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The two-midnight rule has brought to hospitals not only a lot of confusion, but also a lot of consternation. As we all know, the new rule features a time-based determination of the expectation of length of hospitalization as a determinant of proper status; those patients who are expected to require more than two midnights of care (or having an inpatient-only surgery) are to be admitted as inpatient, and those who are not expected to require two midnights are expected to be treated as outpatient. The Centers for Medicare & Medicaid Services (CMS) was also clear that the setting of the care does not constitute an exception to the rule – outpatients can be treated in the intensive care unit. This has led many within the industry to express their discomfort or outright objection to treating potentially critically ill patients who require invasive procedures, are at high risk for complications, or are receiving intensive treatment in the ICU as outpatients if they are not expected to require two midnights of care in the hospital.

The classic example of this would be a patient presenting to the hospital with an ST elevation myocardial infarction (STEMI). Because of relatively recent advances in invasive cardiology, these patients often are taken from the emergency department directly to the cardiac catheterization lab to have a stent placed, hopefully stopping their heart attack in its tracks. If all goes well, in an efficient hospital the patient often goes to a monitored bed for a day and goes home the next day. These patients present with a severe complication of ischemic heart disease, the No. 1 cause of death in the U.S. and the world, then have a small tube threaded into their heart and a small expandable spring placed right into the blocked artery, pulling them back from the brink of death. But per the new rule, these patients are to be classified as outpatient. “Outpatient?” critics cry incredulously. “CMS might as well tell physicians to treat heart attacks in the cafeteria!”

In reality, of course, CMS is not telling the hospital that they should treat patients in the cafeteria  (or the parking lot). This two-midnight rule has nothing to do with the treatment of patients, only with the classification of, and payment for, their care. The term “outpatient” has two meanings: for one thing, it can refer to any patient in a bed who is not an inpatient – even, for instance, a patient on a ventilator receiving dialysis in the ICU who has an expected length of stay of one midnight. “Outpatient” also describes a patient walking into the hospital lab to get his cholesterol checked. And therein lies the discomfort of many a physician.

So, to alleviate this discomfort, I propose that CMS adopt a new term: hospitalized patient. There would continue to be outpatients, which would refer to those patients who are receiving hospital services on an ambulatory basis, getting a blood test or X-ray, receiving an intravenous antibiotic or chemotherapeutic or blood transfusion in the infusion center, receiving radiation therapy, or receiving treatment in the ED. These patients are not receiving medical care in a hospital bed. On the other hand, any patient who requires care that only can be provided safely in a hospital bed would be called a “hospitalized patient.”

Falling under the “hospitalized patient” umbrella would be several subcategories, just as with the current outpatient status. First would be the “hospitalized inpatient,” which would include any patient requiring hospital care whose stay is expected to exceed two midnights and any patient undergoing an inpatient-only surgery. Next would be a “hospitalized patient with observation,” or a patient who requires hospital care that is not expected to exceed two midnights (and for whom observation services are appropriate and ordered). There also would be the “hospitalized recovery patient,” who is recovering from an outpatient procedure or surgery for which the recovery period is expected to last less than two midnights. And finally there would be the “hospitalized outpatient,” the patient for whom hospitalization is not medically necessary but being provided as a convenience to the patient, doctor, or hospital. These patients currently are called “outpatients in a bed” – a term that sometimes is used to designate post-op surgery patients who spend the night for medically necessary recovery, but for which this use does not apply; those patients would still be “hospitalized recovery patients,” as referenced above). The cost of non-covered care for such patients is either absorbed by the hospital or accepted by the patient with the use of an advance beneficiary notice.

Under this new terminology, the patient with the acute MI who goes to the catheterization lab and is expected to go home the next day would be a “hospitalized patient with observation,” thereby removing the stigma of the term “outpatient.” If such a patient had complications that required a second midnight, he or she then would be admitted as inpatient and labeled a “hospitalized inpatient” – but if he or she was stable on day two and ready to go home but could not get a ride, and the physician deferred discharge for patient convenience, they would be a “hospitalized outpatient.”

While I have no expectation that the officials at CMS will consider this proposal, or even read this article, I am hoping that simply discussing the importance and ambiguity of the terminology we use will alleviate the trepidation that many providers experience when seeing their high-risk or ICU patients being called “outpatients” – even when they are being treated in a setting that is generally considered an inpatient hospital setting.

About the Author

Ronald Hirsch, M.D. serves as vice president of physician advisory services (AccretivePAS®) in the Regulation and Education Group (“the REG Specialists”). Prior to his employment at Accretive Health, Dr. Hirsch, a board certified internist and HIV specialist, practiced and served as president at a multispecialty practice in Illinois, and medical director of case management at Sherman Hospital in Elgin, Ill.

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