Two-Midnight Rule Coordination and Improvement Act of 2014 - Directs the Secretary of Health and Human Services (HHS) to develop appropriate criteria with regard to the two-midnight rule for payment under title XVIII (Medicare) of the Social Security Act for a short inpatient hospital stay.
(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.)
Requires the criteria developed by the Secretary to: (1) account for medical necessity and the appropriateness of an inpatient stay that is less than the two-midnight benchmark, and (2) be developed in consultation with interested stakeholders.
Directs the Secretary to develop a budget-neutral Medicare payment methodology for hospitals for short inpatient hospital stays.
Allows the methodology to be: (1) a reduced payment amount than would otherwise apply to inpatient hospital services if paid for under the Medicare prospective payment schedule, or (2) an alternative payment methodology.
Directs the Secretary to develop: (1) 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 services; and (2) a second crosswalk between Diagnosis-Related Group (DRG) codes for inpatient hospital services and Ambulatory Payment Class (APC) codes for outpatient hospital services.
Prohibits the Secretary from enforcing the two-midnight rule for admissions occurring: (1) before October 1, 2014; and (2) on or after that date until October 1, 2015, or the new two-midnight rule criteria are implemented, if sooner (applicable date).
Prohibits a Medicare review contractor from denying a claim for inpatient hospital services furnished by a hospital, or inpatient critical access hospital services furnished by a critical access hospital, on the basis of the two-midnight rule for discharges occurring before the applicable date for: (1) 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) requirements for orders, certifications, or recertifications, and associated documentation relating to such matters.
Declares that nothing in this Act shall be construed to preclude the Secretary from continuing the conduct by Medicare administrative contractors of the Medicare Probe and Educate program for hospital admissions during the delayed enforcement of the two-midnight rule.
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, such as 10 claims for most hospitals and 25 claims for large hospitals.
[Congressional Bills 113th Congress]
[From the U.S. Government Publishing Office]
[S. 2082 Introduced in Senate (IS)]
113th CONGRESS
2d Session
S. 2082
To provide for the development of criteria under the Medicare program
for medically necessary short inpatient hospital stays, and for other
purposes.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
March 5, 2014
Mr. Menendez (for himself and Mrs. Fischer) introduced the following
bill; which was read twice and referred to the Committee on Finance
_______________________________________________________________________
A BILL
To provide for the development of criteria under the Medicare program
for medically necessary 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 Coordination and
Improvement Act of 2014''.
SEC. 2. DEVELOPMENT OF CRITERIA FOR MEDICALLY NECESSARY SHORT INPATIENT
HOSPITAL STAYS.
(a) In General.--
(1) Development of criteria.--The Secretary shall develop
appropriate criteria with regard to the two-midnight rule (as
defined in subsection (e)) for payment under the Medicare
program under title XVIII of the Social Security Act (42 U.S.C.
1395 et seq.) for a short inpatient hospital stay (as defined
in such subsection).
(2) Requirements.--The criteria developed under paragraph
(1) shall--
(A) account for medical necessity and the
appropriateness of an inpatient stay that is less than
the two-midnight benchmark; and
(B) subject to paragraph (3), be developed in
consultation with interested stakeholders.
(3) Implementation.--The consultation described in
paragraph (2)(B) shall be conducted as part of the annual
notice and comment rulemaking process implementing the Medicare
hospital inpatient prospective payment system for fiscal year
2015.
(b) Development of Short Inpatient Hospital Stay Payment
Methodology.--
(1) In general.--The Secretary shall develop a payment
methodology under the Medicare program under title XVIII of the
Social Security Act for hospitals for short inpatient hospital
stays. Such methodology--
(A) shall be implemented in a budget neutral
manner;
(B) 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 be an alternative
payment methodology; and
(C) shall take into consideration the criteria
developed under subsection (a).
(2) Timeframe.--The Secretary shall promulgate such
methodology as part of the annual regulations implementing the
Medicare hospital inpatient prospective payment system for
fiscal year 2015.
(c) Crosswalk of ICD-10 Codes and CPT Codes; Crosswalk of DRG and
CPT Codes.--
(1) ICD-10-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 ICD-10-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 Web site of the Centers for
Medicare & Medicaid Services.
(III) An announcement on the
Internet Web site 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 ICD-10-to-CPT crosswalk.
(iv) Publication of final crosswalks.--
Taking into consideration comments received on
the proposed crosswalk, the Secretary shall
publish a final ICD-10-to-CPT crosswalk under
subparagraph (A) and shall post such crosswalk
on the Internet Web site 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
ICD-10-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) Delay of Enforcement of the Two-Midnight Rule.--
(1) In general.--The Secretary shall not enforce the
provisions of the two-midnight rule with respect to admissions
to a hospital for which payment is made under the Medicare
program under title XVIII of the Social Security Act--
(A) for admissions occurring before October 1,
2014; and
(B) in the case of admissions occurring on or after
October 1, 2014, prior to the applicable date (as
defined in paragraph (3)).
(2) Application to medicare review contractors.--Paragraph
(1) shall also apply to Medicare review contractors (as defined
in subsection (e)). No Medicare review contractor may, based on
the provisions of the two-midnight rule, 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 applicable date (as defined in
paragraph (3))--
(A) 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
(B) for requirements for orders, certifications, or
recertifications, and associated documentation relating
to the matters described in subparagraph (A).
(3) Applicable date defined.--In this subsection, the term
``applicable date'' means the earlier of--
(A) the date on which the criteria described in
subsection (a) are implemented pursuant to subsection
(a)(3); or
(B) October 1, 2015.
(4) 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 Web
site 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.
(e) Definitions.--In this section:
(1) Hospital.--The term ``hospital'' means the following
(insofar as such terms are used under title XVIII of the Social
Security Act):
(A) An acute care hospital.
(B) A critical access hospital.
(C) A long-term care hospital.
(D) An inpatient psychiatric facility.
(2) Interested stakeholders.--The term ``interested
stakeholders'' means the following:
(A) Hospitals.
(B) Physicians
(C) Medicare administrative contractors under
section 1874A of the Social Security Act (42 U.S.C.
1395kk-1).
(D) Recovery audit contractors under section
1893(h) of such Act (42 U.S.C. 1395ddd(h)).
(E) Other parties determined appropriate by the
Secretary.
(3) IPPS fy 2014 final rule.--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
Fed. Reg. 50496 et seq.).
(4) Medicare review contractor.--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--
(A) Medicare administrative contractors under
section 1874A of the Social Security Act (42 U.S.C.
1395kk-1); and
(B) recovery audit contractors under section
1893(h) of such Act (42 U.S.C. 1395ddd(h)).
(5) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(6) Short inpatient hospital stay.--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 Regulations, as amended under the
amendment 2 referred to in paragraph (7)(A).
(7) Two-midnight rule.--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).
<all>
Introduced in Senate
Read twice and referred to the Committee on Finance.
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