The CMS Two-Midnight Rule and Medical Necessity Criteria (2024)

FAQs

The CMS Two-Midnight Rule and Medical Necessity Criteria? ›

According to the rule: Inpatient services are considered appropriate if the physician expects the patient to require medically necessary hospital care spanning at least 2 midnights. Inpatient services are also appropriate if the physician is providing a service listed as "inpatient only" by Medicare.

§ 412.3, which include a “two-midnight benchmark” (meaning that patients must be in the hospital for at least “two midnights” before being admitted for inpatient care).

The 2MN rule states that a hospital inpatient admission is generally considered reasonable and necessary if the physician (or other qualified practitioner) orders an inpatient admission based on the expectation that the patient will require at least two midnights of medically necessary hospital care.

The two-midnight rule requires patients to be admitted as an inpatient if the treating clinician determines they require hospital care that extends beyond two midnights — rather than being held under observation status as an outpatient.

Medical Necessity - Rehabilitation

Services must be under accepted standards of medical practice and considered to be specific and effective treatment for the patient's condition. The amount, frequency, and duration of the services planned and provided must be reasonable.

Starting this year, private Medicare plans have to cover their members' hospitalizations at the higher inpatient rate if their doctors predict they'll have to stay beyond two midnights. It's the same rule — appropriately called the two-midnight rule — that traditional Medicare has followed for a decade.

To reduce inpatient admission errors, CMS implemented the Two-Midnight Rule in fiscal year 2014. Under the Two-Midnight Rule, CMS generally considered it inappropriate to receive payment under the inpatient prospective payment system for stays not expected to span at least two midnights.

"Medically Necessary" or "Medical Necessity" means health care services that a physician, exercising prudent clinical judgment, would provide to a patient. The service must be: For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms.

The two-midnight rule, enacted in 2013, states that traditional Medicare must pay for an inpatient stay if admitting clinicians anticipate patients will remain in the hospital for at least “two midnights.” Beginning this year, Medicare Advantage insurers must also follow the rule.

On April 4, 2024, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that revises the Medicare Advantage Program, Medicare Prescription Drug Benefit Program (Medicare Part D), Medicare Cost Plan Program, Programs of All-Inclusive Care for the Elderly (PACE), and Health Information Technology ...

What is the 60 day rule for Medicare Advantage? ›

While these overpayments may not be your fault, they expose your lab to the risk of liability under the Affordable Care Act (ACA) rule requiring providers to report and return all Medicare and Medicaid overpayments within 60 days of identifying them.

If you join a Medicare Advantage Plan you'll still have Medicare, but you'll get most of your Part A and Part B coverage from your Medicare Advantage Plan, not Original Medicare.

Specifically, to be classified for payment under Medicare's IRF prospective payment system, at least 60 percent of a facility's total inpatient population must require IRF treatment for one or more of 13 conditions listed in 42 CFR 412.29(b)(2).

The determination of medical necessity is made on the basis of the individual case and takes into account: Type, frequency, extent, body site and duration of treatment with scientifically based guidelines of national medical or health care coverage organizations or governmental agencies.

Medically necessary services: Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. Preventive services: Health care to prevent illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.

Examples of services or treatments a plan may define as not medically necessary include cosmetic procedures, treatments that haven't been proven effective, and treatments more expensive than others that are also effective.

Benchmarks are the point of comparison we use to score the measures you submit. Your performance on each measure is compared to its benchmark to determine how many points the measure can earn. Benchmarks are specific to each collection type even if the measure is the same.

If the patient does require care beyond the two midnights and now meets the medical criteria for a full inpatient admission continued stay, the Centers for Medicare & Medicaid Services' two-midnight rule requires that the patient be converted to an inpatient level of care.

Hospitals count the admission day but not the discharge day.

To count inpatient days, use the midnight-to-midnight method when a day begins at midnight and ends 24 hours later. A part of any day, including the admission day and the day a patient returns from a leave of absence, counts as a full day.

• Benchmarks are the annual. established maximum payments set by the CMS that health plans bid against to provide coverage of Medicare Part A and Part B services for Medicare beneficiaries. • The benchmark is the average.