The Center for Medicare Services (CMS) Two Midnight Rule: Policy at Odds with Reality

Ciara R Huntington, MD, Tiffany C Cox, MD, Laurel J Blair, MD, Tanushree Prasad, MA, Kent W Kercher, MD, FACS, Vedra A Augenstein, MD, FACS, B. Todd Heniford, MD, FACS. Carolinas Medical Center

Introduction: To reduce costs, CMS implemented new policies governing which patients are automatically admitted as inpatients (staying greater than “two midnights”) and which require additional justification with physician documentation to be admitted. This study examines procedures missing from the Medicare Inpatient Only (MIO) list and uses national data to evaluate its appropriateness.

Method: Non-MIO procedures were identified from the current MIO list. Utilizing relevant billing codes, procedures were queried in the National Surgery Quality Improvement Program(NSQIP) database for length of stay(LOS), percentage requiring >2 day stay, and inpatient status from 2005-2012. A separate analysis was performed for patients qualifying for Medicare, namely those 65 years old or older.

Results: A majority of patients stayed more than two days for several procedures not included on the MIO list (Table 1), including component separation with 79.1% of patients staying >2days with a mean LOS of 9.0±13.6days, diagnostic laparoscopy 64.2%>2days LOS, mean 6.3± 9.0days, laparoscopic splenectomy 60.0%>2days LOS, mean 5.9±12.3days, open recurrent ventral hernia repair 58.2% >2 days LOS, mean 5.3±13.3days, laparoscopic esophageal surgery 46.4%>2days LOS, mean 5.5±11.9 days, and open ventral hernia repair 34.8%>2day LOS, mean 3.3±8.2 days. In patients ≥65 years, the average LOS was longer than the general population. In many procedures 60-88% of patients required >2 nights in the hospital with an average LOS of 5.2 days to 10.7 days (see table). In this older group, 40.2% of laparoscopic appendectomy patients and 38.7% of laparoscopic cholecystectomy required more than 2 nights in the hospital.

Conclusions: Commonly encountered non-MIO surgical procedures have national precedents for inpatient status. Before enacting policy, CMS and other regulatory bodies should consider current data to ensure rules are evidence-based and applicable. Inaccurate and onerous regulations impede patient care and obstruct provider productivity.

Table 1-Length of Stay for Common non-MIO List Procedures
%patients with LOS>2 days%patients age ≥65 years with LOS>2 daysAverage LOS(days)— Patients ≥ age 65
Component Separation79.1%85.8%10.45±14.5
Diag Lap64.2%81.8%8.8±9.9
Open Recurrent Ventral Hernia58.2%64.8%6.2±9.4
Lap procedure of the esophagus46.4%61.8%7.4±11.6
Open ventral hernia repair34.5%51.7%5.2±8.8
Lap incisional hernia repair24.7%31.0%2.7±7.8
Lap recurrent ventral hernia repair24.7%32.4%2.5±3.8
Lap cholecystectomy24.0%38.7%3.3±6.5
Lap primary ventral hernia repair17.9%29.9%2.6±6.9
Lap appendectomy17.2%40.2%3.5±8.8
Simple mastectomy16.0%10.3%1.6±6.4

Parotidectomy/Submandibular gland excision

Partial thyroidectomy8.2%5.8%1.5±7.9
Total thyroidectomy6.2%8.4%1.6±3.2

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