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CMS nixes certification requirement for most inpatient hospital stays

Case Management Insider, December 9, 2014

 

The 2-midnight rule certification headache appears to be over, thanks to the 2015 OPPS final rule, published in the November 10 Federal Register.
 
CMS acknowledged in the final rule that the value of the certification requirement—which required organizations to document certification when a physician believes a patient qualifies for an inpatient stay—“may not outweigh the associated administrative requirements placed on hospitals.”
 
Part of the problem with the certification requirement, which generated push back from hospitals, was that it put organizations in a tough position, says Stefani Daniels, RN, MSNA, CMAC, ACM, president and managing partner of Phoenix Medical Management Inc., in Pompano Beach, Florida.
 
“As long as physicians are, by and large, independent contractors, the board of directors are loathe to put any constraints on the physicians that may be viewed as constraining their autonomy,” Daniels says. “Every regulation that is not directly under the control of the hospital is problematic.”
 
As of January 1, 2015, CMS will only require physicians to certify long-stay and outlier cases, which must be included in the chart by the 20th day of the patient’s hospital stay.
 
What does this mean for your organization? It depends on how you responded to the certification requirement in the first place, Daniels says.
 
“While many hospitals implemented burdensome forms to certify an inpatient admission, the utilization review specialist in other hospitals expanded their review process to incorporate the elements of a qualified inpatient admission in addition to the medical necessity criteria,” she says. “The process generally occurred in the emergency department which is the major gateway in many organizations for access to a hospital bed. With some exceptions, hospitals with tight access management programs confirmed certification on a concurrent basis.”
 
Other organizations with less stringent access-management programs used retrospective audits as their fall back, Daniels says. “[This] led to the onerous chore of getting the physician to complete the forms or add further documentation to support inpatient appropriateness, including the expectation of a two midnight stay,” she says.
 
Daniels predicts that the 2-midnight rule still isn’t set in stone—more changes may be in the works. “CMS is still going to mull over the definition of an inpatient and they now acknowledge that the 2-Midnight approach just wasn't working,” she says. “Nevertheless, they are taking the position of making sure that the physician provides comprehensive documentation on why the patient had to stay in the hospital so long, how much longer the physician anticipates the patient will remain in acute level of care, and what plans are being made for discharge and post-acute services.”
 
For more details on the certification requirement change and compliance tips, check out the January issue of Case Management Monthly.