Special Open Door Forum: Midnight Benchmark for Inpatient Hospital Admissions

CMS-1599-F clarifies that for purposes of payment under Medicare Part A, “A Medicare beneficiary is considered an inpatient of a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner.” The new rules address concerns about beneficiaries having long stays in the hospital as outpatients. Under the rule, if the ordering practitioner expects a beneficiary’s stay in the hospital to last at least two midnights, and admits the beneficiary, it is generally appropriate that the hospital receive Medicare Part A payment. The rule also permits the practitioner to consider all time a patient has already spent in the hospital in “observation,” or receiving care in the emergency department or other hospital areas in guiding their two-midnight expectation.

Questions on the two midnight provision for admission and medical review can be sent to IPPSAdmissions@cms.hhs.gov.

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Contact: Susan Bartholomew, sbartholomew@leadingageny.org, 518-867-8850