Two-Midnight Rule Delay Act of 2013 - Prohibits the Secretary of Health and Human Services (HHS) from enforcing the two-midnight rule to a hospital for which payment is made under title XVIII (Medicare) of the Social Security Act for admissions occurring before October 1, 2014.
(The two-midnight rule allows Medicare coverage of only hospital stays for which a physician admits to a hospital a beneficiary expected to require care that crosses two midnights, but generally denies coverage of care expected to require less than a two-midnight stay.)
Applies such prohibition to Medicare review contracts.
Prohibits Medicare review contractors from denying a claim for inpartient hospital services furnished by a hospital, or inpatient critical access hospital services furnished by a critical access hospital, for discharges occurring before October 1, 2014: (1) for medical necessity due to the length of an inpatient stay in such hospital or due to a determination that the services could have been provided on an outpatient basis; or (2) for requirements for orders, certifications, or recertifications, and associated documentation relating to such matters.
Prohibits the Secretary from increasing the sample of claims selected for prepayment review under the Medicare Probe and Educate program above the number and type established by the Secretary as of November 4, 2013.
Directs the Secretary to develop: (1) a Medicare hospital payment methodology for short inpatient hospital stays; (2) general equivalency maps to link the relevant International Statistical Classification of Diseases and Related Health Problems (ICD)-10 codes (used to report medical diagnoses and inpatient procedures) to relevant Current Procedural Terminology (CPT) codes, and the relevant CPT codes to relevant ICD-10 codes, in order to permit comparison of inpatient hospital services and hospital outpatient department servives; and (3) a second crosswalk between Diagnosis-Related Group (DRG) codes for inpatient hospital services and Ambulatory Payment Class codes for outpatient hospital services.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3698 Introduced in House (IH)]
113th CONGRESS
1st Session
H. R. 3698
To delay the enforcement of the Medicare two-midnight rule for short
inpatient hospital stays until the implementation of a new Medicare
payment methodology for short inpatient hospital stays, and for other
purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
December 11, 2013
Mr. Gerlach (for himself, Mr. Crowley, Mr. Reed, Mr. Roskam, and Mr.
Kind) introduced the following bill; which was referred to the
Committee on Ways and Means
_______________________________________________________________________
A BILL
To delay the enforcement of the Medicare two-midnight rule for short
inpatient hospital stays until the implementation of a new Medicare
payment methodology for short inpatient hospital stays, and for other
purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Two-Midnight Rule Delay Act of
2013''.
SEC. 2. ENFORCEMENT DELAY OF MEDICARE TWO-MIDNIGHT RULE TO PERMIT
DEVELOPMENT OF A NEW MEDICARE PAYMENT METHODOLOGY FOR
SHORT INPATIENT HOSPITAL STAYS.
(a) Delay in Enforcement of Two-Midnight Rule.--
(1) In general.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'') shall not
enforce the provisions of the two-midnight rule (as defined in
paragraph (2)) with respect to admissions to a hospital (as
defined in subsection (d)) for which payment is made under the
Medicare program under title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.) for admissions occurring before
October 1, 2014.
(2) Two-midnight rule defined.--In this section, the term
``two-midnight rule'' means the following numbered amendments
to 42 CFR Chapter IV contained in the IPPS FY 2014 Final Rule
(and includes any sub-regulatory guidance issued in the
implementation of such amendments and any portion of the
preamble of section XI.C. of such rule relating to such
amendments):
(A) Amendment 2 (on page 50965), which adds a
section 412.3 of title 42, Code of Federal Regulations
(relating to admissions).
(B) Amendment 3 (on page 50965), which revises
section 412.46 of such title (relating to medical
review requirements).
(C) Amendment 23 (on page 50969), which amends
paragraphs (d) and (e)(2) of section 424.11 of such
title (relating to conditions of payment: General
procedures).
(D) Amendment 24 (on pages 50969 and 50970), which
revises section 424.13 of such title (relating to
requirements for inpatient services of hospitals other
than inpatient psychiatric facilities).
