Ralph Wuebker
Chief Medical Officer

The questions keep rolling in on what many are calling the “two-midnight” rule.

During our live “Monitor Monday” broadcast this past Monday, we received a deluge of questions for our special guest: Ralph Wuebker, MD, the chief medical officer for Executive Health Resources. So, we caught up with the busy physician executive and asked for more answers on the inquiries.

First, the background. The 2014 fiscal-year Inpatient Prospective Payment System (IPPS) Final Rule will not take effect until Oct. 1, 2013.  In the meantime, the Centers for Medicare & Medicaid Services (CMS) will be developing sub-regulatory guidance to further assist providers in making inpatient admission decisions and the review contractors in performing medical necessity reviews. 

“In the interim, it is important to continue to follow existing CMS guidance regarding inpatient admission decision-making and billing,” Wuebker wrote to RACmonitor.  “On Sept. 5, 2013, (CMS) issued clarification regarding the final rule’s impact on inpatient admission order and certification requirements. This document is likely the first of many that CMS will release in the coming weeks in preparation for the 2014 IPPS implementation.” 

“I mention this because I urge everyone to be aware that how we might interpret a rule today could very well change tomorrow, depending on the nature of CMS’s forthcoming sub-regulatory guidance,” Wuebker added.

Wuebker provided the following responses in what he described as “Seven Essential Things to Remember:”

  • Medical necessity remains a critical factor in making the decision to admit a patient as an inpatient.  The decision to admit is a complex medical decision that must consider a number of factors including the patient’s medical history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.  All of these factors are considered together to inform a physician’s length-of-stay expectation.
  • CMS will be issuing sub-regulatory guidance to address what happens when there is a conflict between screening tools such as InterQual or Milliman and Medicare’s new inpatient criteria.
  • As CMS explained during the Special Open Door Forum on August 15, 2013, the physician should admit the patient as an inpatient as soon as he or she can reasonably predict that the patient will need to remain in the hospital for two midnights or more. In other words, the physician should not wait until the patient’s hospital stay crosses two midnights to write the admission order.
  • Not only must the medical record state that the patient is expected to remain in the hospital for at least two midnights, but it must also document the reasons for this expectation. As CMS states in the IPPS rule, “The factors that lead a physician to admit a particular beneficiary based on the physician’s clinical expectation are significant clinical considerations and must be clearly and completely documented in the medical record” (emphasis added).
  • The clock for the 2-midnight benchmark starts when the beneficiary begins receiving hospital services, whether inpatient or outpatient; however, the clock for the 2-midnight presumption starts when the inpatient admission order is issued.
  • The certification does not necessarily need to consist of a separate document. CMS states that “no specific procedures or forms are required for certification and recertification statements. The provider may adopt any method that permits verification. The certification and recertification statements may be entered on forms, notes, or records that the appropriate individual signs, or on a special separate form.”
  • The elements of the certification are: a) Authentication of the practitioner order; b) Reason for inpatient services; c) The estimated time the beneficiary requires or required in the hospital; d) The plans for post-hospital care, if appropriate, and as provided in 42 CFR 424.13; and e) For inpatient CAH services, the physician must certify that the beneficiary may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH.

About Ralph Wuebker, MD

Dr. Ralph Wuebker serves as Chief Medical Officer of Executive Health Resources (EHR). In this role, Dr. Wuebker provides clinical leadership within EHR and works closely with hospital leaders to ensure strong utilization review and compliance programs. Additionally, Dr. Wuebker oversees EHR’s Audit, Compliance and Education (ACE) physician team, which is focused on providing on-site education for physicians, case managers, and hospital administrative personnel and on helping hospitals identify potential compliance vulnerabilities through ongoing internal audit.

Contact Dr. Wuebker


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