted as hospital inpatients.
They may incur financial liability for Medicare
Part B copayments,
the cost of self-administered drugs that are not covered under Part B, and
the cost of post-hospital SNF care because section 1861(i) of the Act requires a prior 3-day hospital inpatient stay for coverage of post-hospital SNF care under Medicare Part A.”
Page 50907, IPPSBeneficiary Impact
Expect “sub-regulatory guidance” (i.e., more detailed information) in these areas:
“Objective medical information” Page 50944, IPPS
Transfers and impact on 2 midnights Page 50948, IPPS
Refunding the part A deductible to the
patient if rebilling for part B Page 50919, IPPS
Verbal orders for inpatient admissions Page 50941, IPPS
Stays expected to last less than 2 midnights
are generally inappropriate for inpatient
hospital admission (plan to explain situations
when < 2 MN is appropriate for inpatient) Page 50946, IPPS
Documentation expectation and Auditor
focus areas CMS Open Door ForumAdditional Guidance
Case Management Protocols for Inpatient Admissions information) in these areas:
Some CMs commented that their current processes provide for admission “to case management protocol” or “to utilization review” rather than specifying inpatient admission.
CMS Response: “As we discussed above, many public comments from physicians indicated that they believed the physician should be involved in the determination of patient status, and we agree.
To reinforce this policy and to reduce confusion among hospitals, beneficiaries, and physicians on the differences between Outpatient Observation and Inpatient services, we (CMS) are providing in this final rule that the order for inpatient admission must specify admission “to or as an inpatient.”
Page 50942, IPPSAdmit to CM Protocol Implications
Cannot be considered inpatient without physician “order” and other documentation to meet medical necessity!
Ensure clarity of the physician order, certification of expected 2-midnight stay, and supporting documentation
Order and documentation must be recorded prior to discharge
OP to IP corrections must take place during hospitalization
Inpatient admission begins at time of order for inpatient services; converting OP to IP later in the stay will result in:
Short stays (1 or 2 day stays) more likely to be audited by MAC, RAC, OIG
Will impact 3-day stay requirement for SNF qualificationAdmission Order Review Vital
Physician order narrative must be improved and specific: and other documentation to meet medical necessity!
Many orders intending for Observation services to be provided actually result in inaccurate Inpatient status because of narrative documented:
“admit to observation”
“admit for observation”
“admit 23 hour observation”
How these will be interpreted under new rule is unclear!
Required: “admit to inpatient”!
Physician order must be signed. Oral order to RN acceptable, but not legal unless signed within time frame in By-laws!
• Observation “time” begins at the time physician order is written.Status Order
Consider a chart audit and other documentation to meet medical necessity!to evaluate current processes to get correct orders on the chart at the time of admission!
Whether printed, electronic or handwritten order for Inpatient admission must read:
“Admit to Inpatient” or “Admit to Inpatient services”
Forms or electronic tools should provide alternative choices to inpatient
“Place in Observation,” “Provide Observation services,” “Needs Outpatient services overnight in hospital bed,” or “Post-op Recovery in Observation bed.”
Avoid multiple orders on record that create conflicting status
All hospital patients should have a status order when care begins!
Start educating nurses and physicians, bringing order sets to committees, as well as getting verification processes in place.Status Order Improvement
For cases with > 2 midnight stay, review to ensure “appropriateness.”
Was the care provided in a timely and efficient manner?
Was there a delay in service that resulted in prolonging the hospital stay?
Why was the Cardiac Catheterization performed on day 3 and not on day 2?
Was there a weekend delay in Stress test, PET scan, or other specialized service, or in the initiation of therapy services?
For “social / personal” discharge challenges, provide HINN and ensure stay is charged and billed appropriately.Documentation - Efficiency
Educate ALL physicians on documentation requirements: “appropriateness.”
“Expectation” of 2 night stay for inpatient admission
Medical necessity rational each day to avoid question of delay in care
Start with ED physicians – if they are driving the majority of admissionsDocumentation Improvement
Review cases as close to time of admission as possible “appropriateness.”
Cases that do not meet screening criteria should be sent to a physician advisor or CM Director for review!
Review should include:
Physician order in medical record
Physician certification in medical record
Documentation of expectation of 2 midnight stay
Documentation supporting medical necessityReview Considerations
Medical cases or procedures with expected same day or next day discharge (hospital care not expected to span 2 midnights)
Procedures on the Medicare Inpatient Only List remain inpatient, require order pre-procedure and other documentation
Other cases will probably not meet threshold for inpatient consideration
Medical cases or procedures with care expected to span 2 midnights
Need order, and usual medical necessity review approach
Inpatient admissions expected to span 2 midnights but did not – will require additional review
Outpatients whose LOS extends beyond 2 midnights will require additional review
Some inpatients spanning 2 midnights may be pulled by contractors for medical necessity and “efficiency of care” review!Impacts on CM Process
Summary day discharge (hospital care not expected to span 2 midnights)
Must evaluate current practices at each location to prepare strategy
Must have a written plan –
For Patient Care Managers
For Patient Access / Registrars
For HIM (medical records documents and Coders)
For PFS (Billers)
Must review admission orders at time of bed placement
Must evaluate today’s admissions based on plan
Must achieve consistency on a daily basis!Two-Midnight Rule