2023 The Two Midnight Rule and Medical Necessity in the Hospital Setting (34.1) – Post Test

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Question 1 of 10

1. Question
1. A patient is admitted for a procedure that is on the “inpatient only” list. They would be admitted as an inpatient
- a. Once the second midnight is passed
- b. Only if the patient had to stay overnight from the surgical procedure
- c. On the admission orders, and if not, this needs to be verified and updated
- d. Only for Medicare patients as Medicare Advantage has their MA-specific IPO list
Question 2 of 10

2. Question
2. Regarding Medicare Fee for Service (not Medicare Advantage), which is TRUE?
- a. Post-acute care is covered for a SNF rehab stay only if the patient has been correctly assigned inpatient status for 3d (midnights) of care in a hospital.
- b. Observation discharged patients who need rehab can still get coverage if the facility has a 4-Star or above ranking. Less than 4-Star is patient responsibility.
- c. All patients must be first placed in Observation status
- d. Inpatient care can only be delivered once the patient is on the wards upstairs. ED place of service care is always observation unless a patient dies
Question 3 of 10

3. Question
3. The Two Midnight Rule
- a. Requires all patients be in-house for two midnights before inpatient status is ordered
- b. Follows the Medical Inpatient Only listing which is updated each year
- c. States that documentation for inpatient far exceeds that for observation status
- d. States that active management of a clinical condition should be expected to transcend two midnights to be considered inpatient.
Question 4 of 10

4. Question
4. Which of the exclusions listed below apply to the Two Midnight Rule:
- a. Death before two midnights have passed
- b. Leaving AMA or being transferred to another facility
- c. Unexpected ventilator use
- d. Conditions that fall under the Ambulatory Care Sensitive Conditions listing
Question 5 of 10

5. Question
5. You have a longstanding Medicare patient (not Medicare Advantage) come in with COPD exacerbation. This presentation is as before, and he usually stays 4-5 days before stabilizing enough to return home. You expect this admission to be as previous and to stay more than two midnights, and so you ordered for inpatient care on admission. The patient responded more quickly than expected and on the evening rounds of day two, asked to go home. Clinically, you agree with his request. Because the patient did not pass two midnights, you should
- a. Change the admit order to Observation AFTER you discharge the patient
- b. Change the admit order to Observation BEFORE you discharge the patient
- c. Leave the Inpatient order in place, but document that the clinical condition responded more rapidly than expected
- d. Keep the patient until after midnight so secure the “two midnight” criteria for inpatient admission
Question 6 of 10

6. Question
6. A surgical procedure was admitted electively as inpatient and is on the “Inpatient Only” list. After the procedure, the Attending Surgeon states she disagrees with that determination because the procedure was “not that hard”. You have knowledge of inpatient and observation status determination, so you offer to help her work through this process. You recommend for her to (choose ALL that are appropriate)
- a. Change the billing status to “Observation”
- b. Leave as “inpatient” because the insurance carrier will only pay for the procedure if it is billed with that level of care
- c. Discharge the patient without a status determination and let billing decide later how to submit the bill on appeal
- d. Bill for inpatient and outpatient observation and let the insurance carrier pay for what is in the contract
Question 7 of 10

7. Question
7. Medical admissions (CHF, pneumonia, etc.) have a specific Medical Inpatient Only (MIO) list that gets updated each year by CMS.
- a. True
- b. False
Question 8 of 10

8. Question
8. A Medicare patient meets medical necessity for inpatient care services for Pneumonia. They stay in the facility for three nights of care and on day four, are ready for discharge. This 88-year-old is very weak, and you feel that they need a post-acute stay for short term rehab to make sure of a safe transition to home. PT has agreed due to gait instability and states that discharge to home is “unsafe” based on their findings. Which of the following is/are true? (choose ALL that are correct).
- a. Medicare will cover short-term, post-acute rehab care in this situation because the inpatient medical need for care lasted more than “three midnights” and there appears to be a clinical need documented.
- b. Medicare Advantage Plans may offer a streamlined process that does not require a full “three midnights” of care to approve post-acute rehab.
- c. Only inpatient only surgeries get acute rehab care approved
- d. Only inpatient medical cases get acute rehab care approved, surgery cases are excluded
Question 9 of 10

9. Question
9. On day two (D-day) of a hospital stay where the patient was admitted as inpatient, what would help secure this inpatient status?
- a. Occasional PACs on overnight monitor
- b. Noting an increased work of breathing on ambulation to the toilet (w/ accessory muscle use and RR 23), RA saturation 86% with sinus tachycardia of 135 noted with ambulation.
- c. Continued subjective shortness of breath (sat 95% off supplemental O2) at rest. RR12.
- d. CBC showing a Hemoglobin of 9.9, down from 11. Baseline 10-10.5.
Question 10 of 10

10. Question
10. Which of the following COPD scenarios would most likely merit INPATIENT hospitalization from initial presentation (active management beyond 2MN?)?
- a. COPD patient with mild confusion exacerbation on day one
- b. COPD exacerbation with RR 15, cough w/ thick increased phlegm, sat 96% on RA
- c. COPD with 2 liters home O2, presents with sat 81% and bumped to 4 liters. CXR with LLL pneumonia and layering effusion. On 4 liters, saturation is 91%.
- d. COPD patient who still smokes AMA, has 3d of wheezing and has used MDI 2x/day for 3d without relief.

2023 The Two Midnight Rule and Medical Necessity in the Hospital Setting (34.1) – Post Test

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