MRA Thought of the Day – Understanding the 2-Midnight Rule Documentation Requirements


Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education Julie-Leah J. Harding CPC, RMC, PCA, CCP, SCP-ED, CDIS Director of Education


CMS has finalized a significant change to its inpatient admission guidelines as part of the 2014 IPPS Final Rule[1], released August 1, 2013.

As presented in a recent MRA blog, the 2-Midnight Rule basics are:

  • For an inpatient stay to be deemed medically necessary, the physician must expect a patient’s treatment to cross two midnights and admit the patient based on that belief
  • It is to be based on the documented presumption that the physician expected the patient to stay two midnights and not on the actual length of stay; some patients may be discharged earlier due to death, faster recovery or transfer

The required documentation capture will be essential, and likely will keep CDI professionals and case management busy. CMS specifically states the physician must formally order an inpatient admission.

If the patient is already in the Emergency Room or in Observation the time spent in these areas will be considered by CMS; time spent as an outpatient before being admitted as an inpatient and will count that time toward meeting the two-midnight benchmark.

CMS announced that it will relax its review of claims during the new-rule implementation period, which will run from Oct. 1 through Dec. 31. According to a FAQ sheet posted on the CMS site, the agency is directing its Medicare administrative contractors (MACs) and RACs to not review inpatient claims dated on or after Oct. 1 that span two midnights. During that 90-day period, the agency is also not allowing RACs to review inpatient admissions that cover only one midnight or less.

Click here for CMS FAQS

What must be included in the documentation?

Documentation in the patient’s medical record must support a reasonable expectation of the need for the patient to require a medically necessary stay lasting at least two midnights. This entry must be signed and dated in the medical record prior to discharge.

If the inpatient admission lasts fewer than two midnights due to an unforeseen circumstance, such as being discharged earlier due to death, a quicker than expected recovery or transfer this too must be clearly documented, signed and dated in the medical record prior to discharge.

Deciding a patient’s stay is complex for providers and should not be minimized. Within the physician’s initial assessment (H&P) or on the patient’s order sheet, the provider must clearly document the intricacies of the patient’s history, comorbidities, severity of signs and symptoms and risk of an adverse event. The provider must be specific to what are the current medical needs. The documentation does not need to be long but ‘.

Educating physicians and hospitalists is paramount. Hospitals should review their approach to evaluating the medical necessity of inpatient hospital admissions and work with practitioners to bridge this new rule’s criterion but more importantly, ensuring that appropriate documentation exists for any patient treated on an inpatient basis.

What steps has your practice or facility made to assist the physicians with the 2-Minight Rule documentation hurdles? What will be your review process?

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