Knowledge Base Article

Merriam-Webster defines confusion as “a situation in which people are uncertain about what to do or are unable to understand something clearly,” or “the feeling that you have when you do not understand what is happening, what is expected, etc.” and finally as “a state or situation in which many things are happening in a way that is not controlled or orderly.”

All three definitions are apt depictions of how the healthcare industry felt in response to the 2014 Inpatient Prospective Payment System (IPPS) Final Rule and more specifically how to implement the then new 2-Midnight Rule and Physician Certification Requirements. Adding to the confusion, the Physician Certification Requirements changed again on January 1, 2015 with the implementation of the 2015 Outpatient Prospective Payment System (OPPS) Final Rule and more recently, the Centers for Medicare and Medicaid Services (CMS) have extended the Inpatient Probe and Educate process through April 30, 2015. We have recently come across certain Myths about the regulations and wanted to equip our readers with the Facts.

Myth: As of April 1st, 2015, the Centers for Medicare and Medicaid Services (CMS) have once again delayed implementation of the 2-Midnight Rule.

Fact: On April 1st the CMS indicated that “given potential Congressional action on H.R. 2, the Medicare Access and CHIP Reauthorization Act of 2015, CMS will continue the Inpatient Probe and Educate process until April 30, 2015 and will continue to prohibit Recovery Auditor inpatient hospital patient status reviews for dates of admission occurring between October 1, 2013 and April 30, 2015.”

However, hospitals should have implemented the 2-Midnight Rule at the start of the CMS 2014 Fiscal Year on October 1, 2013. This rule was intended as guidance for Physicians in identifying patients appropriate for inpatient admission. CMS has NEVER delayed the implementation date for hospital compliance with the 2-Midnight Rule. The Inpatient Probe and Educate Process was put in place to delay Contractor inpatient hospital status reviews thereby allowing hospitals time to further understand and implement this policy.

Note: Congress has passed legislation and, at the time of this posting, President Obama has indicated that he will sign it into law. This means that the Probe and Educate process will be extended to the end of the fiscal year on September 30, 2015.

Myth: As a result of the 2-Midnight Rule, CMS will not reimburse hospitals for inpatient hospitalizations that do not span 2 Midnights.

Fact: In Sub-regulatory guidance following implementation of the 2014 IPPS Final Rule, the CMS indicated that there may be “unforeseen circumstances” or possible “exceptions” to when a beneficiary is appropriately placed in an inpatient status but does not remain in the hospital 2 Midnights. To date the CMS has identified four Unforeseen Circumstances and one possible Exception.

Unforeseen Circumstances

• Beneficiary death or transfer,
• A beneficiary rapidly improving and the reasonable 2-Midnight expectation was clearly documented in the record,
• A beneficiary leaves Against Medical Advice (AMA), or
• In the event that a beneficiary declines further workup and/or treatment and elects Hospice Care.

Exception

• “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 1 midnight of hospital care, inpatient admission and Part A payment is nonetheless generally appropriate. NOTE: This exception is not intended to apply to anticipated intubations related to minor surgical procedures or other treatment.”

Myth: CMS has suspended review of all inpatient claims submitted by hospitals to the Medicare program between October 1, 2013 and April 30 of this year.

Fact: It is true that Recovery Auditors are prohibited from patient status reviews on inpatient claims with dates of service from October 1, 2013 now through April 30, 2015.

However, during this time, Medicare Administrative Contractors (MACs) are facilitating the Probe & Educate program in which they are performing a limited number of pre-payment probe reviews of 1 day or less inpatient hospitalizations with dates of services on or after October 1, 2013. MACs were instructed to assess for compliance with the admission order requirements, physician certification requirements and 2-Midnight Benchmark Guidance. While this is a Probe and Educate program, hospitals do not receive payment for denied claims.

CMS outlines reviews not impacted by the 2014 IPPS Final Rule on the Inpatient Hospital Reviews Webpage. Specifically, “MACs, Recovery Auditors and the Supplement Medical Review Contractor will continue other types of inpatient hospital reviews, including, but not limited to:

• Coding reviews,
• Reviews for the medical necessity of a surgical procedure provided to a hospitalized beneficiary, and
• Inpatient hospital patient status reviews for dates of admission prior to October 1, 2013 (based on the applicable policy at the time of admission).”

Myth: All Medicare inpatient admissions need an Initial Physician Certification completed prior to the patient being discharged

Fact: This was true for Medicare admissions with dates of service on or after October 1, 2013 through December 31, 2014. However, this changed with the 2015 OPPS Final Rule. As of January 1, 2015, CMS finalized their “policy as proposed in the CY 2015 OPPS/ASC proposed rule, which limits the requirement for physician certification to long-stay (20 days or longer) and outlier cases.” Furthermore, they finalized their “proposed revision of paragraph (b) of § 424.13, without modification, to specify that certifications for long-stay cases must be furnished no later than 20 days into the hospital stay.”

Myth: Any practitioner treating a Medicare Inpatient can write a valid Inpatient Status Order.

Fact: Per the January 30, 2014 CMS Sub-regulatory guidance Hospital Inpatient Admission Order and Certification, the order must be provided by a Physician or other practitioner that meets the following criteria

1. Is licensed by the state to admit inpatients to hospitals,
2. Has been granted privileges by the hospital to admit inpatients to that specific facility, and
3. Is knowledgeable about the patient’s hospital course, medical plan of care, and current condition at the time of the admission.

Resources:

CMS Inpatient Hospital Reviews Web page: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/InpatientHospitalReviews.html

January 30, 2014 CMS Sub-regulatory Guidance: Hospital Inpatient Admission Order and Certification

http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf