Inpatient Admissions
(new 42 CFR 412.3)
Effective October 1, 2013
Learning Outcomes
• At the end of this course, each participant should
be able to:
1. Define Medicare’s new two-midnight rule
beginning October 1, 2013.
2. Recognize how the new two-midnight rule will
impact your hospital.
3. Identify the necessary steps in order to comply
with the new two-midnight rule requirements.
Terms we need to clearly understan
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“Practitioner Order”
Two Midnight Rule
Authentication
Certification
Recertification
The New Two-Midnight Rule
• For admissions on or after October 1,
2013, a Medicare inpatient admission is
based on the physician’s expectation that
the patient will be in the hospital for at
least 2 midnights.
• Admissions will need to be approached
differently than how a hospital handles
admissions for commercial payers using
Interqual or other criteria.
Inpatient Admissions
• An individual is considered an inpatient of a
hospital if formally admitted as an inpatient
pursuant to an order for inpatient
admission by:
▫ A physician, or
▫ Other qualified practitioner
• In guidance released on September 5, 2013, CMS
refers to the inpatient admission order as the
“Practitioner Order”.
Practitioner Order –
Condition of Payment
• General Requirements – Practitioner Order
• The practitioner order must be present in the
medical record, and the practitioner order must
be supported by:
▫ The physician admission
▫ The progress notes
September 5th Guidance
• “The order must specify admission for inpatient
services.”
▫ CMS also states, however, that in “event that
explicit identification of the admission as
inpatient is not specified, the admission order
[may still satisfy] provided that the intent to admit
as an inpatient is clear.
Practitioner Orders –
Authentication Issues
• Orders must be “authenticated” by the Ordering
Practitioner (or by another practitioner with the
required admitting qualifications) prior to
discharge.
Verbal Orders
• Inpatient order may also be directly communicated
by staff as a verbal order (not standing order) in
accordance with 42 CFR 482.24(c)
▫ ― A verbal order may be initially documented in the
medical record by the staff receiving the order.
▫ Should identify the Ordering Practitioner.
▫ Verbal and telephone inpatient admission orders
must be authenticated (signed, dated and timed) by
the Ordering Practitioner (or by another practitioner
with the required admitting qualifications) prior to
discharge.
Timing of Practitioner Order
• General Requirement:
▫ Must be furnished at or before the time of the
inpatient admission.
• The order can be written in advance of the formal
admission but the admission does not occur until
formal admission by the hospital.
• Medicare does not permit retroactive orders or the
inference of orders.
• Authentication of the order is required prior to
discharge and may be documented as part of the
physician certification.
Timing of Practitioner Order–
Further Clarification
• Under the final rule CMS would expect the physician to
document inpatient order ASAP, 1 day stays will be
designated outpatient, but at the point of order, the
patient is an inpatient.
• Two midnight rule can include the first midnight that
they were on observation status. If there is an
expectation that the patient is going to stay an additional
midnight, the physician needs to write the order as soon
as they have this expectation before the 2nd night. (1st
night will be outpatient, and 2nd night will be inpatient).
• Date of admission HAS to be the date the order is
written. Patient is not inpatient until there is an order.
Again, It is NOT retroactive.
• REFERENCE
2 Midnight Rule
• Presumption of Inpatient Status –
▫ If physician expects the patient stay to require a
stay that crosses at least 2 midnights:
 Services are generally presumed to be appropriate
for inpatient admission, and
 Services are generally presumed to be appropriate
for inpatient payment.
Medical Review Contractors will
evaluate:
• Certification - The Practitioner Order for
inpatient admission to the hospital along with the
other required elements of the physician
certification.
• Initial Expectation - The medical documentation
supporting the expectation that the care would span
at least 2 midnights.
• Duration of Stay - Medical documentation
supporting a decision that it was reasonable and
necessary to keep the patient at the hospital to
receive such care.
Exceptions to 2 Midnight Rule –
Unforeseen Circumstances
• Shorter Stays Than Expected – CMS
officially recognizes very limited situations in
which shorter than 2 midnight stay may
nevertheless qualify for inpatient status:
▫ Beneficiary death
▫ Beneficiary transfer
• Remember: Physician must have initially
expected the patient stay to cross 2 midnights;
but Patient stay was shorter due to “unforeseen
circumstances”.
Unforeseen Circumstance
• 2 midnights is a benchmark based on physician
expectation, but if there is an unforeseen
circumstance, then hospitals should not use
condition code 44 (IP admission changed to
OP). Through internal audit, if UR believes 2
midnights wasn’t warranted, then you can’t bill
as observation because the inpatient stay was
already a fact. You could bill as Part B inpatient
based on medical necessity.
