Inpatient Admissions ( new 42 CFR 412.3)

1. Inpatient Admissions (new 42 CFR 412.3) Effective October 1, 2013

2. Learning Outcomes • At the end of this course, each participant should be able to: • Define Medicare’s new two-midnight rule beginning October 1, 2013. • Recognize how the new two-midnight rule will impact your hospital. • Identify the necessary steps in order to comply with the new two-midnight rule requirements.

3. Terms we need to clearly understan • “Practitioner Order” • Two Midnight Rule • Authentication • Certification • Recertification

4. The New Two-Midnight Rule • For admissions on or after October 1, 2013, a Medicare inpatient admission is based on the physician’s expectation that the patient will be in the hospital for at least 2 midnights. • Admissions will need to be approached differently than how a hospital handles admissions for commercial payers using Interqual or other criteria.

5. Inpatient Admissions • An individual is considered an inpatient of a hospital if formally admitted as an inpatient pursuant to an order for inpatientadmission by: • A physician, or • Other qualified practitioner • In guidance released on September 5, 2013, CMS refers to the inpatient admission order as the “Practitioner Order”.

6. Practitioner Order – Condition of Payment • General Requirements – Practitioner Order • The practitioner order must be present in the medical record, and the practitioner order must be supported by: • The physician admission • The progress notes

7. September 5thGuidance • “The order must specify admission for inpatient services.” • CMS also states, however, that in “event that explicit identification of the admission as inpatient is not specified, the admission order [may still satisfy] provided that the intent to admit as an inpatient is clear.

8. Practitioner Orders – Authentication Issues • Orders must be “authenticated” by the Ordering Practitioner (or by another practitioner with the required admitting qualifications) prior to discharge.

9. Verbal Orders • Inpatient order may also be directly communicated by staff as a verbal order (not standing order) in accordance with 42 CFR 482.24(c) • ― A verbal order may be initially documented in the medical record by the staff receiving the order. • Should identify the Ordering Practitioner. • Verbal and telephone inpatient admission orders must be authenticated (signed, dated and timed) by the Ordering Practitioner (or by another practitioner with the required admitting qualifications) prior to discharge.

10. Timing of Practitioner Order • General Requirement: • Must be furnished at or before the time of the inpatient admission. • The order can be written in advance of the formal admission but the admission does not occur until formal admission by the hospital. • Medicare does not permit retroactive orders or the inference of orders. • Authentication of the order is required prior to discharge and may be documented as part of the physician certification.

11. Timing of Practitioner Order– Further Clarification • Under the final rule CMS would expect the physician to document inpatient order ASAP, 1 day stays will be designated outpatient, but at the point of order, the patient is an inpatient. • Two midnight rule can include the first midnight that they were on observation status. If there is an expectation that the patient is going to stay an additional midnight, the physician needs to write the order as soon as they have this expectation before the 2nd night. (1st night will be outpatient, and 2nd night will be inpatient). • Date of admission HAS to be the date the order is written. Patient is not inpatient until there is an order. Again, It is NOT retroactive. • REFERENCE

12. 2 Midnight Rule • Presumption of Inpatient Status – • If physician expects the patient stay to require a stay that crosses at least 2 midnights: • Services are generally presumed to be appropriate for inpatient admission, and • Services are generally presumed to be appropriate for inpatient payment.

13. Medical Review Contractors will evaluate: • Certification - The Practitioner Order for inpatient admission to the hospital along with the other required elements of the physician certification. • Initial Expectation - The medical documentation supporting the expectation that the care would span at least 2 midnights. • Duration of Stay - Medical documentation supporting a decision that it was reasonable and necessary to keep the patient at the hospital to receive such care.

14. Exceptions to 2 Midnight Rule –Unforeseen Circumstances • Shorter Stays Than Expected – CMS officially recognizes very limited situations in which shorter than 2 midnight stay may nevertheless qualify for inpatient status: • Beneficiary death • Beneficiary transfer • Remember: Physician must have initially expected the patient stay to cross 2 midnights; but Patient stay was shorter due to “unforeseen circumstances”.

15. Unforeseen Circumstance • 2 midnights is a benchmark based on physician expectation, but if there is an unforeseen circumstance, then hospitals should not use condition code 44 (IP admission changed to OP). Through internal audit, if UR believes 2 midnights wasn’t warranted, then you can’t bill as observation because the inpatient stay was already a fact. You could bill as Part B inpatient based on medical necessity.

