Health Information Management

CMS extends 2-midnight rule enforcement delay, proposes 2016 changes

APCs Insider, August 14, 2015

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By Steven Andrews
CMS announced this week an expected extension of the enforcement delay for Recovery Auditor reviews of patient status related to the 2-mdinight rule through December 2015. The enforcement delay was set to expire September 30.
The agency left itself little choice for an extension when it failed to address the 2-midnight rule in the IPPS rule, which takes effect October 1. Instead, CMS proposed changes in the OPPS rule, which takes effect January 1.
In the 2016 OPPS proposed rule, CMS proposed that for stays a physician expects to last less than two midnights, it will reimburse an inpatient admission on a case-by-case basis, depending on the judgment of the physician and the documentation justifying the stay. CMS expects short stays for minor surgical procedures or hospital care to be rare and will prioritize these types of admissions for medical review.
Quality Improvement Organizations (QIO) would take over responsibility for educating physicians and enforcing the 2-midnight rule from Recovery Auditors, according to the proposed rule. QIOs would perform these reviews based on the current policies beginning October 1, according to CMS. Beginning January 1, 2016, QIOs and Recovery Auditors will conduct the reviews based on policies in the OPPS final rule.
Recovery Auditors may conduct these reviews after QIOs refer providers who have high denial rates, consistently fail to adhere to the 2-midnight rule, or fail to improve performance after QIO intervention.
Recovery Auditors may continue to review short-stay inpatient claims for other reasons, including CMS-approved claim reviews unrelated to patient status, such as coding reviews.
For more on CMS’ proposed changes, visit Jugna Shah, MPH, and Valerie A. Rinkle, MPA, will analyze the 2016 OPPS proposed rule and give a comprehensive overview of the changes and what providers may want to comment on in HCPro’s annual OPPS proposed rule webcast from 1-2:30 p.m. (Eastern) Tuesday, August 18. Look for more in-depth coverage of the 2016 OPPS proposed rule in the September 2016 issue of Briefings on APCs.


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