For stays in which the physician expects the patient will need less than two midnights of hospital care, inpatient admission may be allowed on a case-by-case basis determined by the judgment of the admitting physician. The documentation must support the admission and will be subject to review by a QIO. CMS expects inpatient admission for minor surgical procedures to be unlikely and will prioritize those cases for medical review. For hospital stays expected to last two midnights or longer, CMS policy remains unchanged.

 

Finalizing the 2-midnight rule proposal doesn’t come as much of a surprise, says Jugna Shah, MPH, president and founder of Nimitt Consulting, based in Washington, D.C., and Spicer, Minnesota, but what remains to be seen is how the QIOs handle the review process compared to Recovery Auditors.

For providers who worked with their physician staff on improving documentation practices, this change is likely to have little or no impact, she says.

 

Providers submitted vastly divergent comments on how CMS should handle the 2-midnight rule. CMS noted that some providers asked for no changes at all. Other providers suggested a 1-midnight rule, in which any Medicare beneficiary who required an overnight hospital stay, other than a patient in the ED or routine recovery following a procedure, would be paid under Medicare Part A.

 

To facilitate this, providers suggested CMS create an “extended outpatient evaluation” APC to replace outpatient observation. Admission orders would become effective at midnight the day the order was given, except for late ED arrivals. Commenters also suggested changes to order authentication and how inpatient deductibles would be paid.

 

However, CMS thought this change would present new challenges, including low-acuity patients being held longer in order to quality for Part A payment. CMS also said the proposal could lead to additional costs that might require a greater negative payment adjustment than the 0.2% already deducted when the rule was introduced. The American Hospital Association and other hospital groups have been fighting that deduction for years, leading to a lengthy legal battle against CMS.

 

In addition to the new policies and payments outlined in the final rule, providers will find some guidance on specific coding and billing issues.

 

CMS released HCPCS codes G0296 (counseling visit to discuss need for lung cancer screening using low-dose CT scan) and G0297 (low-dose CT scan for lung cancer screening) for billing January 1, 2016. It’s great to see CMS finally release these long-awaited codes, says Shah, and it’s good to see the rule specify that the effective date for these codes goes back to the national coverage determination (NCD) effective date of February 5, 2015.

 

“Unfortunately, CMS did not extend the timely filing date for these claims, so providers will need to prepare and submit claims for payment as soon as possible after January 1,” says Shah.

 

CMS changed the status indicator for CPT code 99497 (advance care planning including the explanation and discussion of advance directives such as standard forms [with completion of such forms, when performed], by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member, and/or surrogate) from N (no additional payment, payment included in line items with APCs for incidental service) to Q1.

 

This means that separate payment will be provided when this service is provided on a date of service without a visit (status indicator V) or procedure (status indicator S or T).

 

“While it’s great that CMS again listened to commenter requests for separate payment for this important service, it’s unfortunate CMS assigned status Q1 instead of V,” says Shah. “It’s likely patients would receive this service on the same date of service as another scheduled procedure rather than on a totally separate day.”

 

Add-on code 99498 (advance care planning; each additional 30 minutes), like most other add-on codes under the OPPS, is unconditionally packaged and assigned status indicator N.

 

Editor’s note: This article was originally published in Briefings on APCs. Email your questions to editor Steven Andrews at [email protected].