(E) Amendment 25 (on page 50970), which revises
paragraphs (a), (b), (d)(1), and (e) of section 424.14
of such title (relating to requirements for inpatient
services of inpatient psychiatric facilities).
(F) Amendment 26 (on page 50970), which revises
section 424.15 of such title (relating to requirements
for inpatient CAH services).
(3) IPPS fy 2014 final rule defined.--In this section, the
term ``IPPS FY 2014 Final Rule'' means the final rule (CMS-
1599-F, CMS-1455-F) published by the Centers for Medicare &
Medicaid Services in the Federal Register on August 19, 2013,
entitled ``Medicare Program; Hospital Inpatient Prospective
Payment Systems for Acute Care Hospitals and the Long-Term Care
Hospital Prospective Payment System and Fiscal Year 2014 Rates;
Quality Reporting Requirements for Specific Providers; Hospital
Conditions of Participation; Payment Policies Related to
Patient Status'' (78 Federal Register 50496 et seq.).
(4) Application to medicare review contractors.--
(A) In general.--Paragraph (1) shall also apply to
Medicare review contractors (as defined in subparagraph
(B)). No Medicare review contractor may deny a claim
for payment for inpatient hospital services furnished
by a hospital, or inpatient critical access hospital
services furnished by a critical access hospital, for
which payment may be made under title XVIII of the
Social Security Act for discharges occurring before the
date specified in paragraph (1)--
(i) for medical necessity due to the length
of an inpatient stay in such hospital or due to
a determination that the services could have
been provided on an outpatient basis; or
(ii) for requirements for orders,
certifications, or recertifications, and
associated documentation relating to the
matters described in clause (i).
(B) Medicare review contractor defined.--In
subparagraph (A), the term ``Medicare review
contractor'' means any contractor or entity that has
entered into a contract or subcontract with the Centers
for Medicare & Medicaid Services with respect to the
Medicare program to review claims for items and
services furnished for which payment is made under
title XVIII of the Social Security Act, including--
(i) Medicare administrative contractors
under section 1874A of the Social Security Act
(42 U.S.C. 1395kk-1); and
(ii) recovery audit contractors under
section 1893(h) of such Act (42 U.S.C.
1395ddd(h)).
(5) Continuation of medicare probe and educate program for
inpatient hospital admissions.--
(A) In general.--Subject to subparagraph (B),
nothing in this subsection shall be construed to
preclude the Secretary from continuing the conduct by
Medicare administrative contractors of the Medicare
Probe and Educate program (as defined in subparagraph
(C)) for hospital admissions during the delay of
enforcement under paragraph (1).
(B) Maintenance of sample prepayment record
limits.--The Secretary may not increase the sample of
claims selected for prepayment review under the
Medicare Probe and Educate program above the number and
type established by the Secretary under such program as
of November 4, 2013, such as 10 claims for most
hospitals and 25 claims for large hospitals.
(C) Medicare probe and educate program defined.--In
this paragraph, the term ``Medicare Probe and Educate
program'' means the program established by the
Secretary as in effect on November 4, 2013 (and
described in a public document made available by the
Centers for Medicare & Medicaid Services on its Website
entitled ``Frequently Asked Questions 2 Midnight
Inpatient Admission Guidance & Patient Status Reviews
for Admissions on or after October 1, 2013'') under
which Medicare administrative contractors--
(i) conduct prepayment patient status
reviews for inpatient hospital claims with
dates of admission on or after October 1, 2013,
and before March 31, 2014; and
(ii) based on the results of such
prepayment patient status reviews, conduct
educational outreach efforts during the
following 3 months.
(b) Short Inpatient Hospital Stay Payment Methodology.--
(1) In general.--The Secretary shall develop a payment
methodology under the Medicare program for hospitals for short
inpatient hospital stays (as defined in paragraph (2)). Such
payment methodology may be a reduced payment amount for such
inpatient hospital services than would otherwise apply if paid
for under section 1886(d) of the Social Security Act (42 U.S.C.
