The change in the definition of inpatient admitting status is crucial for hospitals to understand, says James S. Kennedy, MD, CCS, CDIP, managing director for FTI Consulting.
CMS made it clear that the inpatient order is required for payment of hospital inpatient services under Medicare A. "What I believe this rule says is that the physician must also state at the time he or she writes the inpatient order that he or she expects the patient to require care for two or more midnights and why he or she believes that," Kennedy says. "I personally know of no physician or admitting process that captures this information; changing this documentation process will be a tremendous paradigm shift."
The presumption is based on the expected length of stay and not on the actual time the patient spends as an inpatient. In some cases, such as death, faster than expected recovery, or transfer, a patient's stay may not cross two midnights. However, the presumption still applies because the physician expected the patient to be in the hospital over two midnights as long as the physician documented why he or she believed the stay would cross two midnights.
CMS stressed that deciding whether to admit a patient is a complex medical decision that only the physician can make using his or her clinical judgment. CMS also expects the physician to use his or her clinical judgment to determine what services and level of nursing care (for example, low-level, monitored, or one-on-one) the beneficiary will need and where (unit) the services should be provided.
"All patients are unique in their presentation and in their resolution of their illness and even CMS states in the rule that they 'have expected and continue to expect that physicians will make the decision to keep a beneficiary in the hospital when clinically warranted and will order all appropriate treatments and care in the appropriate location based on the beneficiary's individual medical needs,' Mackaman says. "Unfortunately, it appears that the two-midnights rule paints all of the patients with the same brush and paints the physicians into a corner."