The Centers for Medicare & Medicaid Services (CMS) has issued additional guidance, updated frequently asked questions (FAQs), and information for Medicare Administrative Contractors (MACs) about selecting inpatient hospital claims for review under the 2-Midnight Rule (Rule). CMS has extended the transition period under the Rule, instructing recovery auditors (RACs) not to review inpatient admissions of 0-1 midnights during the period of October 1, 2013 through March 31, 2014.
CMS also provided guidance related to the probe audits that will be conducted by MACs during the transition period. During the probe audits, MACs will select a sample of claims for prepayment review. A sample of 10 claims will be selected for most hospitals, and a sample of 25 claims will be selected for large hospitals. Noncompliant claims will be denied, with the reasons explained in letters from the MAC. CMS clarified that providers found to have moderate to significant concerns (defined as 2-6 non-compliant claims out of a 10 claims sample) or major concerns (7 or more non-compliant claims out of a 10 claims sample) will be offered individualized phone calls with the MACs to discuss the reasons for denial, to provide education and reference materials, and answer questions. For providers continuing to have concerns after the 6-month transition period, the MACs will conduct additional probe reviews, selecting samples of 100 claims for most hospitals, and 250 claims for large hospitals.
Further, CMS stated that it would provide sub-regulatory guidance for “rare and unusual circumstances” for situations that would justify inpatient admission absent an expectation of care spanning at least 2 midnights. CMS has already anticipated that exceptions to the 2-midnight benchmark may arise in the context of beneficiary death, transfer, or departure against medical advice. However, CMS will determine if there are any additional categories that should be added to the list of exceptions to the 2-midnight benchmark by working with the hospital industry and with MACs. Suggestions to CMS on rare and unusual circumstances constituting an exception to the 2-midnight benchmark should be e-mailed to [email protected] with “Suggested Exceptions to the 2-Midnight Benchmark” in the subject line.
The additional guidance issued by CMS is available at:
The FAQs posted by CMS are available at:
The claims review information for MACs is available at:
Centers for Medicare & Medicaid Services. “Selecting Hospital Claims for Patient Status Reviews: Admissions on or After October 1, 2013.” Guidance Document. 4 Nov. 2013.
Centers for Medicare & Medicaid Services. “Frequently Asked Questions: 2 Midnight Inpatient Admission Guidance & Patient Status Reviews for Admissions on or After October 1, 2013.” FAQs. 4 Nov. 2013.
Centers for Medicare & Medicaid Services. “Reviewing Hospital Claims for Patient Status: Admissions on or After October 1, 2013.” Guidance Document. 1 Nov. 2013.