Finalized Changes to Physician Certification Requirements

on Friday, 07 November 2014. All News Items | Case Management | Patient Status | Documentation

Is There Really a Reason to be Thankful?

The 2014 IPPS Final Rule placed a significant burden on hospitals by requiring that a Physician Certification be completed on ALL Medicare inpatient admissions. In their effort to achieve “policy goals with the minimum administrative requirement necessary,” CMS finalized the 2015 OPPS proposed changes to the physician certification process that only requires physician certification for long-stay and outlier cases.

Implications for Hospitals:

  • The physician certification change does not change the fact that there must be a signed inpatient order prior to a beneficiary being discharged as a hospital Condition of Participation (CoP) & a requirement for payment for Medicare Part A Services.
    • Physician documentation in the medical record (e.g., History & Physical, MD Progress Notes and Physician Orders) still must support the medical necessity for hospital care that is expected to span at least two midnights.
  • For Medicare beneficiaries that reach a 20 day length of stay it will be important to make sure that the “physician certifies or recertifies the following:
  1. (1)The reasons for either –
      1. (i)Continued hospitalization of the patient for medical treatment or medically required diagnostic study; or
      2. (ii)Special or unusual services for cost outlier cases (under the prospective payment system set forth in subpart F or part 412 of this chapter).
    1. (2)The estimated time the patient will need to remain in the hospital.
    2. (3)The plans for posthospital care, if appropriate.’
  • The physician certification continues to be a requirement until January 1, 2015 and must include the following:
    • Authentication of the Practitioner order prior to the beneficiary being discharged,
    • The reason for inpatient services,
    • The estimated time that the patient will require as an inpatient; and
    • The plans for hospital care.

Final Rule Comments and Responses

  • Comment: CMS indicates that several commenters “continued to disagree that CMS has the statutory authority to require signed admission orders for all inpatient cases.”

    Commenters further “argued that the continued requirement for admission orders is essentially the same as the certification requirement and stated that section 1814(a)(2) of the Act is explicit in requiring physician certification only for services “furnished over a period of time” and not for all services.”

    Response: Not surprising, CMS disagrees noting that, “While the inpatient admission order was a required component of the physician certification under our previous policy, the order and the physician certification do not serve identical policy goals under our proposal, which we are now finalizing. For all cases, a properly authorized and documented admission order is necessary because the admission order is integral to a clear regulatory definition of when and how a beneficiary becomes an inpatient.”
  • Comment: There were also several commenters that requested that the timing of a signed admission order be by the time of billing as is permitted for Critical Access Hospitals (CAHs).

    Response: Again, not surprising, CMS disagrees and indicates that “we believe that, in most cases, matters relating to the determination of patient status should be resolved before discharge, due to the consequences that flow from such a determination. For example, whether services are billed under Medicare Part A or Part B can have a significant impact on a beneficiary’s financial liability. Therefore, we do not believe it is appropriate to change our existing policy which requires that inpatient orders be signed prior to discharge by a practitioner familiar with the case and authorized by the hospital to admit inpatients.”
  • Comment: Several commenters also requested additional guidance around the required content and format of the physician certification statement.

    Response: CMS reiterates in the Final Rule that “the physician certification requirements at § 424.13 generally may be satisfied by elements routinely found in a patient’s medical record, such as progress notes. CMS does not require that a physician certification comply with a specific standard or format--only that it ensures that the conditions at § 424.13(a) were met. If the medical record adequately describes the reasons for continued hospitalization, the estimated time the patient is expected to require inpatient care, and discharge planning (where appropriate), and the medical record is signed by a physician involved with and responsible for the patient’s care, this would satisfy certification requirements.”

Final Rule

“We are finalizing the policy as proposed in the CY 2015 OPPS/ASC proposed rule, which limits the requirement for physician certification to long-stay (20 days or longer) and outlier cases”

“We are also are finalizing our proposed revision of paragraph (b) of § 424.13, without modification, to specify that certifications for long-stay cases must be furnished no later than 20 days into the hospital stay.”

For those interested, the Revision of the Requirements for Physician Certification of Hospital Inpatient Services Other Than Psychiatric Inpatient Services can be found on pages 901-912 of the Display Copy of the Final Rule.

Link to the Display Copy of the Final Rule: http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Hospital-Outpatient-Regulations-and-Notices-Items/CMS-1613-FC.html?DLPage=1&DLSort=2&DLSortDir=descending

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-three years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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