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Checklist: Inpatient admission documentation

Two-midnight rule

On August 2, 2013, CMS issued fiscal year (FY) 2014 Inpatient Prospective Payment System (IPPS) final rule (CMS-1599-F), which modifies and clarifies CMS' longstanding policy on how Medicare contractors review inpatient hospital admissions for payment purposes. 

The two-midnight presumption outlined in CMS-1599-F specifies hospital stays spanning two or more midnights after the beneficiary is formally admitted as an inpatient will be presumed to be reasonable and necessary for the inpatient status as long as the hospital stay is medically necessary. Inpatient stays spanning less than two midnights after the beneficiary is formally admitted as an inpatient are not subject to the presumption and may be selected for medical review. However, if total time in the hospital receiving medically necessary care (including pre-admission outpatient time from the time care is initiated in the hospital) spans two or more midnights, the two-midnight benchmark for inpatient admission will be met and payment supported upon medical review.

This checklist was created as a tool to assist hospital personnel when responding to medical record documentation requests. The provider of service must ensure correct submission of documentation to the Medicare contractor within the specified calendar days outlined in the request.

The documentation submitted for review should include, if applicable, but is not limited to the following:

Check

 Documentation description
  Name of beneficiary and date of service in all documentation
 

Inpatient certification:

  • Signed and dated by a physician prior to discharge

  • Reason for inpatient admission

  • Estimated and/or actual hospital time

  • Progress notes support the reason for admission and explain current treatment plans

  • Post-hospital care plans

  • Valid inpatient admission order
 

Admission order:

  • Includes specific language such as “admit to inpatient,” “admit to inpatient services,” or similar

  • Written order

  • Verbal order:

    • Includes specific language such as “admit to inpatient,” “admit to inpatient services,” or similar

    • Identity of the ordering physician / practitioner

    • Countersigned and dated by a physician / practitioner

  • Written at or before the time of the inpatient admission

  • Authenticated prior to discharge
 

Two-midnight benchmark:

  • Include all outpatient services time

  • Observation

  • Emergency department

  • Operating room

  • Other treatment areas
 

Exceptions or unforeseen circumstances:

  • Patient’s death

  • Patient transferred to another facility

  • Patient left against medical advice (AMA)

  • Unexpected recovery is clearly documented in medical record

  • Other
  Signed, timed, and dated physician orders for each day of care / service
  History and physical
  Legible physician progress notes
  All diagnostic and laboratory reports, as applicable
  Surgical procedure reports
  Anesthesia reports
  Medication administration record
  Nurses' notes
  Ambulance run sheet
  Discharge summary
  Signature log or physician’s attestation for any missing signatures
  Signed ABN / HINN
  Any other clinical records that support the medical necessity of the service billed
  Any other documentation a provider deems necessary to support medical necessity of services billed, as well as documentation specifically requested in the letter

 

Disclaimer

This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.