Knowledge Base Article

What do Probe Reviews, the start time for when the 2 midnight benchmark begin, Physician Documentation, automatic denials and Occurrence Span Code 72 have in common? All of these issues were addressed in the CMS Frequently Asked Questions (FAQs) December 23, 2013 update. Let’s break it down be each updated FAQ.

Q1.1: “Will CMS direct the Medicare review contractors to apply the 2-midnight presumption-that is, contractors should not select Medicare Part A inpatient claims for review if the inpatient stay spanned 2 midnights from the time of formal admission?”

• Yes, when a patient has been in your hospital for two midnights AFTER the inpatient order was written review contractors are to presume that the Medicare Part A inpatient admission was reasonable and necessary.
• New to this answer is that for inpatient admissions from October 1, 2013 through March 31, 2014 “CMS will not permit Recovery Auditors to conduct patient status reviews on inpatient claims with dates of admission between October 1, 2013 and March 31, 2014. These reviews will be disallowed permanently; that is, the Recovery Auditors will never be allowed to conduct patient status reviews for claims with dates of admission during that time period.”
• Caution: These same admissions CAN be reviewed for other issues (i.e. medical necessity of a surgical procedure or coding validation).

Q2.1: “Can CMS clarify when the 2 midnight benchmark begins for a claim selected for medical review, and how it incorporates outpatient time prior to admission in determining the general appropriateness of the inpatient admission?

• All time that a Medicare beneficiary is receiving outpatient services at the hospital will be considered in whether or not the 2-midnight benchmark was met.
• Note: “The Medicare review contractor will count only medically necessary services responsive to a beneficiary’s clinical presentation as performed by medical personnel.”
• Services to be included: observation services, treatments in the Emergency Department, and procedures provided in the operating room or other treatment area
• Services not to be included: treatment received in an outlying Emergency Department or in an ambulance en-route to your hospital.

Q4.1: “What documentation will Medicare review contractors expect physicians to provide to support that an expectation of a hospital stay spanning 2 or more midnights was reasonable?”

• Physician complex medical decision making: The expectation of a 2-midnight stay “must be supported by complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.”
• Documentation: Medicare review contractors will expect the Physician’s decision making factors to be documented in the physician assessment and plan of care. “CMS does not anticipate that physicians will include a separate attestation of the expected length of stay, but rather that this information may be inferred from the physician’s standard medical documentation, such as his or her plan of care, treatment orders, and physician’s notes.”

Q4.9: “Under the new guidance, will all inpatient stays of less than 2 midnights after formal inpatient admission be automatically denied?”

• Medicare does anticipate that most stays less than 2 midnights would be as an outpatient. However, “because this is based upon the physician’s expectation, as opposed to a retroactive determination based on actual length of stay, we expect to see services payable under Part A in a number of instances for inpatient stays less than 2 total midnights after formal inpatient admission.”
• CMS has provided specific exceptions to the 2-midnight benchmark when inpatient would still be appropriate:
• Beneficiary death,
• Beneficiary transfer to another acute inpatient facility,
• Beneficiary leaving against medical advice (AMA),
• Beneficiary was admitted for a medically necessary service on the Inpatient-Only List,
• Mechanical ventilation initiated during the present visit (Note: is not intended to apply to anticipated intubations related to minor surgical procedures or other treatment),
• Or a Beneficiary unexpectedly improves and was discharged in less than 2 midnights.
• New to this answer: “Lastly, there may be rare and unusual cases where the physician did not expect a stay lasting 2 or more midnights but nonetheless believes inpatient admission was appropriate and documents such circumstance. The MACs are being instructed to deny these claims and to submit these records to CMS Central Office for further review. If CMS believes that such a stay warrants an inpatient admission, CMS will provide additional subregulatory instruction and the Part A contractors will review any claims that are subsequently submitted for payment in accordance with the most updated list of rare and unusual situations in which an inpatient admission of less than 2 midnights may be appropriate.”

Q5.2: “Is there a way for providers to identify any time the beneficiary spent as an outpatient prior to admission on the inpatient claim so that Medicare review contractors can readily identify that the 2-midnight benchmark was met without conducting complex review of claim.”

• “Effective December 1, 2013, Occurrence Span Code 72 was refined to allow hospitals to capture ‘contiguous outpatient hospital services that preceded the inpatient admission’ on inpatient claims.”
• For now, “Occurrence Span Code 72 is a voluntary code, but may be evaluated by CMS for medical review purposes.”

The entire FAQ download can be found at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/QuestionsandAnswersRelatingtoPatientStatusReviews_12232013_508Clean.pdf With the MAC Probe and Educate program just getting underway, you can expect there to be several additional updates to the FAQs.