Initial I/P Certification Requirements
CMS and its contractors will look for the following medical
record elements in order to meet the initial inpatient
certification requirements.
a. The authentication requirement for the practitioner order will be
met by the signature or countersignature of the I/P admission order
by the certifying physician.
b. The requirement to certify the reasons that hospital I/P services are
or were medically required will be met either by the diagnosis and
plan documented in the inpatient admission assessment or by the
inpatient admitting diagnosis and orders.
c. The estimated time requirement will be met by the I/P admission
order written in accordance with the 2‐midnight benchmark,
supplemented by the physician notes and discharge instructions.
d. The post hospital care plan requirement will be met either by
physician notes or by discharge planning instructions.
Physician Certification
• Provider may adopt any method that permits
verification.
• Content Should Include:
▫ Authentication of the Practitioner Order,
▫ The reason for the inpatient services, I/P medical
treatment or I/P diagnostic study, etc.
▫ The estimated time the patient requires or required in
the hospital,
▫ The plans for post-hospital care, if appropriate,
and as provided in 42 CFR 424.13,
▫ For CAHs: Physician must certify that the beneficiary
may reasonably be expected to be discharged or
transferred to a hospital within 96 hours.
CMS Clarification
CMS is requiring [xiii] that the certification be
documented via a separate signed statement within
the medical record (except for delayed
certifications), [xiv] and payment for a Part A claim
will be tied to the physician’s documentation
supporting the order and certification generally.
Therefore, it is essential that admitting physicians
and hospitalists are educated regarding CMS’
“clarified” requirements, in order to ensure that
payment is made for the medically necessary care
provided.
http://www.thehealthlawpartners.com/docs/8232013.pdf
Physician Certification
• Physician certifies that the inpatient services
were ordered in accordance with the Medicare
regulations governing the Order.
• This concept includes certification:
▫ that hospital inpatient services are reasonable and
necessary, and ― in cases not specified as
inpatient-only, they are appropriately provided as
inpatient services in accordance with the 2
Midnight Benchmark.
Physician Certification
• Timing
▫ Certification begins with the Practitioner Order for
inpatient admission.
▫ Certification must be completed, signed and
documented in the medical record prior to discharge.
• Exception to Timing Rule
▫ Outlier cases must be certified and recertified as
provided in 42 CFR 424.13.
▫ CAH inpatient services must be certified no later than
1 day prior to the date on which the claim for payment
for the inpatient CAH is submitted.
Physician Re-Certification
• Medicare Part A pays for inpatient hospital services
of hospitals other than psychiatric hospitals only if a
physician certifies and recertifies the following:
(1) The reasons for either—
• (i) Continued hospitalization of the patient for
medical treatment or medically required inpatient
diagnostic study; or
• (ii) Special or unusual services for cost outlier cases
(under the prospective payment system set forth in
subpart F of part 412 of this chapter
Physician Re-Certification
• The first recertification is required no later than
as of the 18th day of hospitalization.
• (3) Subsequent recertifications are required at
intervals established by the UR committee (on a
case-by-case basis if it so chooses), but no less
frequently than every 30 days.
• http://www.law.cornell.edu/cfr/text/42/424.13
Physician Re-Certification
• Medicare Part A pays for inpatient hospital services
of hospitals other than psychiatric hospitals only if a
physician certifies and recertifies the following:
(1) The reasons for either—
• (i) Continued hospitalization of the patient for
medical treatment or medically required inpatient
diagnostic study; or
• (ii) Special or unusual services for cost outlier cases
(under the prospective payment system set forth in
subpart F of part 412 of this chapter
Be Sure to Have on File:
• Physician Acknowledgment Statement:
▫ Notice to Physicians: Medicare payment to hospitals is
based in part on each patient’s principal and secondary
diagnoses and the major procedures performed on the
patient, as attested by the patient’s attending physician by
virtue of his or her signature in the medical record. Anyone
who misrepresents, falsifies, or conceals essential
information required for payment of federal funds, may be
subject to fine, imprisonment, or civil penalty under
applicable Federal laws.
• Must be signed & dated at the time physician is granted
admitting privileges for the hospital or before or at the
time the physician admits their first patient.
Learning Outcomes
• At the end of this course, each participant should
be able to:
1. Define Medicare’s new two-midnight rule
beginning October 1, 2013.
2. Recognize how the new two-midnight rule will
impact your hospital.
3. Identify the necessary steps in order to comply
with the new two-midnight rule requirements.
References
• New Guidance: http://www.cms.gov/Center/ProviderType/HospitalCenter.html?redirect=/center/hospital.asp
• http://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/AcuteInpatientPPS/Downloads/IPCertification-and-Order-09-05-13.pdf
• Special Open Door Forum Transcript:
http://www.google.com/url?sa=t&rct=j&q=&esrc=s&fr
m=1&source=web&cd=2&cad=rja&ved=0CDMQFjAB&
url=http%3A%2F%2Fwww.cms.gov%2FOutreach-andEducation%2FOutreach%2FOpenDoorForums%2FDow
nloads%2F081513InpHosAdm2MidnightProvSODFAnn
ouncementAudioTranscript.pdf&ei=Yd