Two-Midnight Rule Process

1
Two-Midnight Rule Process

• Pam Applegate, MA, RHIT
• Senior Program Director

2
Two-Midnight Rule

• October 2013 Two-Midnight Rule is implemented
• Adopted for inpatient admissions occurring on or
  after October 1, 2013 (fiscal year 2014)
• FY 2014 Hospital IPPS Final Rule CMS-1599-F
  established two distinct, but related, medical
  review policies
• 2-Midnight presumption claims with LOS gt2
  midnights after formal admission order are
  presumed to be appropriate for Part A payment and
  are not the focus of medical review efforts
• 2-Midnight benchmark provides guidance to
  Medicare review contractors to identify inpatient
  admissions generally appropriate for Part A
  payment under CMS-1599-F, as revised by
  CMS-1633-F

3
Two-Midnight Rule

• October 2015 Responsibility for reviews of lt2
  midnight inpatient stays transitioned from MACs
  to QIOs
• MAC reviews were prospective (pre-pay)
• QIO reviews are retrospective (post-pay)
• Inpatient claims have three dates
• From Date (Date patient started receiving
  services)
• Admission Date (Date inpatient order is written)
• Thru Date (Discharge Date)
• A claim is subject to review under lt 2 midnight
  inpatient stay if the date of admission to the
  date of discharge is less than 2 days (0-1 day
  length of stay)

4
Two-Midnight Cycles

• There are two 6-month review cycles per year
• October March
• April September
• Hospitals will be sampled no more than once in a
  6-month cycle

5
Two-Midnight Universes

• Paid claims with 0-1 day LOS are supplied to the
  QIO monthly
• October 2015 universes contained claims from May
  2015
• November 2015 universes contained claims from
  June 2015
• December 2015 universes contained claims from
  October 2015
• January 2016 universes contained claims from
  November 2015
• February 2016 universes contained claims from
  December 2015
• March 2016 universes contained claims from
  January 2016
• Future universes will most likely continue to
  follow a two-month lag period

6
Two-Midnight Sampling

• Monthly sample is chosen
• 0-day stays are prioritized, as directed by CMS
• Large hospitals 25 claim sample
• Average hospitals 10 claim sample
• Sampled claims may be pulled from multiple
  universes to reach desired number of claims for
  the hospital so one sample may contain
  discharges from multiple months
• If a hospital has less than the required number
  of claims for sampling within a 6-month cycle, it
  will not be sampled

7
2M Medical Record Requests

• Monthly samples are imported into the
  CMS-supplied Case Review Information System
  (CRIS) and medical record requests are generated
• Medical Record contact information for these
  requests is stored in the government system and
  updated as hospitals request
• The government system only allows for one Medical
  Record contact and one QIO Liaison cannot be
  unique for different claim types
• One envelope is mailed via USPS and contains
  instructions for submitting the medical records
  along with a cover sheet for each record
  requested
• Note that the cover sheet lists the From and Thru
  Dates
• Medical records are due 30 days from the request

8
2M Submission Instructions
9
2M Example Cover Sheet
10
Record Request Follow-Up

• Around day 15 of an outstanding medical record
  request, Livanta calls the provider to ensure
  that the request was received and is in process
• We can then fax the request and cover sheets to
  the provider, if needed
• Around day 30 Livanta will send a Technical
  Denial Warning letter to the provider with cover
  sheets of outstanding records
• Around day 45 if the records have still not been
  received, a technical denial letter is sent to
  the beneficiary, provider, and MAC

11
Reopening Technical Denials

• If Livanta receives the medical record for which
  a technical denial has been issued, the case will
  be reopened, provided the final determination for
  the sample has not yet been mailed
• If the technical denial is reopened, the
  beneficiary, the provider, and the MAC are
  notified that the record will be reviewed

12
2M Review Process

• Medical records are first screened by our
  Registered Nurse Review Coordinators who check
  for the following
• Admission Order requirements are met
• Two-Midnight Benchmark is met
• InterQual or MCG may be used to support medical
  necessity for approval of the admission
• No inpatient order billing error
• Independent licensed practicing physician
  reviewers who are board-certified with hospital
  privileges make the final determination on any
  case not clearly meeting the requirements of the
  Two-Midnight Rule

13
Two-Midnight Rule Benchmark

• Two-Midnight Benchmark
• Provides guidance to Medicare review contractors
  for identifying when an inpatient admission is
  generally appropriate for payment under Part A
• Patient admitted for an Inpatient-Only procedure
• Medical record supports the admitting physicians
  determination that the patient requires inpatient
  care despite the lack of a two-midnight
  expectation case-by-case exception
• Complex medical factors such as history,
  comorbidities, severity of signs and symptoms,
  current medical needs, risk of an adverse event
  all can support need for inpatient hospital care
• Physician expects medically necessary acute
  hospital services will be needed for 2 or more
  midnights as supported by documentation in the
  record

14
Two-Midnight Rule Benchmark

• Two-Midnight Benchmark
• Unforeseen Circumstances death, transfer to
  another hospital, discharge against medical
  advice (AMA), clinical improvement, election of
  hospice care
• Based upon physicians expectation of the
  required duration of medically necessary acute
  hospital services at the time the inpatient order
  is written
• Reasonableness of the inpatient admission based
  on the information known to the physician at the
  time the inpatient order is written may be
  inferred from medical documentation (care plan,
  orders, notes, etc.)

