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To Be or Not to Be: An Inpatient Status
By Tracy C. M. Rowland, RHIA

Hospitals and physicians are trying to comply with the new two-midnight rule that the Centers for Medicare & Medicaid Services (CMS) implemented on October 1, 2013, as part of the 2014 Inpatient Prospective Payment System. But the guidance issued by the CMS lacks the clarity hospitals and physicians seek.

Ultimately, the Two-Midnight Rule Delay Act of 2013 extended the start of compliance until October 1, 2014. Though this means claims auditing won’t occur from the rule’s inception through September 30, 2014, facilities still are expected to comply with the rule now.

The CMS also has loosened the requirement that emergency physicians and midlevel practitioners must confer with the attending physician before admitting a patient. The revised guidance states that the emergency department physician and midlevel practitioners can write the orders if they are authorized by the state and facility bylaws or policies, and the orders are cosigned before discharge.

CMS officials also discussed the Medicare administrative contractor (MAC) “probe and educate reviews” at an open-door forum. Melanie Combs-Dyer, acting director of the CMS Provider Compliance Group, said that even though MACs have six more months to complete the reviews, they will audit the same number of claims per hospital—10 to 15—with repeat audits at hospitals found with deficiencies. MACs will deny payment for claims that are not consistent with the two-midnight rule and will educate hospitals on improving their compliance. Recovery audit contractors and MACs are free to audit all claims for the medical necessity of the services and coding compliance.

The CMS generally presumes that if a patient stay crosses two midnights, it is medically necessary. Exceptions would be those shorter stays due to inpatient-only list surgical procedures and unforeseen circumstances such as death, transfer, unforeseen recovery, or election of hospice. The physician expects the patient to require a stay that crosses at least two midnights and admits the patient to the hospital based on that expectation.

If you spend too much time trying to figure out the ins and outs of a certification form, the physician will have no time left to explain why the patient needs to be in the hospital. Hospitals should take advantage of the extension of the two-midnight rule to educate physicians on the best way to count the two midnights and capture the necessary documentation to support the inpatient status.

“What we are looking for certification purposes is regular, good documentation,” Donald Thompson, acting deputy director of the Division of Acute Care said at the open forum. “We are not looking for magic words. We are not looking to change the nature of medical practice or good documentation practice. We hope this puts hospitals at ease. We are looking for what they do every day.”

Physicians do not have to use the language “I certify,” added Daniel Schroeder, insurance specialist in the Division of Acute Care. “More specific documentation is always better than less specific documentation, but for certification, we are not looking for inherently new requirements when reviewing [cases] under the two-midnight policy. It is status quo for a majority of the sections referenced.”

Reviewers will be looking for the timely documentation of a physician order and certification as well as supportive documentation of the reason for inpatient status. The CMS specifically states that the medical record should clearly indicate why a physician deemed an inpatient stay necessary, supported by documented factors such as patient history, the presence of comorbidities, current patient care requirements, signs and symptoms that the patient currently is exhibiting, and the potential risk of an adverse event during the hospital stay. The certification itself must be supported by other documentation such as severity of signs and symptoms, current medical needs, and the risks of any adverse events that supports the patient remaining in the hospital.

Clinical documentation is key to ensuring that the medical record supports a physician’s care decisions. Properly capturing comorbidities and interventions helps determine that the inpatient status will, in turn, be clear-cut upon any audit review. Clinical documentation improvement specialists have known for a long time how good documentation can help improve the case mix index and the true reflection of patient acuity. In turn, it will help support the physician’s intent for inpatient status.

— Tracy C. M. Rowland, RHIA, is president and CEO of Michigan-based TCB Consulting.