• Skip to primary navigation
  • Skip to main content
  • Skip to primary sidebar
  • Skip to footer

SAGES

Reimagining surgical care for a healthier world

  • Home
    • COVID-19 Annoucements
    • Search
    • SAGES Home
    • SAGES Foundation Home
  • About
    • Who is SAGES?
    • SAGES Mission Statement
    • Advocacy
    • Strategic Plan, 2020-2023
    • Committees
      • Request to Join a SAGES Committee
      • SAGES Board of Governors
      • Officers and Representatives of the Society
      • Committee Chairs and Co-Chairs
      • Full Committee Rosters
      • SAGES Past Presidents
    • Donate to the SAGES Foundation
    • Awards
      • George Berci Award
      • Pioneer in Surgical Endoscopy
      • Excellence In Clinical Care
      • International Ambassador
      • IRCAD Visiting Fellowship
      • Social Justice and Health Equity
      • Excellence in Community Surgery
      • Distinguished Service
      • Early Career Researcher
      • Researcher in Training
      • Jeff Ponsky Master Educator
      • Excellence in Medical Leadership
      • Barbara Berci Memorial Award
      • Brandeis Scholarship
      • Advocacy Summit
      • RAFT Annual Meeting Abstract Contest and Awards
  • Meetings
    • NBT Innovation Weekend
    • SAGES Annual Meeting
      • 2024 Scientific Session Call For Abstracts
      • 2024 Emerging Technology Call For Abstracts
    • CME Claim Form
    • Industry
      • Advertising Opportunities
      • Exhibit Opportunities
      • Sponsorship Opportunities
    • Future Meetings
    • Past Meetings
      • SAGES 2022
      • SAGES 2021
    • Related Meetings Calendar
  • Join SAGES!
    • Membership Benefits
    • Membership Applications
      • Active Membership
      • Affiliate Membership
      • Associate Active Membership
      • Candidate Membership
      • International Membership
      • Medical Student Membership
    • Member News
      • Member Spotlight
      • Give the Gift of SAGES Membership
  • Patients
    • Healthy Sooner – Patient Information for Minimally Invasive Surgery
    • Patient Information Brochures
    • Choosing Wisely – An Initiative of the ABIM Foundation
    • All in the Recovery: Colorectal Cancer Alliance
    • Find a SAGES Member
  • Publications
    • SAGES Stories Podcast
    • SAGES Clinical / Practice / Training Guidelines, Statements, and Standards of Practice
    • Patient Information Brochures
    • TAVAC – Technology and Value Assessments
    • Surgical Endoscopy and Other Journal Information
    • SAGES Manuals
    • SCOPE – The SAGES Newsletter
    • COVID-19 Annoucements
    • Troubleshooting Guides
  • Education
    • OpiVoid.org
    • SAGES.TV Video Library
    • Safe Cholecystectomy Program
      • Safe Cholecystectomy Didactic Modules
    • Masters Program
      • SAGES Facebook Program Collaboratives
      • Acute Care Surgery
      • Bariatric
      • Biliary
      • Colorectal
      • Flexible Endoscopy (upper or lower)
      • Foregut
      • Hernia
      • Robotics
    • Educational Opportunities
    • HPB/Solid Organ Program
    • Courses for Residents
      • Advanced Courses
      • Basic Courses
    • Video Based Assessments (VBA)
    • Robotics Fellows Course
    • MIS Fellows Course
    • Facebook Livestreams
    • Free Webinars For Residents
    • SMART Enhanced Recovery Program
    • SAGES OR SAFETY Video
    • SAGES at Cine-Med
      • SAGES Top 21 MIS Procedures
      • SAGES Pearls
      • SAGES Flexible Endoscopy 101
      • SAGES Tips & Tricks of the Top 21
  • Opportunities
    • NEW-Area of Concentrated Training Seal (ACT)-Advanced Flexible Endoscopy
    • SAGES Fellowship Certification for Advanced GI MIS and Comprehensive Flexible Endoscopy
    • Multi-Society Foregut Fellowship Certification
    • SAGES Research Opportunities
    • Fundamentals of Laparoscopic Surgery
    • Fundamentals of Endoscopic Surgery
    • Fundamental Use of Surgical Energy
    • Job Board
    • SAGES Go Global: Global Affairs and Humanitarian Efforts
  • Search
    • Search All SAGES Content
    • Search SAGES Guidelines
    • Search the Video Library
    • Search the Image Library
    • Search the Abstracts Archive
  • Store
    • “Unofficial” Logo Products
  • Log In

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 days Average LOS(days)— Patients ≥ age 65
Component Separation 79.1% 85.8% 10.45±14.5
Diag Lap 64.2% 81.8% 8.8±9.9
Open Recurrent Ventral Hernia 58.2% 64.8% 6.2±9.4
Lap procedure of the esophagus 46.4% 61.8% 7.4±11.6
Open ventral hernia repair 34.5% 51.7% 5.2±8.8
Abdominoplasty 26.7% 55.7% 5.4±8.8
Lap incisional hernia repair 24.7% 31.0% 2.7±7.8
Lap recurrent ventral hernia repair 24.7% 32.4% 2.5±3.8
Lap cholecystectomy 24.0% 38.7% 3.3±6.5
Lap primary ventral hernia repair 17.9% 29.9% 2.6±6.9
Lap appendectomy 17.2% 40.2% 3.5±8.8
Simple mastectomy 16.0% 10.3% 1.6±6.4

Parotidectomy/Submandibular gland excision

11.2% 17.0% 1.9±3.7
Partial thyroidectomy 8.2% 5.8% 1.5±7.9
Total thyroidectomy 6.2% 8.4% 1.6±3.2
147

Share this:

  • Twitter
  • Facebook
  • LinkedIn
  • Pinterest
  • WhatsApp
  • Reddit

Related

« Return to SAGES 2015 abstract archive

Hours & Info

11300 West Olympic Blvd, Suite 600
Los Angeles, CA 90064
1-310-437-0544
sagesweb@sages.org
Monday - Friday
8am to 5pm Pacific Time

Find Us Around the Web!

  • Facebook
  • Twitter
  • YouTube

Important Links

SAGES 2023 Meeting Information

Healthy Sooner: Patient Information

SAGES Guidelines, Statements, & Standards of Practice

SAGES Manuals

 

  • taTME Study Info
  • Foundation
  • SAGES.TV
  • MyCME
  • Educational Activities

Copyright © 2023 Society of American Gastrointestinal and Endoscopic Surgeons