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The 2-Midnight Rule National Provider Call

Published on 

Tuesday, January 21, 2014

 | Outpatient Services 
 | Documentation 
 | Patient Status 

The Centers for Medicare and Medicaid Services (CMS) hosted a National Provider Call regarding the 2-Midnight Rule that went into effect on October 1, 2013 with the Fiscal Year (FY) 2014 IPPS Final Rule. For those of you that were unable to attend here is a run-down of 5 key takeaways from the session.

  1. CMS is already planning future training sessions for Physician Orders/Certification and Transfers.
  2. CMS has acknowledged that there could be times when an inpatient stay would still be appropriate even though an “unforeseen circumstance” occurs and the patient ultimately does not require a 2-Midnight or greater hospitalization. Specific examples from CMS have included patient death, transfer, leaving against medical advice (AMA) or the patient rapidly improving. New to this list is a patient that is admitted, documentation clearly supports a 2-Midnight expectation and the patient / family elect Hospice care and the patient is discharged home to hospice. Key to all of these “unforeseen circumstances” is that documentation in the record clearly supports the physician expectation of a 2-Midnight stay.
  3. Effective December 1, 2013, the NUBC redefined Occurrence Span Code 72 to allow “Contiguous outpatient hospital services that preceded the inpatient admission” to be reported on inpatient claims. At this time this is a voluntary code but CMS encourages hospital to use this code.
  4. Prior to opening the call up to questions and answers, CMS provided answers to two common questions that they had received prior to this call.
  5. Q: How does level of care factor into the 2-Midnight Rule?
  6. A: Under the 2014 IPPS Final Rule, the decision to admit is based on medical necessity of hospital care whether it is observation or inpatient care. If the answer is yes then the next question to ask is do you think this patient will be in the hospital for at least 2-Midnights?
  7. Q: Can any elective surgeries be ok in Inpatient setting?
  8. A: If there is an “unexpected circumstance” requiring 2-Midnights (i.e. a complication) then the stay would be appropriate as an Inpatient admission.
  9. During the open Q&A session a question was asked regarding patients staying beyond 2-Midnights and whether or not a hospital would still be able to use InterQual® criteria. CMS responded by indicating that they believe hospitals will not use InterQual® or Milliman. They did go on to indicate that these screening tools could be used to help determine whether a patient should remain in the hospital or is safe for discharge.

The entire slide presentation from this call can be downloaded at http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/2014-01-14-Midnight-Presentation.pdf

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

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.