Health Information Management

CMS guidance addresses reviews of inpatient admissions

HIM-HIPAA Insider, October 14, 2013

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by Jaclyn Fitzgerald, Associate editor


CMS recently released guidance addressing three key questions surrounding the review of inpatient admissions in relation to the 2-midnight rule. In a more notable aspect of the guidance, CMS stated it instructed Medicare Administrative Contractors (MACs) and Recovery Auditors to refrain from reviewing inpatient admissions of one midnight or less for a 90-day implementation period beginning October 1, 2013.

In the guidance, CMS said it would direct MACs to apply the 2-midnight presumption to claims spanning more than two midnights after a formal inpatient admission for stays that begin on or after October 1, 2013. Under this presumption, MACs are to assume these claims are appropriate and medically necessary, according to CMS.

When a review is necessary, MACs must base their review of a physician’s expectation of a stay of two or more midnights on the information available to the admitting practitioner at the time of admission, according to CMS’ guidance.

At the instruction of CMS, MACs will review a small sample of inpatient claims spanning less than two midnights to determine medical necessity in accordance with the 2-midnight benchmark. 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. The 2-midnight presumption states that MACs will presume a stay is medically necessary if it crosses two or more midnights, including time spent as an outpatient.

MACs will conduct probe reviews of these claims based on a CMS-established prepayment record limit of 10-25 claims per hospital with admission dates of October 1, 2013, through December 31, 2013. The probe samples will determine a hospital’s compliance with the 2-midnight rule. Conducting the probe reviews on a prepayment basis will allow hospitals to rebill denied admissions, according to the CMS guidance.

If a MAC cannot identify issues at a hospital during the probe review, that hospital will not be subject to further reviews during the 90-day implementation period, according to CMS. MACs will educate and follow-up with hospitals with identified problems. MACs and Recovery Auditors will not review claims of more than two midnights during the implementation period and will not review critical access hospital claims.

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