Although the Two Midnight Rule became effective on October 1, 2013, CMS had not updated manual guidance to incorporate the Two Midnight Rule until recently. As previously reported here, CMS updated the Medicare Benefit Policy Manual earlier this year to incorporate the Two Midnight Rule and its revisions to inpatient admission order requirements. Most recently, CMS updated the Medicare Program Integrity Manual (MPIM) to reflect contractor reviews of patient status claims under the Two Midnight Rule, to be effective June 13, 2017.
On May 12, 2017, CMS issued Change Request 10080 that updates the MPIM to clarify the medical review requirements for Part A payment of short stay hospital claims under the Two Midnight Rule for Medicare contractors. In an accompanying Medicare Learning Network (MLN) article, CMS notes that currently, patient status reviews are mainly overseen by Quality Improvement Organizations (QIOs).
The MPIM updates are generally consistent with prior CMS guidance, and do not offer significant substantive changes or new guidance. For example, the MPIM updates incorporate instructions that CMS has previously provided to its contractors with respect to patient status reviews, including concepts known as the Two Midnight Presumption and the Two Midnight Benchmark. CMS also addresses contractor review of cases involving “inpatient only” procedures, as well as cases involving unforeseen circumstances interrupting an otherwise reasonable expectation that a patient’s hospital stay will span two midnights. In addition, CMS incorporates updates in connection with the recently expanded case-by-case exception to the Two Midnight Rule that permits Part A payment in certain cases based on the admitting practitioner’s judgment that the beneficiary required hospital care on an inpatient basis despite the lack of a two midnight expectation, as previously reported here. However, CMS did not take this opportunity to provide any additional guidance or case examples regarding the case-by-case exception.
Change Request 10080 is available here, and the CMS MLN article on the update is available here.
