Corporate Compliance

Note from the instructor: CMS issues guidance on hospital inpatient admission order and certification requirements, Part I: Physician certification

Medicare Insider, October 15, 2013

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This week’s note from the instructor is written by Judith Kares, JD, regulatory specialist for HCPro.

As part of its efforts to clarify issues surrounding hospital inpatient admission criteria, CMS provided additional guidance on inpatient order and certification requirements. These requirements generally apply to all inpatient hospitals and critical access hospitals (CAH). As a condition of payment under Medicare Part A, relevant law requires physician certification as to the medical necessity of inpatient hospital services. In doing so, the physician is not only certifying that the services are medically necessary to treat the patient’s condition, but that it is medically necessary to provide these services in the inpatient hospital setting.

On September 5, CMS issued sub-regulatory guidelines establishing key requirements for the initial physician admission order and certification for each stay, as well as the requirements for additional certification and recertification for outlier cases. In this week’s note, we will focus on the rules related to physician certification. In next week’s note, we will examine the rules for physician orders. For more in-depth information on both topics, hospitals and CAHs should review the underlying regulations, which can be found at 42 CFR Part 424, Subpart B and 42 CFR 412.3.


Physician Certification

Content and format

Physician certification begins with the admission order, and must contain the following components:

  1. Authentication of the practitioner order, stating the practitioner ordered inpatient services in accordance with Medicare regulations, including the medical necessity of inpatient care and compliance with the 2-midnight benchmark. This requirement may be met by the signature or countersignature of the inpatient admission order by the certifying physician.
  2. Reason for inpatient services, including the patient’s need for:
    1. Inpatient medical treatment or medically-required inpatient diagnostic study; or
    2. Special or unusual services qualifying for cost outlier payment under the inpatient prospective payment system (IPPS). This requirement may be met by the diagnosis and plan documented in the inpatient admission assessment or by the inpatient admitting diagnosis and orders.
  3. The estimated time the beneficiary requires or required in the hospital. This requirement may be met by the inpatient admission order written in accordance with the 2-midnight benchmark, supplemented by the physician notes and discharge planning instructions.
  4. The plans for post-hospital care, if appropriate. This requirement may be met by physician notes or by discharge planning instructions.
  5. That provider reasonably expects the beneficiary to be discharged or transferred to a hospital within 96 hours after admission to the CAH. This requirement may be met by physician notes or by actual discharge within 96 hours.

Currently, no specific procedures or forms are required. The certification may be entered on various forms, notes, or records (with appropriate signatures) included in the medical record, or on a special form, so long as there is a separate signed statement for each certification. In the absence of specific certification forms, the medical record elements identified above may be sufficient to meet the initial inpatient certification requirements for each component.


As noted previously, the certification begins with the inpatient admission order and must be completed, signed, dated, and documented in the medical record prior to discharge, with two exceptions:

  • Outlier cases must be certified and recertified in accordance with relevant regulations (42 CFR 424.13); and
  • Inpatient CAH services must be certified no later than one day prior to the date on which the claim for payment is submitted.

Authorization to sign the certification

The certification or recertification may be signed only by one of the following:

  • A physician who is a doctor of medicine or osteopathy
  • A dentist, in limited circumstances set out in related regulations (42 CFR 424.13(d))
  • A doctor of podiatric medicine if his or her certification is consistent with the functions he or she is authorized to perform under state law

In any event, certifications and recertifications must be signed by the physician responsible for the case, or by another physician who has knowledge of the case and is authorized to do so by the responsible physician or the hospital’s medical staff. CMS considers only the following practitioners to have sufficient knowledge of the case to serve as the certifying physician:

  • The admitting physician of record (“attending”) or a physician on call for him or her
  • A surgeon responsible for a major surgical procedure on the beneficiary or a surgeon on call for the beneficiary
  • A dentist functioning as the admitting physician of record or as the surgeon responsible for a major dental procedure
  • In the specific case of a non-physician, non-dentist admitting practitioner who is licensed by the state and has been granted privileges by the facility, a physician member of the hospital staff who reviewed the case and who enters into the record a complete certification statement that contains all of the content elements discussed above


Implementation Challenges

The rules related to authority to sign are fairly straight forward. With respect to timing and content, the initial certification generally does not have to be completed until discharge. The first, second, third, and fifth components mentioned above contain key information that is instrumental in making the admission decision. The timing and content of the initial documentation are important. The more contemporaneous and complete that documentation, the better, particularly with respect to the application of the 2-midnight benchmark. The most ambiguous aspects of these requirements are those related to content and format, although the default documentation suggestions are helpful. The second and third components appear to be the most important substantively, and are likely to come under scrutiny by review contractors.

Hospitals and CAHs are encouraged to form a task force key personnel (e.g., utilization review, case management, compliance, medical records, training) and a the medical staff representative to review these certification and order requirements. The task force should review current medical records to determine what existing elements can be used to initially meet these requirements. For the future, it would be more efficient to create a single certification document or to reconfigure the existing medical record format to meet the certification requirements. The latter would be preferable, since it would avoid duplication of efforts, while assuring compliance with billing requirements.

Work with the medical staff into consideration to decide how to proceed, and then create applicable policies and procedures. Communicate this information to all relevant hospital personnel and medical staff. Be as explicit as possible about what you need from physicians. Making things easier for physicians will be to everyone’s advantage. Good luck!

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