Although the Two-Midnight Rule has proved to be a lot beneficial for the healthcare organizations, still there are confusions regarding its implementation. When does the clock start ticking when it comes to counting a patient’s midnight in a hospital stay? How can a physician predict how long a patient will need to stay in the hospital? And many more questions come in the mind of healthcare professionals.
Therefore, we should have a clear idea of what exactly the Two-Midnight Rule is all about?
CMS had, in the past, provided guidance that states that the expectation of a hospital stay of 24 hours or greater was one of the components to be taken into consideration when evaluating a potential admission. CMS has stated that the decision to admit a patient as an inpatient is a complex medical decision based on many factors, including the risk of an adverse event during the period considered for hospitalization, and an assessment of the services that the beneficiary will need during the hospital stay. The crux of the medical decision is the choice to keep the beneficiary at the hospital in order to receive services or reduce risk, or discharge the beneficiary home because they may be safely treated through intermittent outpatient visits or some other care.
The Final Rule, states that an inpatient admission would be generally deemed appropriate and payment made under Medicare Part A when the physician expects a patient to require a stay that crosses at least Two-Midnights and admits the patient to the hospital based on that expectation or if the patient is undergoing a procedure on the Inpatient-Only list. Inpatient-only procedures are appropriate for exclusion from the Two-midnight benchmark.
The IPPS Final Rule establishes two distinct, but related, medical review policies: a Two-midnight benchmark and a Two-midnight presumption. Implications of the Two-Midnight Rule for Case Management in an effort to summarize how the Two-midnight benchmark should be applied by medical reviewers CMS notes that – they will still consider the fact that the beneficiary was in the hospital for greater than two midnights following the onset of care when making the determination of whether the inpatient stay was reasonable and necessary. For those admissions in which the basis for the physician expectation of care surpassing two midnights is reasonable and well-documented, reviewers may apply the 2-midnight benchmark to incorporate all time receiving care in the hospital. The management of hospital stays where the physician expectation is that the beneficiary will stay less than two midnights is not appropriate as inpatient.
Join us on our upcoming webinar on Access Point Case Management and The Two-Midnight Rule, presented by Dr. Toni G. Cesta, RN, BSN, Ph.D.