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CMS Issues Guidance on Physician Certification and Order

CMS Issues Guidance on Physician Certification and Order
The Centers for Medicare & Medicaid Services (CMS) has released sub-regulatory guidance entitled Hospital Inpatient Admission Order and Certification to help hospitals interpret the agency’s requirements for inpatient admission orders and certifications from the Hospital Inpatient Prospective Payment System Final Rule for FY 2014 (the “Final Rule“). After the Final Rule was issued on August 2, 2013, significant confusion surrounded CMS’s requirements for inpatient admission orders and physician certifications of inpatient services. This sub-regulatory guidance, developed by CMS and released on September 5, 2013, details the specific requirements for hospital inpatient coverage and payment under Medicare Part A.

Physician Certification

First, CMS addressed the content that must be included in the physician certification. The physician must verify that the inpatient services were ordered in accordance with Medicare regulations governing the inpatient order. This includes certification that the inpatient services are reasonable and necessary, and in the case of services or procedures not specified as inpatient-only, that they are provided in accordance with the 2-midnight benchmark. Furthermore, physicians must provide justification for inpatient services, an estimated duration of a beneficiary’s stay, and plans for post-hospitalization care.

Second, CMS addressed the proper timing of the certification, stating that the inpatient admission begins with certification, which (with some exceptions) must be completed, signed, dated, and documented in the medical record prior to discharge.

Third, the guidance identifies who is authorized to sign the certification. The certification may be signed by a “physician who is a doctor of medicine or osteopathy…” The signing physician must be responsible for the case, or have knowledge of the case and be authorized to do so by the responsible physician or the hospital’s medical staff. Non-physicians may sign the certification, but will need a physician to co-sign.

Fourth, CMS addressed proper format, stating that there must be separate, signed statements for each certification and recertification. In lieu of a specific form that the hospital uses for certification, CMS also detailed the “Default Methodology for Initial Certification,” which describes what Medicare contractors will look for, in the absence of specific forms or statements, for certification in order to meet the initial inpatient certification requirements:

1. The signature of the inpatient admission order by the certifying physician will satisfy the authentication requirement for the practitioner order.
2. The diagnosis and plan of care in the inpatient admission assessment will satisfy the requirement to certify the reason that hospital inpatient services are medically required.
3. The inpatient admitting written in accordance with the 2-midnight benchmark will satisfy the estimated time requirement.
4. The physician notes or discharge planning instructions will satisfy the post hospital care plan requirement.

Practitioner Order

First, CMS addressed the content that must be included in the physician order. It must include the instruction that the beneficiary should be formally admitted for hospital inpatient care.

Second, CMS detailed the qualifications that the ordering or admitting practitioner must have to properly admit a patient to inpatient care. The ordering practitioner must be: (a) licensed by the state to admit inpatients to hospitals, (b) granted privileges from the hospital to admit inpatients, and (c) knowledgeable about the patient’s hospital course, plan of care, and current condition at the time of admission. The ordering practitioner does not have to be the same physician who signs the certification, and the order does not have to be co-signed by a physician unless the order was signed by a resident.

If a verbal order is made, the verbal inpatient admission order may be initially documented in the medical record by the staff receiving the order as provided above, including identification of the ordering practitioner. Verbal orders must be authenticated by the practitioner (or by another practitioner with the required admitting qualifications) in the medical record prior to discharge.

Third, CMS stated that the ordering practitioner must have knowledge of the patient. Fourth, CMS requires that the order must be in the record at or before the time of admission. Fifth and finally, CMS provides that the order for inpatient admission must specifically state that the order is for “inpatient” services,” or admit “to inpatient,” or “as an inpatient.” If the word “inpatient” is not mentioned, the admission may remain consistent with Medicare regulations provided that the intent to admit as an inpatient is clear.

For Critical Access Hospitals (CAHs), physicians must certify that the beneficiary may reasonably be anticipated to be discharged or transferred to a hospital within 96 hours after admission to the CAH. The CAH certification must be completed no later than one day before the date on the claim for payment is submitted. In the absence of a certification form, the CAH 96 hour expectation requirement will be met by physician notes or actual discharge within 96 hours.

Wachler & Associates will continue to monitor any further developments and guidance related to the Final Rule as the implementation date of October 1, 2013 is quickly approaching. If you or your health care entity need help developing compliance plans or reviewing and refining existing audit defense strategies in light of the Final Rule or this sub-regulatory guidance, please contact an experienced healthcare attorney at 248-544-0888.