15
Two-Midnight Rule Benchmark

• 2M Rule Benchmark and Outpatient Time
• The record must first support the determination
  that the patient required acute hospital services
  to qualify for Part A payment
• If the patient required acute hospital services,
  Livanta will consider the pre-admission time such
  as services provided under observation, treatment
  in the ED, and/or procedures in the operating
  room or other treatment area of the hospital
• For patients transferred to another hospital, the
  time care began at the initial hospital will be
  taken into account

16
2M Review Timelines/Delays

• Delay in initial sampling first medical records
  not requested until mid to late November 2015
• Three monthly samples requested within 3 weeks
  initially overwhelmed our Mailroom and delayed
  getting records ready for review
• Reviews began in earnest in mid-December 2015
• QIO has obligation to complete medical review of
  a record within 30 days of medical record receipt
• We are not yet hitting this target due to the
  confluence of multiple samples and Mailroom delays

17
Stratification

• After determinations are made for a hospitals
  entire sample, the Initial Review Results Letter
  is sent to the QIO Liaison, with a determination
  for each sampled claim and stratification results
• Minor concern hospitals have lt10.01 errors
• May submit additional information within 20 days
• No 11 education required
• Moderate concern  hospitals have gt10 but
  lt20.01 errors
• May submit additional information within 20 days
• May request 11 educational session within 20
  days
• May submit additional information after 11
  session within 10 days
• Major concern hospitals have gt20 errors
• May submit additional information within 20 days
• Must attend 11 educational session (required)
• May submit additional information after 11
  session within 10 days

18
Initial Review Results Letter
19
Initial Review Results Letter
20
Initial Review Results Letter
21
Education Process

• Livantas 2M Nurse Educator will reach out to the
  QIO Liaison at the time of scheduling the
  education session
• To ensure receipt of the letter
• To entertain any questions about the process, and
• To establish of line of communication
• The QIO has 90 days from the completion of a
  hospitals sample to supply provider education

22
Provider Education

• Livanta conducted the first provider education
  sessions in early February 2016
• Livanta Medical Directors present the review
  findings on the preliminarily denied claims on a
  case-by-case basis
• Hospital participation and feedback is expected
  and welcomed
• The hospital has 10 days to respond with
  additional information after the 11 education
  session

23
Final Determination Letters
24
Final Determination Letters
25
Admission Denial Letters

• After the Final Determination letter has been
  mailed to the provider, an Admission Denial
  letter is mailed for each denied claim to the
  beneficiary, the hospital, and the MAC

26
RAC Referrals

• BFCC-QIOs shall rate and stratify providers for
  education and corrective action based upon the
  results of the completed claim reviews
• BFCC-QIOs will refer to the Recovery Audit
  Contractor providers that consistently
  demonstrate a high denial rate
• Failing to adhere to the Two Midnight rule
• Failing to improve performance after BFCC-QIO
  educational intervention has been rendered
• Referral to the RAC must be upon CMS direction

27
RAC Referral Process

• Although the exact process for RAC referral is
  still being refined, it will involve the QIO
  discussing potential referrals with CMS and
  noting any extenuating circumstances
• It is important to note that the timing of the
  education session and subsequent samples and
  reviews for a provider may necessitate several
  cycles of reviews before RAC referral is supported

28
Questions?
29
Case Review Examples

• Lamerial Danaiels, RN
• Redetermination Manager, Area 5

30
Denial Example

• Case 1 Syncope
• This 75-year-old female was brought in by
  ambulance due to a syncopal episode. She had a
  history of vertigo, hypertension, and thyroid
  disease. The patient was admitted to observation
  status.
• This admission did not meet the Two-Midnight Rule
  criteria because at the time of inpatient
  admission the patients condition had improved,
  and there was no anticipation of an additional
  midnight stay. Our physician reviewer concluded
  that there were no acute findings at the time of
  the emergency department evaluation and the
  patient went home the next day. There was no
  indication that the patient would need to stay 2
  midnights.

