On January 31, 2014 CMS extended the “Probe & Educate” review process for implementation of the 2-midnight benchmark for an additional 6 months through September 30, 2014.
What does this mean?
The 2-midnight benchmark is still the rule for FY 2014 in determining the patient’s admission status. However, through September 30, 2014 hospitals will only be subjected to the limited pre-payment probe and educate audits:
- Medicare Administrative Contractors (MACs) will select a sample between 10 and 25 claims depending on size of facility for prepayment review of patient status
- The MACs will provide educational guidance based on the results of the initial review and repeat the process if necessary
- CMS will not conduct post-payment patient status reviews for claims in FY 2014
- Recovery Auditors (RA) will not conduct pre-payment patient status reviews of claims for date of admission between October 1, 2013 and October 1, 2014. RA may continue to conduct CMS-approved reviews unrelated to the patient status/appropriateness of inpatient admission.
- The post-payment inpatient hospital patient status and medical necessity reviews by RA will continue in FY 2014 but will be limited to short stays defined as inpatient zero or one utilization day, for claims prior to October 1, 2013 and for currently approved complex issues.
- CMS has provided additional clarification guidance on the physician order and physician certification of hospital inpatient admissions including:
- New type of inpatient status order referred to as “initial order”. This allows an initial order by a resident, non-physician practitioner or ED physician as proxy for the “ordering practitioner”
- The “initial order” concept requires the ordering practitioner to countersign prior to the patient’s discharge, thereby accepting responsibility for the admission decision
- With this new guidance, the inpatient status starts at the time of the initial order rather than the time of countersignature by the ordering practitioner
- Other clarifications provided by CMS relate to verbal orders, definition of the time of discharge, outlier certification and a 96-hour admission limit for critical access hospitals