Q&A: Criteria for case-by-case admission

Q: What is Medicare's criteria for case-by-case approval of an inpatient stay when the patient is not expected to meet the 2-midnight benchmark?

A: Inpatient admission may be appropriate on a case-by-case basis when the admitting physician expects less than a 2-midnight stay, but nevertheless determines that admission is appropriate based on their clinical judgment supported by the medical documentation. This provision expands and codifies the
subregulatory exception for “rare and unusual” circumstances that justify admission even if the physician does not expect a 2-midnight stay. The “rare and unusual” exception currently only includes newly initiated mechanical ventilation. CMS stated they believe that other similar circumstances exist but have not been specifically identified by providers. This admission option allows providers to identify, on a case-by-case basis, circumstances justifying inpatient admission that may be similar to CMS’ “rare and unusual” exception. If one of these cases is audited, CMS has indicated that the decision to admit the patient on a case-by-case basis is subject to the clinical judgment of the medical reviewer.

For more information, see the Patient Status Training Toolkit for Medicare Utilization Review, Second Edition.