Rules, Rules, Rules

How is your facility going to get this right? Today as healthcare providers, clinical staff and coders we are up against many challenges. With ICD-10-CM/PCS implementation just less than a year away there is urgency to get ready now to avoid lost reimbursement later. 5010 Testing is still continuing for many facilities and payers. Statistics show some are still operating on the 4010. The vendors on 4010 can’t accommodate an ICD-10 data field, which equates to “no payer can accept it.” Time is ticking, how is your facility doing in the timeline of readiness?

If that isn’t enough then we have the final rule release for IPPS. Two-midnights to be specific. This final rule emphasizes the need for a formal order of inpatient admission to begin inpatient status, but permits the ordering practitioner to consider all time a patient has already spent in the hospital as an outpatient receiving observation services, or care in the emergency department, operating room, or other treatment area in guiding their two-midnight expectations. Getting documentation that will support the coding of such services has already been a challenge with implementation of Electronic Health Records not to mention omission of nursing documentation for infusion start and stop times for patient treatments. This continues to be a huge revenue leak for many hospitals as CentraMed has mentioned in previous articles. For 2014 Injection and Infusion services will likely see a decline in reimbursement due to CMS packaging more services in the future.

Now back to the Hospital Inpatient Admission Order and Certification regulation. On September 5, 2013 the following information was released by CMS for clarification of requirements. The following is verbatim from CMS and can be located at:

As a condition of payment for hospital inpatient services under Medicare Part A, section 1814(a) of the Social Security Act requires physician certification of the medical necessity that such services be provided on an inpatient basis. The order to admit as an inpatient (“practitioner order”) is a critical element of the physician certification, and is therefore also required for hospital inpatient coverage and payment under Part A. The physician certification, which includes the practitioner order, is considered along with other documentation in the medical record as evidence that hospital inpatient service(s) were reasonable and necessary. The following guidance applies to all inpatient hospital and critical access hospital (CAH) services unless otherwise specified. The complete requirements for the physician certification are found in 42 CFR Part 424 subpart B and 42 CFR 412.3.

Physician Certification of inpatient services of hospitals other than inpatient psychiatric facilities:

1. Content: The physician certification includes the following information:
a. Authentication of the practitioner order: The physician certifies that the inpatient services were ordered in accordance with the Medicare regulations governing the order. This includes certification that hospital inpatient services are reasonable and necessary and in the case of services not specified as inpatient‐only under 42 CFR 419.22(n), that they are appropriately provided as inpatient services in accordance with the 2‐midnight benchmark under 42 CFR 412.3(e).
b. Reason for inpatient services: 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 inpatient prospective payment system (IPPS);
c. The estimated time the beneficiary requires or required in the hospital.
d. The plans for posthospital care, if appropriate, and as provided in 42 CFR 424.13.
e. CAHs: For inpatient CAH services, the physician must certify that the beneficiary may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH.

2. Timing: Certification begins with the order for inpatient admission. The certification must be completed, signed, dated and documented in the medical record prior to discharge, except for outlier cases which must be certified and recertified as provided in 42 CFR 424.13, and certification of CAH inpatient services which is required no later than 1 day prior to the date on which the claim for payment for the inpatient CAH services is submitted (§ 424.15).

3. Authorization to sign the certification: The certification or recertification may be signed only by one of the following:
(1) A physician who is a doctor of medicine or osteopathy.
(2) A dentist in the circumstances specified in 42 CFR 424.13(d).
(3) 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.

Certifications and recertification’s must be signed by the physician responsible for the case, or by another physician who has knowledge of the case and who is authorized to do so by the responsible physician or by the hospital’s medical staff (or by the dentist as provided in 42 CFR 424.11). Medicare considers only the following physicians, podiatrists or dentists 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 him or her; a dentist functioning as the admitting physician of record or as the surgeon responsible for a major dental procedure; and, 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 (such as a physician member of the utilization review committee) who has reviewed the case and who also enters into the record a complete certification statement that specifically contains all of the content elements discussed above.

