STEP 2– Did the Patient Need Hospital Care
STEP 3– Did the provider render a medically necessary service on the Inpatient Only List?
No
Yes
Claim isNOTPayable Under Part A
STEP 4*-Was it reasonable for the admitting physician to expect the patient to require medically necessary hospital services, or did the patient receive medically necessary hospital services, for 2 Midnights or longer, including all out-patient/observation and inpatient care time?
No
Claimis Payable Under Part A(Assumingall other requirements are met)
STEP 5–Does the claim fit within one of the "rare and unusual" exceptions identified by CMS(Currently Mechanical Ventilation)?
Yes
STEP 6 - for claims with a Date of Admission on or after January 1, 2016Does the medical record support the admitting physician's determination that the patient required inpatient care despite not meeting the two midnight benchmark, based on complex medical factors such as:Patient history and comorbidities and current medical needsSeverity of signs and symptomsRisk of an adverse event
Yes
No
Claim is Payable Under Part A(Assuming all other requirements are met)
Claim isNOTPayable Under Part A
Yes
No
Revised May 3, 2016 1:47pm
* NOTE – If any of the following “Unforeseen Circumstances”resulted in a shorterstaythe stay is payable Under Part ADeathTransferDepartures against medical adviceClinical improvementElection of hospice
STEP 1–Didthe inpatient stay from the point of a validinpatient admissionorder to discharge last “2Midnights,”
Yes
No
Yes
No
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