31
Denial Example

• Case 2 Mental Status Changes
• This 77-year-old male presented to the emergency
  department due to mental status changes. He had a
  history of stroke, transient ischemic attacks
  (TIAs), dementia, and a recent right neck mass
  biopsy.
• This admission did not meet the Two-Midnight Rule
  criteria because the patient had no evidence of a
  stroke or TIA present on admission and he was
  admitted for a work-up to rule out a TIA. This
  diagnostic testing could have been provided at an
  observation level of care. Our physician reviewer
  concluded that the patients evaluation in the
  emergency department was unremarkable, and he was
  discharged the following day after his mental
  status was cleared.

32
Denial Example

• Case 3 Elective Procedure
• This 82-year-old female was admitted electively
  for an anorectal examination under anesthesia and
  a rigid proctosigmoidoscopy. The patient had a
  history of diabetes and was recently diagnosed
  with a rectal mass found to be positive for
  adenocarcinoma.
• This admission did not meet the Two-Midnight Rule
  criteria because the patient was admitted
  following an outpatient procedure with no
  documentation of complications or unstable
  comorbid conditions. The patient was discharged
  in less than 24 hours as expected. The procedure
  was not on the CMS inpatient only list.

33
Denial Rationale Examples

• This admission did not meet the Two-Midnight Rule
  criteria because the treatment of pain control,
  IV hydration, monitoring of lab results, and a
  gastroenterology consultation did not require an
  inpatient admission and could have been done in
  observation status.
• This admission did not meet the Two-Midnight Rule
  criteria because the patient was admitted to
  inpatient status following an outpatient surgical
  procedure with no documentation of complications
  or unstable comorbid conditions. The patient was
  discharged within 24 hours as expected.
• This admission did not meet the Two-Midnight Rule
  criteria because the patients condition was
  improved prior to admission, and there was no
  indication that a 2 midnight stay was
  anticipated. The patients ongoing inpatient care
  for diagnostic testing and oral medications could
  have been provided at an outpatient level of
  care.
• This admission did not meet the Two-Midnight Rule
  criteria because the patients care for mild CHF
  exacerbation without significant acute symptoms
  did not require an inpatient level of care. The
  patients care could have been provided at an
  observation level of care.

34
Good Documentation Example

• A 72-year-old female patient presented on May 04,
  2015 to have an implantable cardioverter
  defibrillator for severe ischemic cardiomyopathy.
• The patients history included myocardial
  infarction, coronary artery disease, chronic
  systolic heart failure, hypercholesterolemia,
  multi-vessel coronary artery disease, status post
  diagonal vessel PCI in March as distal LAD
  balloon angioplasty pleural effusion, and chronic
  kidney disease, stage 3.
• Her vital signs were Temperature 98.3, blood
  pressure 121/84, heart rate 80, oxygen saturation
  97 on 2 liters of oxygen.
• The patients laboratory results were white
  blood cells 9.8, hemoglobin 9, hematocrit 23,
  platelet count 172, sodium 133, potassium 4.4,
  blood urea nitrogen 127, and creatinine 2.32.
• The original order for the patient was
  observation status however, the patient developed
  acute chronic systolic heart failure, anemia, and
  acute kidney injury post procedure and on May 6,
  2015 at 0951, the patient was admitted to
  inpatient.
• The patient was discharged on May 7, 2015.
• This claim meets the guidelines for the
  Two-Midnight Rule.

35
Documentation Supporting Admission
Condition Observation Inpatient
Atrial Fibrillation Rapid response to treatment Recurrent bouts or associated with another event, such as MI or PE
Chest Pain Negative Workup Positive troponins or EKG changes
COPD Exacerbation Responds to treatment Does not respond to treatment or is associated with pneumonia
VTE or Small PE Uncomplicated and responds to treatment PE with hemodynamic compromise or not eligible for Thrombin inhibitors
GI Bleed Chronic with normal BP and Hct Acute requiring transfusion and intervention
Abdominal Pain Negative Workup Acute findings (rebound tenderness, free fluid, or signs of inflammatory or obstructive process on CT
Acute neurological condition or Altered Mental Status Negative Workup Head and/or carotid imaging, TEE, active therapy
Electrolyte Disturbance Early response Persistent abnormalities
36
Key Points for Education

• Part A reimbursement is based on the continued
  need for acute hospital services for a second
  midnight
• Document what happens between the first and
  second midnight to warrant continued acute
  hospital services
• Documentation of reassessment at 18-30 hours
  after initial decision (observation or inpatient)
  helps us understand decision-making process
• Patient status changes require documentation of
  the thought process for the change to support the
  decision

37
Livanta 2M Contacts

• Website Livanta.com or BFCCQIOarea5.com
• Area 5 Helpline 1-866-603-0970
• Area 1 Redetermination Manager Lamerial Daniels
  ldaniels_at_livanta.com
• UR/2M/Senior Program Director Pam Applegate
  papplegate_at_livanta.com
• Please feel free to contact us regarding status
  of your reviews and/or hospital contact updates

38
Questions?