4. Format: As specified in 42 CFR 424.11, no specific procedures or forms are required for certification and recertification statements. 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. Except as provided for delayed certifications, there must be a separate signed statement for each certification or recertification.

5. Default Methodology for Initial Certification: In the absence of specific certification forms or certification statements, CMS and its contractors will look for the following medical record elements in order to meet the initial inpatient certification requirements.
a. The authentication requirement for the practitioner order will be met by the signature or countersignature of the inpatient admission order by the certifying physician.
b. The requirement to certify the reasons that hospital inpatient services are or were medically required will be met either by the diagnosis and plan documented in the inpatient admission assessment or by the inpatient admitting diagnosis and orders.
c. The estimated time requirement will be met by the inpatient admission order written in accordance with the 2‐midnight benchmark, supplemented by the physician notes and discharge planning instructions.
d. The post hospital care plan requirement will be met either by physician notes or by discharge planning instructions.
e. The CAH 96 hour expectation requirement will be met either by physician notes or by actual discharge within 96 hours.

Practitioner Order: A Medicare beneficiary is considered an inpatient of a hospital, including a CAH, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner

1. Content: The practitioner order contains the instruction that the beneficiary should be formally admitted for hospital inpatient care. The order must specify admission for inpatient services. Inpatient rehabilitation facilities (IRFs) also must adhere to the admission requirements specified in 42 CFR 412.622, and the 2‐midnight benchmark does not apply in IRFs.

2. Qualifications of the ordering/admitting practitioner: The order must be furnished by a physician or other practitioner (“ordering practitioner”) who is: (a) licensed by the State to admit inpatients to hospitals, (b) granted privileges by the hospital to admit inpatients to that specific facility, and (c) knowledgeable about the patient’s hospital course, medical plan of care, and current condition at the time of admission. The ordering practitioner makes the determination of medical necessity for inpatient care and renders the admission decision. The ordering practitioner may be, but is not required to be, the physician who signs the certification.

At some hospitals, practitioners who lack the authority to admit inpatients under either State laws or hospital by‐laws may nonetheless frequently write the sets of admitting orders that define the initial inpatient care of the patient. In these cases, the ordering practitioner need not separately record the order to admit. Following discussion with and at the direction of the ordering practitioner, the order (including a verbal order) may be documented by an individual who does not possess these qualifications (such as a physician assistant, resident, or registered nurse), as long as that documentation (transcription) of the order is in accordance with State law including scope‐of‐practice laws, hospital policies, and medical staff bylaws, rules, and regulations. In this case, the order must identify the qualified “ordering practitioner”, and must be authenticated by the ordering practitioner (or by another practitioner with the required admitting qualifications) prior to discharge. A transcribed and authenticated order also satisfies the order part of the physician certification as long as the ordering practitioner also meets the requirements for a certifying physician.
Example: “Admit to inpatient v.o. (or t.o.) Dr. Smith” and “Admit to inpatient per Dr. Smith” would be considered acceptable methods of identifying the ordering practitioner and would meet the order requirement if they are appropriately authenticated by Dr. Smith. This method is also acceptable for residents and students who are not licensed or do not have privileges to admit inpatients, and may be used by all residents and fellows working within their GME program. If Dr. Smith meets the qualifications for a certifying physician, then the authentication of this order by Dr. Smith also meets the requirement for the order component of the certification.
Verbal orders: In accordance with 42 CFR 482.24(c), the inpatient order to admit may also be directly communicated to staff as a verbal (not standing) order. A 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. A verbal or telephone inpatient admission order must be authenticated (signed, dated and timed) by the ordering practitioner (or by another practitioner with the required admitting qualifications in his or her own right) in the medical record prior to discharge, unless the hospital or the State requires an earlier timeframe. An authenticated verbal order also satisfies the order part of the physician certification as long as the ordering practitioner also meets the requirements for a certifying physician.

