Health Information Management

CMS extends 2-midnight probe and educate period, and releases new guidance

HIM-HIPAA Insider, February 10, 2014

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by Jaclyn Fitzgerald, Associate Editor

CMS recently announced that it will extend the probe and educate period for review of admissions related to the 2-midnight rule through September 30, 2014. The probe and educate period was originally slated to end March 31, 2014. In a related update, CMS recently released additional guidance on physician orders and certification for inpatient hospital admissions.
The extension means that Medicare Administrative Contractors (MAC) will continue to conduct prepayment reviews of inpatient hospital claims that are not believed to comply with the 2-midnight rule. Claims selected for review must have dates of admission on or after October 1, 2013, but before September 30, 2014. MACs will also continue to host educational sessions related to the rule with hospitals. It is not likely that MACs and Recovery Auditors will conduct post-payment reviews of inpatient hospital claims with dates of admission on or after October 1, 2013, through October 1, 2014, according to CMS.
CMS’ recent guidance on the 2-midnight rule included new information about the following aspects of physician certification: 
  • Content:
    • The authentication requirement may be met by including signature or countersignature of the certifying physician.
    • Documentation of an admitting diagnosis can fulfill the requirement that the reason for inpatient services must be included in the certification.
    • The certification must include the estimated time the beneficiary will stay in the hospital or the actual time the patient stayed in the hospital. Expected or actual length of stay may be documented on the order, a separate certification or recertification form, the progress notes, or as part of discharge planning. Beneficiaries that already met inpatient criteria can remain in the hospital as an inpatient if they are waiting for a skilled nursing facility bed. 
    • For critical access hospitals (CAH), outpatient time will not count towards the 96-hour requirement for admission. CAH swing-bed time does not count toward the 96-hour inpatient limit. In the event that unforeseen circumstances lead to an extended CAH stay, there will not be a problem with CAH designation as long as the stay does not exceed the 96-hour annual average condition of participation requirement and the physician admitted the patient in good faith. If the physician did not in good faith certify that the patient was expected to be discharged or transferred within 96 hours of admission, the CAH will not receive Medicare reimbursement for the inpatient stay. 
    • For inpatient rehabilitation hospitals, certification and recertification requirements may be satisfied through the completion of documentation that these hospitals are already required to complete to meet coverage requirements (i.e., preadmission screening, post-admission physician evaluation, and physician admission orders).
  • Timing: A delay in certification or recertification of outlier cases may be acceptable in some circumstances if the delay does not extend past discharge. In addition, beneficiaries are considered patients until activities outlined by the physician have occurred, which means discharge may not necessarily coincide with the time the order is written by rather when an event occurs (i.e., discharge after dinner).
  • Authorization to sign certification: The guidance expands the criteria for who is authorized to sign the certification to include ED physicians or hospitalists. In addition, Medicare will not require the certifying physician to have admitting privileges at the hospital.Format: If all required information is included in progress notes, the physician can say in his or her statement that the medical record contains the information required and that inpatient services continue to be medically necessary.
With regard to inpatient orders, the guidance reiterated the language in the 2014 IPPS Final Rule that states that hospitals should not submit Part A claims if the order is not properly documented because the 2-midnight benchmark alone does not qualify a beneficiary for Part A payment. The guidance included new information about the following aspects of physician orders:
  • Qualifications of the ordering/admitting practitioner: The ordering practitioner is not required to write the order, but must sign it to confirm he or she decided to admit as inpatient. The ordering practitioner does not have to be the physician who signs the certification. The admission decision may not be given by anyone who is not authorized by the state to admit patients or has not been given admitting privileges at the hospital. A resident, physician assistant, nurse practitioner, or other non-physician practitioner may act as a proxy for the ordering practitioner pursuant to state law certain and CMS requirements outlined in the guidance.
  • Knowledge of the patient’s hospital course: The definition of who qualifies as a practitioner knowledgeable of the patient’s care has not changed. However, the guidance clarifies that utilization review may not be conducted by any individual who was professionally involved in the care of the patient whose case is being reviewed.
  • Specificity of the order: CMS does not require specific language for the inpatient order, but now recommends that hospitals use language that clearly expresses the intent of the admission so that anyone who reviews the order can understand the documentation. CMS advises hospitals to refrain from using language specific to a hospital, such as “admit to 7W.” In situations when the order is missing or defective but the practitioner’s intent to admit is stated in the medical record, contractors will be permitted to determine whether the information in the record satisfies the order requirements.
Learn more in this week's Medicare Insider note from the instructor.



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