Two-midnight clarification: A doctor must 'accept responsibility' for each Medicare admission

Agency clarifies process surrounding verbal orders, physician proxies

CMS this week clarified that a physician must certify and "accept responsibility" for any Medicare inpatient admission prior to a patient's discharge under the "two-midnight" rule, Modern Healthcare reports.

Background on the two-midnight rule

The controversial policy included in Medicare's inpatient payment rule for 2014 instituted a time-based presumption period for medically necessary inpatient care. Under the two-midnight rule, an admission is assumed to be appropriate for a Medicare Part A payment if a physician expects a beneficiary's treatment to require a two-night hospital stay and admits the patient under that assumption.

The rule was intended to limit the growth in extended observation stays at hospitals, which have skyrocketed in recent years. However, hospitals and physicians argue that the rule could be financially devastating for their institutions, and several hospitals have laid the groundwork for potential litigation on the matter.

In an attempt to assuage hospitals, CMS last week announced that it would extend the probe and education period until Sept. 30, 2014. The move is intended to give hospitals more time to adapt to the new rule. 

Hospitals plan three-pronged attack on the 'two-midnight rule'

Clarifications

During a Tuesday conference call, CMS officials specified that, although a nurse can document a physician's verbal orders to admit Medicare patients, a doctor must countersign the decision before any patient admitted under the rule is discharged. If the doctor disagrees with the decision and refuses to sign the order, the hospital may still submit claims for lower-paying outpatient care.

In addition, CMS says that medical residents, nurse practitioners, and physician assistants also may write an inpatient admitting order while serving as a proxy for the physician. But this is only permissible when a physician "approves and accepts responsibility for the admission decision by countersigning the order prior to discharge."

Additionally, the agency confirmed that that Medicare's recovery auditors will not be permitted to audit inpatient claims under the two-midnight rule until after Sept. 30. However, the enforcement moratorium does not apply to all contractors. Administrative contractors, who process claims for payment, will continue to audit small numbers of cases and provide instruction to hospitals (Carlson, Modern Healthcare, 2/5 [subscription required]).


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