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Monday Memo
Monday, November 23, 2015
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Athena Forum Update to CM Express: CMS Two-Midnight Rule

Since 2013, the Centers for Medicare and Medicaid Services (CMS) has implemented changes first to the inpatient prospective payment system (IPPS) rule and more recently, in 2016, to the Outpatient Prospective Payment system (OPPS), which provide clarification to hospitals and physicians for determining when a patient should be designated as an inpatient and the application of the "Two-Midnight Rule."

It order for CMs to understand these rulings and what must be done to comply, the Athena Forum course, CM Express has been edited to reflect the most current information available. To learn more, please see the following excerpts and be sure to check out Athena Forum's CM Express course on the website.

[CM Express, Module C, Effective Resource Management]

www.athenaforum.com

Tips from our featured course

Health Care: An Ever-changing World

The world prior to October 1, 2013

  • Medical necessity for inpatient versus observation
  • Risk stratification of outpatient procedures and surgery

The new world after October 1, 2013

  • Medical necessity for hospital care
  • Two-midnight presumption and benchmarkrules
  • Certification of all inpatient admissions

The newer world after January 1, 2015

  • All of the above, plus:
    • Certification of Outlier Admissions

The newest world as of January 1, 2016

  • All of the above, plus:
    • New exception for physician judgment of the need for inpatient admission
    • QIO taking over short stay audit activity

Ronald L Hirsch, MD, FACP

[CM Express, Module C, Effective Resource Management]

www.athenaforum.com


CM and UM Professionals, Take Note

"CMs and UM professionals must understand the ins and outs of the CMS two-Midnight rule, including that this rule can not only impact the hospital but also the patient.Depending on whether the patient remains in observation or is placed into an inpatient status can impact the patient's co-pay and ability to be discharged to a skilled nursing facility.

Providing timely and efficient UM review and assuring physician documentation is key to preventing medical record documentation scrutiny and audit by the QIO."

Teresa C Fugate, RN, BBA, CCM, CPHQ

[CM Express, Module C, Effective Resource Management]

www.athenaforum.com

Notice from the Publisher

I want to thank our 20,000 healthcare professionals for requesting new topics on Athena Forum.

Thanks,
Thomas A. Rasmussen
CEO & Publisher
Athena Forum Institute

Monday Memo Editor

Cathy Wright, BSN, RN

Clinical Editor

Athena Forum

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