In the 2014 Inpatient Prospective Payment System (IPPS) Proposed Rule, the Centers for Medicare & Medicaid Services (CMS) proposed changes to the Code of Federal Regulations that were widely interpreted by the provider community to indicate that physicians would be required to complete a certification form for each inpatient admission. The final rule seemed to address those fears in several places, stating “we note that the particular elements of the certification, for example, the order for inpatient services and documentation of the reason for continued hospitalization (diagnosis) should be documented within the medical record. Therefore, we are not finalizing any new documentation requirements.”
“The existing provisions in § 424.11 continue to apply, for example paragraphs (b) and (c), which provide that no specific procedures or forms are required for certification and recertification statements,” that passage continues. “The provider may adopt any method that permits verification. The certification and recertification statements may be entered on forms, notes, or records that the appropriate individual signs, or on a special separate form.”
Unfortunately, these statements were not viewed as particularly compelling, and the RAC and case management discussion groups went crazy with speculation. Hospitals posted their proposed forms for critique, suggested changes to computerized physician order entry (CPOE) admission order templates were discussed, and several posters discussed early retirement as the best solution.
To try to clarify, CMS released a memo on Sept. 5 offering a breakdown of the various elements of the certification. Let’s go ahead and break things down a bit ourselves. Here is the relevant section of the Code of Federal Regulations:
§ 424.13 Requirements for inpatient services of hospitals other than inpatient psychiatric facilities.
(a) Content of certification and recertification. Certification begins with the order for inpatient admission. Medicare Part A pays for inpatient hospital services (other than inpatient psychiatric facility services) only if a physician certifies and recertifies the following:
(1) That the services were provided in accordance with § 412.3 of this chapter (which specifies admission order requirements).
(2) The reasons for either—
(i) Hospitalization of the patient for inpatient medical treatment or medically required inpatient diagnostic study; or
(ii) Special or unusual services for cost outlier cases (under the prospective payment system set forth in subpart F of Part 412 of this chapter).
(3) The estimated time the patient will need to remain in the hospital.
(4) The plans for post-hospital care, if appropriate.
So, starting with the admission order, it is clear and accepted by all that the rule requires that the order must come from a physician with admitting privileges who is licensed by the relevant state and is familiar with the patient. This order can be transcribed by others (such as nurses, ED doctors, nurse practitioners, physician assistants, residents, fellows, and medical students), but it must be authenticated prior to discharge, and preferably promptly. The rule even indicates that an admit order (such as “admit to inpatient, per Dr. Smith)” is acceptable and there is no requirement of a written indication that the order was given as a telephone order (such as “t.o., Dr. Smith)..” But to be clear, an order transcribed by anyone other than the admitting physician only should be used, in the language of the rule, “following discussion with and at the direction of the ordering practitioner.”
Wording of the order was another concern. The final rule reads, “therefore, we are providing that, for payment of hospital inpatient services under Medicare Part A, the order must specify the admitting practitioner’s recommendation to admit ‘to inpatient,’ ‘as an inpatient,’ ‘for inpatient services,’ or similar language specifying his or her recommendation for inpatient care.”
Many read this to suggest that if the words “admit” and “inpatient” are not present, the admission order is invalid and the hospital is be noncompliant if it billed the stay as an inpatient visit. But in its memo, CMS clarified that the word “admit” alone would be acceptable if the intent for inpatient status was clear in the medical record. Of course, they complicated things by referring to “inpatient units” (“admit to 7W” or “admit to ICU,” for example). The reality is that in most if not all hospitals, there is no designation of units as “inpatient” or “outpatient.” In addition, CMS made it clear in the final rule that location is not a determining factor for level of care, and that patients in the ICU can be in outpatient status. Nonetheless, the agency has made it clear that both words are not required for a hospital to submit an inpatient claim.
Next is the issue of reason for hospitalization. The memo specifies that this requirement will be met by the diagnosis and plan as indicated in the admission assessment (aka H&P), so as long as the H&P is authenticated prior to discharge, this requirement is met.
