by David M. Glaser, Esq.
June 23rd, 2022
Are you using something other than two-midnight? Here’s why you shouldn’t be.
Is there the possibility that your utilization management team and physician advisors are applying InterQual, MCG, or any other utilization tool other than the two-midnight rule to your Medicare admissions? Over the last few months, it has become clear to me that many hospitals are systemically under coding, classifying patients who should be inpatients as outpatients because reviewers believe that some type of tool must be used to review the medical necessity of Medicare admissions. While there are times that InterQual or MCG might be appropriate for private pay patients, in the realm of Medicare, there should never, ever, ever be a situation where your team is using InterQual or MCG for anything. There is one thing, and ONLY one thing that determines patient status for Medicare: the Two-Midnight rule. I know we’ve talked about this before, but it is worth repeating the exact wording of the Two-Midnight rule. 42 C.F.R. § 412.3 says that: “Except as specified in paragraphs (d)(2) and (3) of this section, an inpatient admission is generally appropriate for payment under Medicare Part A when the admitting physician expects the patient to require hospital care that crosses two midnights.”
Paragraphs (d)(2) and (3) allow a person to be an inpatient when they receive a surgical procedure on the inpatient-only list, or when the physician expects a shorter stay but feels that the patient’s condition justifies an admission. In essence, those paragraphs allow inpatient status at times when the physician expects a stay shorter than two midnights. Those paragraphs are expanding, not narrowing, coverage. When the stay is expected to EXCEED to midnights, paragraph (1) provides coverage.
This article originally published on June 1, 2022 by RACmonitor.