Revised Two-Midnight Rule Guidelines

January 15, 2016
Policy Snapshot

CMS has revised guidelines on Reviewing Short Stay Hospital Claims for Patient Status: Admissions On or After January 1, 2016. Starting October 1, 2015 Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) began conducting initial patient status reviews of claims for inpatient admissions. Under the revised exceptions policy (CMS-1633-F), which became effective January 1, 2016, for admissions not meeting the two midnight benchmark, Part A payment may be appropriate on a case-by-case basis where the medical record supports the admitting physician’s determination that the patient requires inpatient care, despite the lack of a 2 midnight expectation.

BFCC-QIOs will consider complex medical factors such as history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event to determine whether the medical record supports the need for inpatient hospital care. Two-Midnight Short-Stay Reviews focus on educating doctors and hospitals about the Part A payment policy for inpatient admission. Recovery auditor patient status reviews will be conducted by recovery auditors for those hospitals that have consistently high denial rates based on the BFCC-QIO Two-Midnight Short-Stay Review outcomes. Visit the Inpatient Hospital Reviews webpage for additional information. CMS will be discussing the new guidance at the Hospital Open Door Forum on January 26.