Then comes the point that has hospitals the most flustered: the requirement for the physician to estimate the time the patient will need to remain in the hospital. As we all know, the final rule imposes the so-called two-midnight rule, which indicates that patients who require two medically necessary midnights in the hospital should be admitted as inpatients. Given this, many thought that physicians now would have to document that a patient required care spanning greater than two midnights in the hospital. Some proposed adding a statement reading “I certify this patient requires an estimated (x) days of care,” or “I certify that this patient requires greater than two midnights of care.” Others proposed requiring the physician to choose from a range of days, such as “2-3 days,” “3-5 days,” or “ 5 or more days.” Once again, CMS tried to clarify this by indicating that “the estimated time requirement will be met by the inpatient admission order written in accordance with the two‐midnight benchmark, supplemented by the physician notes and discharge planning instructions.”
So, what does this mean? This writer interpreted it to mean that if the doctor writes a compliant admission order based on the two-midnight rule, the admission order itself serves as the certification that the stay will exceed two midnights and nothing else is required – as long as the documentation in the H&P and progress notes supports the reasonableness of that expectation. And sure enough, in private correspondence with CMS, my viewpoint was confirmed. A CMS official confirmed that “if the doctor writes an inpatient order (reading) ‘admit as inpatient’ for a patient that has the expectation of a greater-than-two-midnight stay and the notes describe the illness and treatment plan, they have satisfied the requirement to certify the estimated time the beneficiary requires or required in the hospital.”
The last requirement of certification, plans for post-hospital care, is fulfilled on every single patient that is ever seen in a hospital. No doctor ever discharges a patient without indicating the follow-up plans, such as “see me in office in two weeks” or “send to SNF this PM.” And as long as that is contained in a signed order or progress note, the requirement is met.
So, in essence, this is much ado about nothing. Get an authenticated admission order from a doctor who has admitting privileges, get a signed H&P, and get a discharge plan, and you have met the requirements for certification.
It is also worth noting that the requirement for certification is not new; the CFR has always required that outlier stays be certified with documentation of the reason for hospitalization, the estimated length of stay, and the post-discharge plans. Yet despite this requirement being on the books for many years, no hospital makes physicians complete a certification form for outlier stays, nor has any hospital ever been denied an outlier payment because of lack of documentation of the elements of the certification. On the other hand, there have been and will continue to be audits of outlier stays for medical necessity.
But why all the fuss? The real story is the clause that CMS added to the Code of Federal Regulations to codify a stance that it has had since the initiation of the RAC program. Section 412.46(b) was added and reads, “physician’s order and certification regarding medical necessity. No presumptive weight shall be assigned to the physician’s order under § 412.3 or the physician’s certification under Subpart B of Part 424 of the chapter in determining the medical necessity of inpatient hospital services under section 1862(a)(1) of the Act. A physician’s order or certification will be evaluated in the context of the evidence in the medical record.”
This was in response to the many often successful appeals taken before administrative law judges, through which hospitals argued that a physician ordered inpatient status, therefore inpatient status should be upheld. It is now incumbent upon the doctor and the hospital to be certain that the documentation in the medical record clearly supports the medical necessity for the inpatient admission to the hospital and explains why the care only could be provided safely in the hospital, rather than in the home or in the office, “where they may be safely treated through intermittent outpatient visits or some other care.”
So there you have it. While we all were needlessly worried about certifying admissions properly, CMS pulled a quarterback sneak and took away physician’s presumptive rights to admit patients to the hospital for inpatient care. It serves us right for taking our eyes off the ball.
About the Author
Ronald Hirsch, M.D. serves as vice president of physician advisory services (AccretivePAS®) in the Regulation and Education Group (“the REG Specialists”). Prior to his employment at Accretive Health, Dr. Hirsch, a board certified internist and HIV specialist, practiced and served as president at a multispecialty practice in Illinois, and medical director of case management at Sherman Hospital in Elgin, Ill.
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