Health Information Management

Tip: OPPS proposed rule includes changes for physician certification

APCs Insider, September 19, 2014

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CMS' 2015 OPPS proposed rule includes changes to requirements related to inpatient physician certification. While CMS will continue to require a physician order for all inpatient services, it will no longer require formal physician certification to indicate that the stay was medically necessary in most cases.
CMS believes that for most inpatient admissions, the admission order, medical record, and progress notes contain sufficient information to support the medical necessity of an inpatient admission without a separate requirement of an additional, formal physician certification. There are two exceptions: stays of 20 days or longer and outlier cases.
In these cases, CMS believes physician certification is needed and therefore proposes to require formal physician certification beyond the admission order to substantiate the medical necessity for these cases. If the physician certification is not signed before the patient leaves the hospital, CMS does not reimburse for any of the inpatient services. These changes should significantly reduce administrative burden for hospitals, and CMS has requested feedback on the proposal.
This tip is adapted from “CMS reintroduces Comprehensive APCs along with complexity adjustments” in the September issue of Briefings on APCs.

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