CMS Clarifies Two Midnight Rule (Again) with New Guidance Letter (2/24)

On February 24th, the Centers for Medicare & Medicaid Services (CMS) issued a guidance letter regarding its controversial Two Midnight Rule that has been extremely confusing to providers. Not even a month prior to this announcement, CMS announced that it was extending the “probe and educate” period for Medicare Administrative Contractors (MACs) through September 14th, 2014. The review period had originally been slated to end on March 31, 2014. The new guidance from CMS, “Medicare Inpatient Hospital Probe and Educate Status Update,”  provides samples of common denials that have been made thus far and notes that MACs will be re-reviewing denied claims as necessary.

This letter provides general guidance to providers regarding information that may have affected their claims, including that:

  • No specific language has to be used on the inpatient admission order, but the admitting practitioner should “clearly express intent to admit the patient as inpatient”
  • When the expected length of stay of a procedure is expected to be less than two midnights, it should be initiated as outpatient. If there are complications, then an inpatient admission can be ordered by a physician at that time
  • Medical records need to support the expectation of a two midnight stay due to the fact that “Medicare policy specifies that observation care is a well-defined set of specific, clinically appropriate services that includes ongoing short term treatment, assessment and reassessment before a decision can be made regarding whether a beneficiary will require further treatment as a hospital inpatient”
  • While attestation statements that include language that a stay is expected to span two or more midnights is not required, such an attestation is not adequate by itself to support a two midnight stay – the whole medical record must provide that evidence

More information on the Two Midnight Rule and its various clarifications can be found on the CMSCG Blog:

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