Case Management

Proposed OPPS rule suggests tweaks to 2-midnight rule

Case Management Insider, August 4, 2015

The 2-midnight rule may get a little tweak if the proposals in CMS’ 2016 OPPS proposed rule comes to fruition. The rule proposes that physicians now be granted a little more flexibility when it comes to ordering inpatient admissions, even when the stay is expected to be less than two midnights—provided of course that the stay is justifiable from a medical standpoint and the physician clearly documents his or her thinking on the case.

“It appears that CMS has softened its stance by allowing physicians to exercise judgment to admit patients for short hospital stays on a case-by-case basis,” says Stefani Daniels, RN, MSNA, CMAC, ACM, the founder and managing partner of Phoenix Medical Management, Inc., in Pompano Beach, Florida.

Currently under the 2-midnight rule, CMS stipulates that a patient will only qualify for inpatient admissions if he or she needs at least two midnights of care. If the patient is expected to need less than two midnights of hospital care, the hospital should bill the case as outpatient, Daniels says.

“The proposed regulations would modify the existing rare and unusual exception to the rule to permit the case-by-case medical determination,” she says.

And that’s not the only change the proposal would bring. CMS also proposed shifting education and enforcement of the 2-midnight rule from RACs to Quality Improvement Organizations (QIO).

“By moving oversight from the RACs to the QIOs it appears that the QIOs will be doing the reviews though details about the review process have not been published yet,” Daniels says. “The RACs will still be required to focus on hospitals with patterns of unusually high rates of denied claims.”

What hasn’t changed is the need for organizations to ensure that documentation is accurate, complete, and justifies medical necessity, she says.

This has presented a problem for many organizations, and it will be an area that case managers need to continue to focus on moving forward. “In my opinion, it will remain the weakest link so long as physicians continue to resist ‘learning’ how to document fully,” Daniels says.

For more about the proposed rule and the changes it may bring, register for HCPro’s 90-minute webcast, 2016 OPPS Proposed Rule, at 1 p.m. (Eastern) Tuesday, August 18.

A full analysis of the rule’s impact on case managers will be featured in the September issue of Case Management Monthly.

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