Medicare Two-Midnight Rule Exceptions (Short Stays)Deborah Greer, MD Physicians can struggle with the concept that Medicare patients that cross less than two midnights have inpatient status based on the determination of the severity of illness and intensity of services. For example, if a patient received a diltiazem drip for rapid atrial fibrillation, in the mind of some physicians, this situation would automatically count as inpatient even if the patient was discharged the next day. This may have been the case prior to October 1, 2013, but with the implementation of the two-midnight rule by CMS noted in the 2014 Inpatient Prospective Payment System (IPPS), a physician expecting the patient to cross two midnights with the medical records supporting that expectation would be able to pay under Medicare Part A. Patient stays less than two midnights may possibly be paid under Medicare Part B but not A, whether if placed as outpatient from the onset, if changed to outpatient via the condition code 44 process, or via self-denial and rebilling after discharge. Following release of the rule, CMS received extensive feedback from stakeholders, and in order to clarify updated the rule with CY 2016 OPPS Final Rule addressing hospitalized exceptions of less than two midnights. They added the Case by Case exception at that time to the exception for inpatient only list procedures and newly initiated mechanical ventilation. The list of patients that may now be compliantly billed to part A is:
Knowledge and documentation are predicated on the successful appropriateness of the inpatient short stay. There are instances where the surgeon/proceduralist will place an outpatient order for a procedure on the Inpatient only list, and the inaccurate order is not caught until the patient leaves the hospital building. This exception would be an easy inpatient stay if the correct CPT code was documented in the outpatient setting and transferred to hospital billing. Patient financial services/admitting then ensures the physician status order is indeed inpatient with care coordination as secondary support and reviewer. Communication is key, especially if the procedure is new to the hospital and the procedure is not known to be on the Inpatient only list. For case-by-case and unexpected circumstances exceptions, medical documentation that supports the physician’s decision for the exception is vital if an audit occurs, whether internal or external. Rote notes written either as a short “dot phrase” or a copy carry can affect the final determination of appropriateness. For unexpected circumstances, there must be documentation of why the patient requires inpatient status, including an expectation of the hospitalization crossing 2 midnights in the History & Physical. If there is rapid clinical improvement, information that is sought would be, what were the severity of signs and symptoms, the treatment that required the patient to stay two midnights, and how the patient improved and can now be discharged. Continuous education to reinforce thoughtful documentation provides a tangible account of each decision made in the course of patients’ care which further supports Medicare exceptions based on medical necessity under short stays. This ensures accurate reimbursement, decreases poor audit results, and improves patient safety and quality of care. “Knowledge is not power; it is only potential. Applying that knowledge is power. Understanding why and when to apply that knowledge is wisdom.” – Takeda Shingen Dr Greer is Medical Director, Advisory Services at Sequoia Hospital |