96-Hour Medicare Condition of Payment and CAH Condition of Participation
According to The American Hospital Association (AHA), since 1997, as part of a CAH condition of payment, physicians must certify that there is a reasonable expectation that a Medicare patient admitted to an acute inpatient bed will be discharged or transferred within 96 hours of admission to the CAH, if this is the best care strategy for the patient. This is not the same as the CAH Condition of Participation for average annual length of stay of 96 hours, but they go hand in hand. According to the State Operations Manual, Appendix W, §485.620(b) Standard: Length of Stay, “The CAH provides acute inpatient care for a period that does not exceed, on an annual average basis, 96 hours per patient.”
According to 42 CFR Chapter IV Subchapter B – Medicare Program, Part 424 – Conditions for Medicare Payment, Section 424.15 Requirements for Inpatient CAH services, Medicare Part A pays for inpatient CAH services only if a physician certifies that the individual may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH, and that the services are provided in accordance with § 412.3. Certification begins with the order for inpatient admission and must be completed, signed, and documented in the medical record prior to discharge. Certification is required no later than 1 day before the date on which the claim for payment for the inpatient CAH services is submitted.
For more information, visit these documents from The Federal Register and the Government Printing Office.
Two-Midnight Rule
The Two Midnight Inpatient Admission Guidance and Patient Status Review for Admission, commonly called the “two-midnight rule” will be reviewed by The Centers for Medicare & Medicaid Services (CMS), and part of the enforcement of Inpatient Prospective Payment System (IPPS) admission will be delayed. This stems from a “Dear Colleague” letter written to CMS, signed by Members of the U.S. House of Representatives and supported by National Rural Health Association (NRHA), urging a 6-month delay of a new policy established in the 2014 IPPS final rule.
This rule does apply to CAHs. In essence, the rule went into effect on October 1, 2013, but will not be enforced by the Medicare Administrative Contractors (MAC) for 90 days (after December 31, 2013). During the implementation period of October 1, 2013 until December 31, 2013, CMS will instruct the MACs and Recovery Auditors not to review claims spanning more than two midnights after admission for appropriateness of patient status. MACs and Recovery Auditors will not review any claims related to Critical Access Hospitals. In addition, during this period, CMS will not permit Recovery Auditors to review inpatient admissions of one midnight or less that occur on or after October 1. If an issue is identified by A MAC during this 90-day period, the MAC will conduct education to the hospital and follow-up as necessary.
For more information, visit frequently asked questions on this topic from CMS.