16. Initial I/P Certification Requirements CMS and its contractors will look for the following medical record elements in order to meet the initial inpatient certification requirements. a. The authentication requirement for the practitioner order will be met by the signature or countersignature of the I/P admission order by the certifying physician. b. The requirement to certify the reasons that hospital I/P services are or were medically required will be met either by the diagnosis and plan documented in the inpatient admission assessment or by the inpatient admitting diagnosis and orders. c. The estimated time requirement will be met by the I/P admission order written in accordance with the 2‐midnight benchmark, supplemented by the physician notes and discharge instructions. d. The post hospital care plan requirement will be met either by physician notes or by discharge planning instructions.

17. Physician Certification • Provider may adopt any method that permits verification. • Content Should Include: • Authentication of the Practitioner Order, • The reason for the inpatient services, I/P medical treatment or I/P diagnostic study, etc. • The estimated time the patient requires or required in the hospital, • The plans for post-hospital care, if appropriate, and as provided in 42 CFR 424.13, • For CAHs: Physician must certify that the beneficiary may reasonably be expected to be discharged or transferred to a hospital within 96 hours.

18. CMS Clarification CMS is requiring [xiii] that the certification be documented via a separate signed statement within the medical record (except for delayed certifications), [xiv] and payment for a Part A claim will be tied to the physician’s documentation supporting the order and certification generally. Therefore, it is essential that admitting physicians and hospitalists are educated regarding CMS’ “clarified” requirements, in order to ensure that payment is made for the medically necessary care provided. http://www.thehealthlawpartners.com/docs/8232013.pdf

19. Physician Certification • Physician certifies that the inpatient services were ordered in accordance with the Medicare regulations governing the Order. • This concept includes certification: • that hospital inpatient services are reasonable and necessary, and ― in cases not specified as inpatient-only, they are appropriately provided as inpatient services in accordance with the 2 Midnight Benchmark.

20. Physician Certification • Timing • Certification begins with the Practitioner Order for inpatient admission. • Certification must be completed, signed and documented in the medical record prior to discharge. • Exception to Timing Rule • Outlier cases must be certified and recertified as provided in 42 CFR 424.13. • CAH inpatient services must be certified no later than 1 day prior to the date on which the claim for payment for the inpatient CAH is submitted.

21. Physician Re-Certification • Medicare Part A pays for inpatient hospital services of hospitals other than psychiatric hospitals only if a physician certifies and recertifies the following: (1) The reasons for either— • (i) Continued hospitalization of the patient for medical treatment or medically required inpatient diagnostic study; or • (ii) Special or unusual services for cost outlier cases (under the prospective payment system set forth in subpart F of part 412 of this chapter

22. Physician Re-Certification • The first recertification is required no later than as of the 18th day of hospitalization. • (3) Subsequent recertifications are required at intervals established by the UR committee (on a case-by-case basis if it so chooses), but no less frequently than every 30 days. • http://www.law.cornell.edu/cfr/text/42/424.13

23. Physician Re-Certification • Medicare Part A pays for inpatient hospital services of hospitals other than psychiatric hospitals only if a physician certifies and recertifies the following: (1) The reasons for either— • (i) Continued hospitalization of the patient for medical treatment or medically required inpatient diagnostic study; or • (ii) Special or unusual services for cost outlier cases (under the prospective payment system set forth in subpart F of part 412 of this chapter

24. Be Sure to Have on File: • Physician Acknowledgment Statement: • Notice to Physicians: Medicare payment to hospitals is based in part on each patient’s principal and secondary diagnoses and the major procedures performed on the patient, as attested by the patient’s attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies, or conceals essential information required for payment of federal funds, may be subject to fine, imprisonment, or civil penalty under applicable Federal laws. • Must be signed & dated at the time physician is granted admitting privileges for the hospital or before or at the time the physician admits their first patient.

25. Learning Outcomes • At the end of this course, each participant should be able to: • Define Medicare’s new two-midnight rule beginning October 1, 2013. • Recognize how the new two-midnight rule will impact your hospital. • Identify the necessary steps in order to comply with the new two-midnight rule requirements.

26. References • New Guidance: http://www.cms.gov/Center/Provider-Type/Hospital-Center.html?redirect=/center/hospital.asp • http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-09-05-13.pdf • Special Open Door Forum Transcript: http://www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=2&cad=rja&ved=0CDMQFjAB&url=http%3A%2F%2Fwww.cms.gov%2FOutreach-and-Education%2FOutreach%2FOpenDoorForums%2FDownloads%2F081513InpHosAdm2MidnightProvSODFAnnouncementAudioTranscript.pdf&ei=Yd