3. Knowledge of the patient: Medicare considers only the following practitioners to have sufficient knowledge about the beneficiary’s hospital course, medical plan of care, and current condition to serve as the ordering practitioner: the admitting physician of record (“attending”) or a physician on call for him or her, primary or covering hospitalists caring for the patient in the hospital, the beneficiary’s primary care practitioner or a physician on call for the primary care practitioner, a surgeon responsible for a major surgical procedure on the beneficiary or a surgeon on call for him or her, emergency or clinic practitioners caring for the beneficiary at the point of inpatient admission, and other practitioners qualified to admit inpatients and actively treating the beneficiary at the point of the inpatient admission decision. Although a utilization review committee physician may sign the certification on behalf of a non‐physician admitting practitioner, a practitioner functioning in that role does not have direct responsibility for the care of the patient and is therefore not considered to be sufficiently knowledgeable to order the inpatient admission. The order must be written by one of the above practitioners directly involved with the care of the beneficiary, and a utilization committee physician may only write the order to admit if he or she also fulfills one of the direct patient care roles, such as the admitting physician of record.

4. Timing: The order must be furnished at or before the time of the inpatient admission. The order can be written in advance of the formal admission (e.g., for a pre‐scheduled surgery), but the inpatient admission does not occur until formal admission by the hospital. Conversely, in the unusual case in which a patient is formally admitted as an inpatient prior to an order to admit, the inpatient stay should not be considered to commence until the inpatient admission order is documented. Medicare does not permit retroactive orders or the inference of orders. Authentication of the order is required prior to discharge and may be performed and documented as part of the physician certification.

5. Specificity of the Order: The regulations at 42 CFR 412.3 require that, as a condition of payment, an order for inpatient admission must be present in the medical record. The preamble of the FY 2014 IPPS Final Rule at 78 FR 50942 specifies that, “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.” The purposes of this requirement are to reinforce the policy that the physician should be involved in the determination of patient status and to improve clarity among hospitals, beneficiaries, and ordering practitioners regarding whether the beneficiary is being treated as a hospital inpatient or hospital outpatient.

The specificity requirements outlined in the FY 2014 IPPS Final Rule are most clearly met by the inclusion of the term “inpatient” in the admission order, as illustrated above. However, in the event that explicit identification of the admission as “inpatient” is not specified, the admission order may still be consistent with 42 CFR 412.3 provided that the intent to admit as an inpatient is clear. Orders that specify admission to an inpatient unit (e.g., “Admit to 7W”, “Admit to ICU”), admission for a service that is typically provided on an inpatient basis (“Admit to Medicine”), or admission under the care of an admitting practitioner (“Admit to Dr. Smith”), and orders that do not specify beyond the word “Admit,” will be considered to specify admission to an inpatient status provided that this interpretation is consistent with the remainder of the medical record.

Treatment of such admission orders as properly inpatient is consistent with CMS’ historical interpretation of inpatient admission orders and hospitals’ historical standards of practice. However, if the usage of the order to specify inpatient or outpatient status is ambiguous, the hospital is encouraged to obtain and document clarification from the physician before initial Medicare billing (ideally before the beneficiary is discharged). Under this policy, CMS will continue to treat orders that specify a typically outpatient or other limited service (e.g., admit “to ER,” “to Observation,” “to Recovery,” “to Outpatient Surgery,” “to Day Surgery,” or “to Short Stay Surgery”) as defining a non‐inpatient service, and such orders will not be treated as meeting the inpatient admission requirements.

Annual HCPCS updates reminder effective January 2014 can be found at: Medicare contractors shall download the 2014 annual HCPCS update from the CMS mainframe. The update will be available after 8:00 p.m. Eastern time, on October 30, 2013. The filename is as follows: P@HCP.@AAA2360.HCPC2014.CONTR
NOTE: The new HCPCS update is effective for dates of service on or after January 1, 2014. For more information go to:


Stay tuned for OPPS updates that will be coming soon!

Speak Your Mind


Powered by WishList Member - Membership Software