1395ww(d)) or may be an alternative payment methodology. The
Secretary shall promulgate such payment methodology as part of
the annual regulations implementing the Medicare hospital
inpatient prospective payment system for fiscal year 2015.
(2) Short inpatient hospital stay defined.--In this
section. the term ``short inpatient hospital stay'' means, with
respect to an inpatient admission of an individual entitled to
benefits under part A of title XVIII of the Social Security Act
to a hospital, a length of stay that is less than the length of
stay required to satisfy the 2-midnight benchmark described in
section 412.3 of title 42, Code of Federal Regulation, as
amended under the Amendment 2 referred to in subsection
(a)(2)(A).
(c) Crosswalk of ICD-10 Codes and CPT Codes; Crosswalk of DRG and
CPT Codes.--
(1) ICD10-to-CPT crosswalk.--
(A) In general.--Not later than 2 years after the
date of the enactment of this Act, the Secretary shall
develop general equivalency maps (referred to in this
subsection as ``crosswalks'') to link the relevant ICD-
10 codes to relevant CPT codes, and the relevant CPT
codes to relevant ICD-10 codes, in order to permit
comparisons of inpatient hospital services, for which
payment is made under section 1886 of the Social
Security Act (42 U.S.C. 1395ww), and hospital
outpatient department services, for which payment is
made under section 1833(t) of such Act (42 U.S.C.
1395l(t)). In this subsection the terms ``ICD-10
codes'' and ``CPT codes'' include procedure as well as
diagnostic codes.
(B) Process.--
(i) In general.--In carrying out
subparagraph (A), the Secretary shall develop a
proposed ICD10-to-CPT crosswalk which shall be
made available for public comment for a period
of not less than 60 days.
(ii) Notice.--The Secretary shall provide
notice of the comment period through the
following:
(I) Publication of notice of
proposed rulemaking in the Federal
Register.
(II) A solicitation posted on the
Internet Website of the Centers for
Medicare & Medicaid Services.
(III) An announcement on the
Internet Website of the Centers for
Medicare & Medicaid Services of the
availability of the proposed crosswalk
and the deadline for comments.
(IV) A broadcast through an
appropriate Listserv operated by the
Centers for Medicare & Medicaid
Services.
(iii) Use of the icd-9-cm coordination and
maintenance committee.--The Secretary also
shall instruct the ICD-9-CM Coordination and
Maintenance Committee to convene a meeting to
receive input from the public regarding the
proposed ICD10-to-CPT crosswalk.
(iv) Publication of final crosswalks.--
Taking into consideration comments received on
the proposed crosswalk, the Secretary shall
publish a final ICD10-to-CPT crosswalk under
subparagraph (A) and shall post such crosswalk
on the Internet Website of the Centers for
Medicare & Medicaid Services.
(v) Updating.--The Secretary shall update
such crosswalk on an annual basis.
(2) DRG-to-APC crosswalk.--
(A) In general.--The Secretary shall, using the
ICD10-to-CPT crosswalk developed under paragraph (1),
develop a second crosswalk between diagnosis-related
group (DRG) codes for inpatient hospital services and
Ambulatory Payment Class (APC) codes for outpatient
hospital services.
(B) Data to be used.--In developing such crosswalk,
the Secretary shall use claims data for inpatient
hospital services for discharges occurring in fiscal
years beginning with fiscal year 2015 and for
outpatient hospital services furnished in years
beginning with 2015.
(C) Publication.--Not later than June 30, 2017, the
Secretary shall publish the DRG-to-APC crosswalk
developed under this paragraph.
(d) Hospital Defined.--For purposes of this section, the term
``hospital'' means the following (insofar as such terms are used under
title XVIII of the Social Security Act):
(1) An acute care hospital.
(2) A critical access hospital.
(3) A long-term care hospital.
(4) An inpatient psychiatric facility.
<all>
Introduced in House
Introduced in House
Referred to the House Committee on Ways and Means.
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