Friday, December 18, 2015

What is 2-midnight rule and how to calculate it?

Q2.1: Can CMS clarify when the 2 midnight benchmark begins for a claim selected for medical review, and how it incorporates outpatient time prior to admission in determining the general appropriateness of the inpatient admission?

A2.1: For purposes of determining whether the 2‑midnight benchmark was met and, therefore, whether inpatient admission was generally appropriate, the Medicare review contractor will consider time the beneficiary spent receiving outpatient services within the hospital. This will include services such as observation services, treatments in the emergency department, and procedures provided in the operating room or other treatment area. From the medical review perspective, while the time the beneficiary spent as a hospital outpatient before the beneficiary was formally admitted as an inpatient pursuant to the physician order will not be considered inpatient time, it will be considered during the medical review process for purposes of determining whether the 2-midnight benchmark was met and, therefore, whether payment for the admission is generally appropriate under Medicare Part A.

Whether the beneficiary receives services in the emergency department (ED) as an outpatient prior to inpatient admission (for example, receives observation services in the emergency room) or is formally admitted as an inpatient upon arrival at the hospital (for example, inpatient admission order written prior to an elective inpatient procedure or a beneficiary who was an inpatient at another hospital and is transferred), the starting point for the 2 midnight timeframe for medical review purposes will be when the beneficiary starts receiving services following arrival at the hospital. CMS notes that this instruction excludes wait times prior to the initiation of care, and therefore triaging activities (such as vital signs before the initiation of medically necessary services responsive to the beneficiary's clinical presentation) must be excluded. A beneficiary sitting in the ED waiting room at midnight while awaiting the start of treatment would not be considered to have passed the first midnight, but a beneficiary receiving services in the ED at midnight would meet the first midnight of the benchmark. The Medicare review contractor will count only medically necessary services responsive to the beneficiary's clinical presentation as performed by medical personnel.


Q2.2: How should providers calculate the 2-midnight benchmark when the beneficiary has been transferred from another hospital?

A2.2: The receiving hospital is allowed to take into account the pre-transfer time and care provided to the beneficiary at the initial hospital. That is, the start clock for transfers begins when the care begins in the initial hospital. Any excessive wait times or time spent in the hospital for non-medically necessary services shall be excluded from the physician’s admission decision. (Note: for the purposes of this question, hospital is defined as acute care hospital, long-term care hospital (LTCH), critical access hospital (CAH), and inpatient psychiatric facility.) Medicare review contractors may request records from the transferring hospital to support the medical necessity of the services provided and to verify when the beneficiary began receiving care to ensure compliance and deter gaming or abuse. Claim submissions for transfer cases will be monitored and any billing aberrancy identified by CMS or the Medicare review contractors may be subject to targeted review. The initial hospital should continue to apply the 2-midnight benchmark based on the expected length of stay of the beneficiary for hospital care within their
facility


Q2.3: How should providers calculate the 2-midnight benchmark when the beneficiary has received care in an Off-Campus ED?

A2.3: If the ED is established as a provider-based/practice location of the hospital, CMS does not separately pay to move the patient from an off-campus location of the Medicare hospital to the campus of the same Medicare hospital. Moving the beneficiary within the hospital that participates in Medicare under a single CMS Certification Number (CCN) from a provider-based off-campus ED to a separate on-campus unit, or moving the bene from an on-campus ED to a specified floor on the same campus would be considered the same from a Medicare perspective.

The provider-based or practice location (off-campus) ED is subject to all of the hospital Conditions of Participation (COPs) and is considered an integral part of the Medicare participating hospital.

Therefore, if a hospital ED is either an on-campus ED or an off-campus provider-based ED/practice location of a Medicare-certified hospital, the ED is considered part of that hospital for purposes of the 2-midnight rule, and therefore the total time in the hospital should be counted for purposes of the 2 midnight benchmark. On the other hand, if the ED is not established as an off-campus provider/practice location (unrelated to that hospital’s CCN), then the beneficiary movement would be considered a transfer and the rules outlined in question 2.2 are applicable.

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