Medical necessity: Inpatient admissions and the 2-midnight rule
HIM-HIPAA Insider, September 22, 2014
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CMS' 2014 IPPS final rule redefined inpatient admissions when it implemented the 2-midnight rule, which requires a validated physician order, documentation of medical necessity, and the expectation of a stay crossing two or more midnights.
The 2-midnight benchmark states that a physician should order inpatient admission if he or she reasonably expects the patient's stay to cross at least two midnights. Under the 2-midnight presumption, MACs will presume an inpatient stay is medically necessary if it crosses two or more midnights, including time spent as an outpatient.
"The two areas where I think it's going to evolve as the auditors are looking at one-midnight inpatient cases, and two and three midnights where there is evidence of convenience, evidence of a delay, evidence of custodial care," said Ralph Wuebker, MD, MBA, chief medical officer for Executive Health Resources in Newtown Square, Pennsylvania. "And it's just not going to be very hard to pick out those individual cases."
Concurrent reviews are the best means of determining whether a patient's status is appropriate, Wuebker said. "CMS spelled out very clearly, not in an update, not in an open door forum, but in the original IPPS document that use of Condition Code 44 or Part B inpatient self-audit is not intended to be served as a substitute for adequate staffing of the utilization management personnel," he said.
In other words, although postdischarge reviews are acceptable, organizations should not rely on them rather, their utilization review committee should be appropriately staffed and up to date on medical necessity requirements.
Continue reading "Medical necessity: Inpatient admissions and the 2-midnight rule" on the HCPro website. Subscribers to Medical Records Briefing have free access to this article in the September issue. The article is based on HCPro’s webcast “Medical Necessity 2014: Inpatient Admissions and the 2-midnight Rule,” which is available on-demand.
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