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Over the years I have heard many say that they would like to be able to attend their own funeral, so for the last update of the year, I thought I would give a eulogy for the admission certification requirement – even though its death is not scheduled to take place until 11:59 p.m. on Dec. 31. 

Oh admission certification, how we shall miss you. We never really understood you – were you the phrase “I expect two midnights” or the nebulous concept of medical necessity for hospital care? You were so loved by the auditors because you represented a simple way for them to deny an admission, but you were reviled by the many IT people in hospitals who were commanded to make immediate changes to their electronic health record (EHR) systems. They even came up with a nickname for you: “hard stop.”

You were so worshipped by some that the Centers for Medicare & Medicaid Services (CMS) scheduled one open door forum to celebrate you, but due to an overwhelming response, it had to add more forums to share your virtues. Alas, your uniqueness made it difficult for the agency to respond to questions about those very virtues, resulting in long, silent pauses and references to a mysterious time and place called “send that question to our email address and we’ll get back to you later.” 

There were Internet battles over you – some wanted to protect your purity and immortalize you in writing, insisting on a certification form in the record. They faced rebellion by their physicians, who were already frustrated with your cousin, meaningful use, and were dreading the visit on Oct. 1, 2015 from your aunt, ICD-10. Yet others wanted to protect your integrity by placing you where you were meant to be, within the history and physical and progress notes. This faction trusted their physicians to defend your honor with thorough documentation and clinically useful notes, undeterred by the ever-present allure of copying-and-pasting, check boxes, and documentation templates.

But all is not lost, for your memory will live on. While your creator has turned its back on you and allowed you to perish, CMS is still requiring that every inpatient admission contain all of your amazing attributes: an admission order from a physician with admitting privileges (authenticated prior to discharge), an explanation within the medical record of why inpatient admission is required based on the severity of the patient’s illness (and the expected course of that illness), and, of course, an indication of the plans for the patient after discharge. Your short life will be commemorated on the 20th day of every admission, when the physician must unambiguously state in his or her notes why the patient still requires hospital care (and, in the words of your creator, the 2014 IPPS Final Rule, whom you affectionately called “1599-F,” denoting why the patient “cannot be safely be treated through intermittent outpatient visits or some other care.”) We will be calling it an outlier certification, but we will always remember these 465 days when you, inpatient admission certification, were with us.

Rest well, admission certification. And know that on New Year’s Eve, at the strike of midnight, we will all be raising our champagne glasses and toasting to your demise.  

About the Author

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the American Case Management Association and a Fellow of the American College of Physicians.

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