The Two Midnight Rule and Medical Necessity in the Hospital Setting – Post Test

Quiz Summary

0 of 10 Questions completed

Questions:

You have already completed the quiz before. Hence you can not start it again.

Quiz is loading…

You must sign in or sign up to start the quiz.

You must first complete the following:

Results

Quiz complete. Results are being recorded.

Results

0 of 10 Questions answered correctly

You have reached 0 of 0 point(s), (0)

Current
Review
Answered
Correct
Incorrect

Question 1 of 10

1. Question
1. A surgical procedure is on the “Inpatient Only” list and after the procedure, the physician states she disagrees with that determination because the procedure was “not that hard”. The best course of action would be 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
- d. Complete the process as recommended and contact the RHP CMO for additional clarification later
Question 2 of 10

2. Question
2. With respect to NON-inpatient only procedures and the inpatient-only list (choose ALL that are appropriate):
- a. These procedures may be billed as inpatient if comorbid conditions or extenuating circumstances are documented to add intensity of care and complexity to the case
- b. Inpatient only procedures have length of stays > 5 days to make the list
- c. The total knee arthroplasty is not in the inpatient only list
- d. The total hip is still on the inpatient only list for 2020, but will not be in 2021
Question 3 of 10

3. Question
3. 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. 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 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
Question 4 of 10

4. Question
4. Correct statements for the “Two Midnight Rule” include:
- a. It is mandated by CMS that this “rule” be followed
- b. Two Midnights of active clinical management are needed to be documented to show the medical necessity of the condition and “inpatient” care needed
- c. Weekends and holidays are not counted
- d. There are no exclusions for the “Two Midnight Rule”
Question 5 of 10

5. Question
5. On day two of a hospital stay where the patient was admitted as inpatient, what would help secure this on day two?
- a. Occasional PACs on overnight monitor
- b. Noting an increased work of breathing on ambulation to the toilet (no accessory muscle use and RR 13) and RA saturation 96%
- c. Continued shortness of breath (sat 95% off supplemental O2) at rest. RR12
- d. Shortness of breath on ambulation with O2 saturation 88% in a patient not on home O2
Question 6 of 10

6. Question
6. Which of the following COPD scenarios would most likely merit INPATIENT hospitalization from initial presentation?
- 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. 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
Question 7 of 10

7. Question
7. A 82 year old with HFrEF (31%) presents with a 2 day history of weight gain, DOE, LE edema of +3, and a RA saturation of 92% (baseline is 95%). His labs are stable with K+ 4.2, Hgb 9.9, and a Cr of 1.4 (baseline 0.9). CXR shows increased lung markings and a slight effusion. You order inpatient, but the Physician Advisor has requested a reconsideration for placement in Observation. What are some clinical indicators on day TWO that would confirm a need for continued care beyond two midnights and merit an inpatient admission? Choose ALL that are correct:
- a. The saturation drops to 88% and the 2 liters of oxygen is titrated to 3 liters with a sat of 93%
- b. The renal numbers increase on day two and you document a concern that further diuresis is needed and as such, the renal status may worsen
- c. When removing the oxygen (2 liters), the saturation drops to 85% on ambulation to the bathroom, requiring a re-institution of oxygen therapy to maintain baseline saturations
- d. The Hgb drops to 9.2. All other conditions are improving
Question 8 of 10

8. Question
8. A 68 year old DM patient with ASCVD and HFrEF (40% EF), presents with Acute HF exacerbation. The patient, on day two has a Cr of 1.15, down from 1.16 (baseline 1.13). There are still crackles in the bases but weight is down 11 pounds and O₂ sats are better overall at 96% off of supplemental oxygen. On ambulation, sats remain > 95% on RA. He was admitted as inpatient by your colleague yesterday. You decide the patient is stable to go home. You feel…
- a. Inpatient care is appropriate because of the O2 sat and crackles
- b. The patient can be discharged to home, but the inpatient order cannot be changed
- c. Observation is appropriate, so a new order needs to be written and case management notified before discharge
- d. Inpatient care is appropriate because of the Cr is still above baseline
Question 9 of 10

9. Question
9. Documentation to show an inpatient medical necessity for a stroke includes which of the following (choose all that pertain)?
- a. A new ischemic infarct on a CT scan associated with persisted left upper extremity weakness on the morning of day 3 of the hospital stay
- b. A subacute infarct noted on CT scan associated with neurologic deficits that persist on the morning of hospital day three
- c. A subacute infarct noted on CT scan associated with mental status changes and persistent mild cognitive deficits noted on the morning of hospital day three
- d. A subacute infarct noted on CT scan associated with resolution of right upper extremity weakness that was noted on presentation by the end of the second hospital day
Question 10 of 10

10. Question
10. National Institutes of Health Stroke Scale (NIHSS) is one tool to use to help determine whether a patient deems to meet medical necessity for inpatient level of care. Which score below is indicative of such consideration from the 15 elements in the tool? (choose the most correct answer)
- a. 4
- b. 1
- c. 2 or more
- d. 0

The Two Midnight Rule and Medical Necessity in the Hospital Setting – Post Test

Quiz Summary

Information

Results

Results

Categories

1. Question

2. Question

3. Question

4. Question

5. Question

6. Question

7. Question

8. Question

9. Question

10. Question