CMS Updates Two-Midnight Guidance to Reflect Latest Implementation Delay

19379278_lThe Centers for Medicare & Medicaid Services (CMS) updated May 12 its guidance on inpatient hospital reviews to implement delays in enforcing its so-called “two-midnight” policy through March 31, 2015 as called for under the Protecting Access to Medicare Act of 2014.

The legislation was the latest delay in a controversial policy that was first introduced in the 2014 Inpatient Prospective Payment System final rule, issuedin August 2013. That rule states that where a physician admits a patient with the assumption that the stay will span at least two midnights, the admission will presumptively qualify as appropriate for payment under Medicare Part A.

Conversely, admissions spanning less than that time period presumptively should have been provided on an outpatient basis under Medicare Part B.

The rule took effect October 1, 2013 but was previously delayed by CMS through September 30. Meanwhile, CMS released guidance explaining that, under a “probe and educate” review process, Medicare Administrative Contractors (MACs) would select 10 to 25 inpatient claims per hospital that span less than two midnights for “prepayment review” to determine medical necessity of the patient status in accordance with the new policy.

Based on the initial reviews, MACs would then conduct additional educational outreach and repeat the process where necessary.

CMS noted in its latest guidance that the legislation permits the agency to continue medical review activities under the probe and educate process through March 30, 2015.

In the guidance, CMS also said it will not allow recovery auditors to conduct inpatient hospital patient status reviews on claims with dates of admission of October 1, 2013 through March 31, 2015.




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