C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 412—PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES › Subpart A—General Provisions

42 C.F.R. § 412.3

Admissions

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(a) For purposes of payment under Medicare Part A, an individual is considered an inpatient of a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner in accordance with this section and §§ 482.24(c), 482.12(c), and 485.638(a)(4)(iii) of this chapter for a critical access hospital. In addition, inpatient rehabilitation facilities also must adhere to the admission requirements specified in § 412.622.

(b) The order must be furnished by a qualified and licensed practitioner who has admitting privileges at the hospital as permitted by State law, and who is knowledgeable about the patient's hospital course, medical plan of care, and current condition. The practitioner may not delegate the decision (order) to another individual who is not authorized by the State to admit patients, or has not been granted admitting privileges applicable to that patient by the hospital's medical staff.

(c) The physician order must be furnished at or before the time of the inpatient admission.

(d)(1) Except as specified in paragraphs (d)(2) and (3) of this section, an inpatient admission is generally appropriate for payment under Medicare Part A when the admitting physician expects the patient to require hospital care that crosses two midnights.

(i) The expectation of the physician should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event. The factors that lead to a particular clinical expectation must be documented in the medical record in order to be granted consideration.

(ii) If an unforeseen circumstance, such as a beneficiary's death or transfer, results in a shorter beneficiary stay than the physician's expectation of at least 2 midnights, the patient may be considered to be appropriately treated on an inpatient basis, and payment for an inpatient hospital stay may be made under Medicare Part A.

(2) An inpatient admission for a surgical procedure specified by Medicare as inpatient only under § 419.22(n) of this chapter is generally appropriate for payment under Medicare Part A regardless of the expected duration of care. Procedures no longer specified as inpatient only under § 419.22(n) of this chapter are appropriate for payment under Medicare Part A in accordance with paragraph (d)(1) or (3) of this section. Claims for services and procedures removed from the inpatient only list under § 419.22 of this chapter on or after January 1, 2021 are exempt from certain medical review activities until the Secretary determines that the service or procedure is more commonly performed in the outpatient setting than the inpatient setting.

(3) Where the admitting physician expects a patient to require hospital care for only a limited period of time that does not cross 2 midnights, an inpatient admission may be appropriate for payment under Medicare Part A based on the clinical judgment of the admitting physician and medical record support for that determination. The physician's decision should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event. In these cases, the factors that lead to the decision to admit the patient as an inpatient must be supported by the medical record in order to be granted consideration.

