Two Midnight Rule
If the planned hospital stay is less than two midnight or uncertain at the time of presentation, an outpatient observation start is appropriate, with an upgrade to recommended hospitalization status as soon as the need for a medically necessary second midnight becomes clear. The first night spent in observation counts towards the completion of the landmark of two midnights. The fact that the patient remains in hospital after two midnight does not automatically justify inpatient status; Time spent in hospital must be medically necessary It`s hard to believe, but CMS`s controversial “two midnight” rule (2MN rule) has been in place for more than five years. The rule was originally intended to provide a clear, time-based method for determining whether patients should be placed under observation or hospitalization. Rule 2MN states that hospitalization is generally considered appropriate and necessary if the physician (or other qualified physician) orders hospitalization expecting that the patient will require at least two medically necessary hospital care by midnight. These changes better support the determination of the patient`s baseline condition at the time of hospitalization, as well as the hospital`s critical decision from observation to decision to hospitalization approaching midnight 2. Exceptions to the two-midnight rule – if inpatient status is still appropriate even if the patient does not complete two nights in hospital: On October 30, 2015, the CMS released updates to the two-midnight rule on when inpatient admissions are eligible for Medicare Part A payment. These changes are consistent with CMS`s longstanding emphasis on the importance of a physician`s medical judgment in meeting the needs of Medicare beneficiaries. These updates were included in the final rule of the Prospective Hospital Outpatient Payment System (OPPS) for calendar year (CY) 2016.
The idea of the two-midnight rule was to address the two concerns mentioned above. According to this rule, most scheduled nightly hospitalizations should be outpatient, even if they last more than 24 hours, and any medically necessary outpatient hospitalization should be “converted” to hospitalization if it is clear that a second night of hospitalization is medically necessary. Despite occasional assertions to the contrary, the determination and documentation of medical necessity remains a prerequisite for the application of the 2MN rule. When CMS first introduced the rule, some organizations mistakenly believed that moving to a time-based metric meant that medical necessity was no longer important. In order to provide greater clarity to hospital and physician stakeholders and to take into account the higher frequency of outpatient treatment of beneficiaries over longer periods than outpatients, CMS introduced the two-midnight rule for admissions as of October 1, 2013. This rule established Medicare`s payment policy with respect to the benchmarks to be used to determine whether hospitalization is appropriate and necessary for the purposes of payment under Part A of Medicare. For more information on the OPPS CY 2016 Final Rule, see this fact sheet. The final rule will be published in the Federal Register on September 13. November 2015 and can be downloaded from the Federal Register at: www.ofr.gov/inspection.aspx?AspxAutoDetectCookieSupport=1 The application of the 2MN rule will continue to be delegated to the two National Organizations for Beneficiaries and Family-Centered Care for Quality Improvement (BFCC-QIOs), Livanta and KEPRO.
These audit bodies are responsible for assessing the adequacy of hospitalization requests for hospitalizations of less than 2 million. To address these concerns, CMS adjusted the definition of inpatients in October 2013 to include the “two-midnight rule.” Basically, CMS stated that to qualify for an inpatient patient, the receiving physician should expect the recipient to need inpatient treatment that includes at least two midnights, rather than the previous 24-hour reference point, regardless of the severity of the illness or the risk of an adverse outcome. (There are exceptions and exceptions to the two-midnight rule, which will be discussed later in this article.) Following the introduction of the two-midnight rule, CMS received extensive feedback from stakeholders, including concerns that the new policy would affect medical and hospital practices. In January 2016, CMS amended the two-midnight rule to recognize, as before October 2013, that some hospitalizations based on a medical assessment would be appropriate for hospitalized patients without expecting a hospital stay of at least two nights. Unfortunately, the CMS did not provide guidance on examples of hospitalizations that would fall into this new category, other than to say that it expects that the application of this new provision will generally not be appropriate for hospitalization of less than 24 hours. In general, the original two-midnight rule states: The evaluation of the medical record based on InterQual is particularly important for admission at the 2nd midnight. In these cases, the patient is initially classified as an outpatient with observation services. The patient is converted to the hospitalization status of the 2nd MN, with discharge the next day. These stays of 1 million inpatients are an important goal for regular 2 MN law enforcement efforts. The final rule also includes a discussion of changes to the CMS`s approach to hospital education and our application of the two-midnight rule.
In particular, CMS began operations on 1. October 2015 with the use of Recipient and Family Centred Care (BCB) CAQs instead of CAMs or Recovery Auditors to perform initial medical examinations of providers submitting requests for short-term hospitalization. Beginning in 2016, BFCC OIQs will begin reviewing inpatient cases under the revised two-midnight rule, which is announced today. While CMS has issued updates and clarifications, particularly with respect to monitoring and enforcement, the underlying rationale for the rule has not changed since it was first included in the final rule of the Forward-Looking Forward Settlement System in 2014. After some changes, the rule now seems stable in its application and application. For stays that are expected to last less than two midnights, CMS adopts the following guidelines: “CMS contractors` blind application of billing rules such as the `two-midnight rule` can lead to absurd results,” the brief says. The two-midnight rule only applies to traditional, paid health insurance. Commercial payers (including Medicare Advantage plans) do not follow the two-midnight rule. Hospitals classify patients who do not initially require a stay of two nights or more as outpatients who receive observation services (OBS). Medically necessary care for outpatients in “OBS status” will be billed to Medicare Part B if the patient`s stay does not actually extend beyond two nights or more. Using InterQual to ensure optimal compliance with the 2MN rule has become easier.
In mid-2018, Change Healthcare streamlined InterQual`s review process and implemented content changes that build on the solution`s strong alignment with the requirements of the 2MN rule. CMS further restricts hospitalization status by thoughtlessly applying its “two-midnight rule,” which states that a patient`s stay must exceed two nights to be billed as a hospital stay. In one of its rarest moments, the government, particularly the Centers for Medicare & Medicaid Services (CMS), attempted to simplify one of its regulations. The status of an inpatient (inpatient or outpatient) was confusing for patients and physicians. Since October 1, 2013, CMS has implemented the now famous “Two Midnight Rule”. I mean, how much easier could it be? Staying two midnight means stationary, right? Unfortunately, hospitals and doctors are still confused by this “simple” rule. Ensemble`s medical advisors have developed this guide, which explains one of the most effective rules impacting the hospital`s financial and compliance well-being. If patients with OBS status continue to require medically necessary care as they approach midnight second, they should be officially admitted to hospital. 2MN baseline monitoring for all benefits received begins at the beginning of treatment, usually in the emergency department. No change for stays beyond the two-midnight threshold: The two-midnight rule also stated that all treatment decisions for recipients were based on the medical judgment of physicians and other qualified practitioners.
The two-midnight rule did not preclude the physician from providing services in a hospital, regardless of the expected length of service. In considering changing this rule, the CMS attempted to balance several objectives, including: continuing to respect physicians` judgment; supporting quality care for Medicare beneficiaries; provide clear guidance to hospitals and physicians; and encourage effective care to protect Medicare trust funds. However, in today`s healthcare system, where hospital costs are typically borne by a third-party payer, “admitting” can have a very different meaning.