CMS finalized its proposals regarding the 2-midnight rule in the 2016 OPPS final rule, including moving responsibility for enforcement and education of the rule from Recovery Auditors to Quality Improvement Organizations (QIO). This latter change occurred October 1, 2015.
CMS says the changes reflect extensive input from industry stakeholders, including hospitals, physicians, and the Medicare Payment Advisory Commission.
CMS maintains the benchmark established in the original 2-midnight rule, but is adopting the following policies for stays expected to last less than two midnights:
- For stays for which the physician expects the patient to need less than two midnights of hospital care (and the procedure is not on the inpatient-only list or otherwise listed as a national exception), an inpatient admission may be payable under Medicare Part A on a case-by-case basis based on the judgment of the admitting physician. The documentation in the medical record must support that an inpatient admission is necessary, and is subject to medical review.
- CMS is reiterating the expectation that it would be unlikely for a beneficiary to require inpatient hospital admission for a minor surgical procedure or other treatment in the hospital that is expected to keep him or her in the hospital for a period of time that is only for a few hours and does not span at least overnight. CMS will monitor the number of these types of admissions and plans to prioritize these types of cases for medical review.
Policies for patients staying more than two midnights remain unchanged. If the admitting physician expects the patient to require hospital care that spans at least two midnights, the services will be considered generally appropriate for Part A payment. The medical record must support the expectation the stay will span two midnights.
As of January 1, QIOs will begin reviewing inpatient cases under these revised policies. The QIOs will refer providers to Recovery Auditors based on patterns including high rates of claims denial after review or failure to improve after QIO assistance. CMS does not expect substantial Recovery Auditor reviews for several months after the transition.