CMS updates admissions rules, but compliance still required

Bradley T Bryan

Bradley Bryan, M.D.
Medical director, Regional Utilization Management

Feb. 19, 2014

Last month, the Centers for Medicare & Medicaid Services issued an update on its new admissions payment policies, which include the controversial “two-midnight rule.”

Contrary to popular belief, implementation of the two-midnight rule – which requires an expected hospital stay of two midnights to qualify for inpatient admission payment – has not been delayed. The update applies only to the “probe and educate” phase, the period in which hospitals can provide staff training and update their systems. This has been extended through Sept. 30, 2014.

We are still obligated to meet the requirements of CMS’s new policies regarding inpatient orders, documentation and the two-midnight-rule, which took effect last October. Failure to comply may result in Medicare audits and denials.

Under “probe and educate,” Medicare administrative contractors may choose only a limited number of charts for audit. The contractor will assess our compliance with the new rules and issue denials when appropriate. Full-scale auditing by CMS begins on Oct. 1.

Currently there are several bills in Congress and multiple lawsuits related to the new CMS policies, specifically the two-midnight rule, so we expect to see updates and clarifications in the coming months.

Nonetheless, we’re expected to comply with regulations issued last fall and will continue to educate and council providers on these rules.

Here’s a summary of the new CMS rules, which apply only to Medicare and Medicare Advantage patients:

To meet inpatient admission qualification requirements the attending physician must:
  1. Write an order in Epic explicitly stating “Admit to Inpatient.”
  2. Provide a diagnosis and justification for inpatient services (H&P, Progress Note, OP Note).
  3. Certify that the hospitalization is expected to exceed two midnights. (Exceptions: inpatient-only procedures, new initiation of mechanical ventilation.)
  4. Document a post-hospital plan.
Notes:
  • This documentation must be completed and signed prior to discharge.
  • If a resident, physician assistant or nurse practitioner completes the certification documentation then it must be cosigned by the attending physician.
  • Currently we do not require a co-signature on an inpatient order” written by a resident, PA or NP, however the latest CMS clarification included language that may require this in the future. As of now we are only expecting the attending physician to acknowledge and agree with the inpatient order, which should be documented as part of their authentication of the resident, PA or NP note. (See smart phrase “.ipcertcosign”.)
  • There has been clarification on the 96-hour rule for critical access hospitals, and we will provide specific recommendations to those facilities and providers.

If you have questions or need more information, feel free to email me.