New Potential Exception to the 2-Midnight Expectation

on Tuesday, 10 December 2013. All News Items | Patient Status

One of the most talked about changes in the 2014 IPPS Final Rule has been the new 2-Midnight Benchmark guidance for Physicians. Physicians are directed to write the order for an inpatient admission when they have the expectation that a Medicare beneficiary will need medically necessary inpatient services beyond a 2-Midnight Benchmark. I can almost hear it now, but what about…

CMS did indicate that there would be exceptions to when a beneficiary would not exceed 2-Midnights but would still be appropriate as an inpatient. Specific examples include:

  • Unforeseen circumstances such as death or transfer,
  • The patient rapidly improves and the reasonable expectation was clearly documented in the record, or
  • A patient leaves against medical advice (AMA).

On November 27, 2013 CMS released an updated Reviewing Hospital Claims for Patient Status: Admissions On or After October 1, 2013 download to include the new potential exception to the 2-midnight rule of mechanical ventilation initiated during the present visit.

CMS has identified the following potential exception to the 2-midnight rule:

1. Mechanical Ventilation Initiated During Present Visit: CMS stated in its discussion of rare and unusual circumstance that treatment in an Intensive Care Unit, by itself, does not support an inpatient admission absent an expectation of medically necessary hospital care spanning 2 or more midnights. Stakeholders have notified CMS that they believe beneficiaries with newly initiated mechanical ventilation support an inpatient admission and Part A payment. CMS believes newly initiated mechanical ventilation to be rarely provided in hospital stays less than 2 midnights, and to embody the same characteristics as those procedures included in Medicare’s inpatient –only list. While CMS believes a physician will generally expect beneficiaries with newly initiated mechanical ventilation to require 2 or more midnights of hospital care, if the physician expects that the beneficiary will only require one midnight of hospital care, inpatient admission and Part A payment is nonetheless generally appropriate.

It is important to pay attention to the NOTE included in this update that indicates that “this exception is not intended to apply to anticipated intubations related to minor surgical procedures or other treatment.” So, those outpatient patient procedures that require mechanical intubation during the procedure where the patient is weaned from ventilator support during recovery may not be an appropriate exception to the 2-Midnight Rule.

CMS continues to seek suggested exceptions from the hospital industry. If you have suggestions you can send them by email to This email address is being protected from spambots. You need JavaScript enabled to view it. and enter “Suggested Exceptions to the 2 Midnight Benchmark” in the subject line.

We would like to share with our readers that CMS will be hosting another Special Open Door Forum: Final Rule CMS-1599-F: Discussion of the Hospital Inpatient Admission Order and Certification; 2 Midnight Benchmark for Inpatient Hospital Admissions on Thursday December 19th from 1:00pm-2:00pm Eastern Time. You can go to the Special Open Door Forum CMS webpage at for more details on how to participate.

MMP also encourages you to continue to watch for 2-Midnight Benchmark and Physician Certification Guidance updates on the CMS Inpatient Hospital Review page at

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-two years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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