[78 FR 50965, Aug. 19, 2013, as amended at 79 FR 67030, Nov. 10, 2014; 80 FR 70602, Nov. 13, 2015; 83 FR 41700, Aug. 17, 2018; 85 FR 86300, Dec. 29, 2020; 86 FR 63992, Nov. 16, 2021; 90 FR 54082, Nov. 25, 2025]
Notes of Decisions
Cited in 15 cases (5 in the last 5 years), 2015–2025 · leading case: Barrows v. Becerra
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Barrows v. Becerra (2022) ca2 · cites it 3× “2008); see also 42 C.F.R. § 412.3 (a). 4 Medicare General Information, Eligibility, and Entitlement Manual, CMS Pub.”
Alexander v. Azar (2019) ctd · cites it 9× “42 C.F.R. § 412.3 (e)(1) (Oct. 1, 2013). The Rule required that a formal, written inpatient order be "present in the medical record" and "supported by the physician admission and progress notes.”
Shands Jacksonville Medical Center, Inc. v. Sebelius (2015) dcd · cites it 4× “19, 2013) (final rule), codified as amended at 42 C.F.R. § 412.3 (d)(1). *244 Plaintiffs in these consolidated actions challenge only one aspect of the final rule: the reduction in compensation for inpatient services.”
Jeffrey Bonkowski v. Oberg Industries Inc (2015) ca3 · cites it 2× “23, 2013) (quoting 42 C.F.R. § 412.3 (e)(1)). 45 for “[a] condition that would likely result in a period of incapacity of more than three consecutive, full calendar days in the absence of medical intervention or treatment, such as cancer (chemotherapy, radiation, etc), severe…”
Jane Winter v. Gardens Regional Hospital (2020) ca9 “” 42 C.F.R. § 412.3 (b). Inpatient admission “is generally appropriate for payment under Medicare Part A when the admitting physician expects the patient to require hospital care that crosses two midnights,” but inpatient admission can also be appropriate under other…”
Jesse Polansky v. Executive Health Resources Inc (2021) ca3 “§ 1395y(a)(1)(A), as explicated by CMS initially in guidance, and as of 2013, in a formal regulation, see 42 C.F.R. § 412.3 (d)(1). From at least 2006 until the filing of his amended complaint in 2019, he alleged, EHR’s certifica- tions were false and caused the submission of…”
United States ex rel. Polansky v. Executive Health Resources, Inc. (2016) paed “Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals .”
Shands Jacksonville Med. Ctr., Inc. v. Azar (2018) cadc “at 50,965, codified as amended at 42 C.F.R. § 412.3 (d)(1). As explained in its FY 2014 notice of proposed rulemaking, the Department's actuaries estimated that the 2-midnight policy would result in a net utilization shift of 40,000 "encounters" from outpatient to inpatient…”
United States of America ex rel Tali Arik, M.D. v. DVH Hospital Alliance, LLC, Inc. (2024) nvd · cites it 3× “”58 Medical necessity is a question of fact, and “[a] physician’s order or 2 certification will be evaluated in the context of the evidence in the medical record.”59 3 4. Rules for critical-access hospitals 4 In 1997, the Balanced Budget Act created the critical-access hospital…”
United States of America ex rel Tali Arik, M.D. v. DVH Hospital Alliance, LLC, Inc. (2020) nvd · cites it 2× “In his opposition, Arik asserts that DVH Hospital submitted fraudulent claims under 42 C.F.R. § 412.3 (d)(1), which states that inpatient 16 admission is appropriate for payment when the admitting physician expects a patient will need to remain for hospital care that “crosses…”
POLANSKY V. EXECUTIVE HEALTH RESOURCES INC. (2019) paed · cites it 2× “19, 2013) (codified as amended 42 C.F.R. § 412.3 (d)(1)). 8 The full Regulation reads: “[A]n inpatient admission is generally appropriate for payment under Medicare Part A when the admitting physician expects the patient to require hospital care that crosses two midnights.”
Shands Jacksonville Medical Center, Inc. v. Sebelius (2018) dcd “at 50,965, codified as amended at 42 C.F.R. § 412.3 (d)(1). As explained in its FY 2014 notice of proposed rulemaking, the Department’s actuaries estimated that the 2-midnight policy would result in a net utilization shift of 40,000 “encounters” from outpatient to inpatient…”
Show all 15 citing cases →
— 42 C.F.R. § 412.3(d)(1)(i) — 3 cases
United States of America ex rel Tali Arik, M.D. v. DVH Hospital Alliance, LLC, Inc. (2020) nvd “In his opposition, Arik asserts that DVH Hospital submitted fraudulent claims under 42 C.F.R. § 412.3 (d)(1), which states that inpatient 16 admission is appropriate for payment when the admitting physician expects a patient will need to remain for hospital care that “crosses…”
United States of America ex rel Tali Arik, M.D. v. DVH Hospital Alliance, LLC, Inc. (2021) nvd
United States of America ex rel Tali Arik, M.D. v. DVH Hospital Alliance, LLC, Inc. (2024) nvd “”58 Medical necessity is a question of fact, and “[a] physician’s order or 2 certification will be evaluated in the context of the evidence in the medical record.”59 3 4. Rules for critical-access hospitals 4 In 1997, the Balanced Budget Act created the critical-access hospital…”
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