The Inpatient Order has been Written, Now What?

on Sunday, 15 September 2013. All News Items | Case Management | Documentation | Coding

The 2014 Inpatient Perspective Payment System (IPPS) Final Rule has certainly created a lot of concern, confusion and a feeling of being overwhelmed at what is to go into in effect in just 12 days from now.

After an August 15th Open Door Forum by CMS, the concern and confusion remained on several issues. On September 5th, CMS provided additional guidance regarding the Hospital Inpatient Admission Order and Certification. The guidance is applicable to all inpatient hospitals and critical access hospitals (CAH) services unless otherwise specified. This week we are going to focus specifically on the Physician Certification of an inpatient admission.

The Physician Certification is a condition of payment for hospital inpatient services and the complete requirements can be found in the Code of Federal Register (CFR) at 42 CFR Part 424 subpart B and 42 CFR 412.3. There are four content elements to the Physician Certification that includes:

  • Authentication of the Practitioner Order,
  • Reason for the Inpatient Services,
  • The estimated time that the patient will require inpatient hospitalization; and
  • The plans for post hospital care.

Note: CMS indicates that for Critical Access Hospitals (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.”

Timing of the Certification:

CMS has made it clear that the certification begins with the inpatient admission order and that it must be completed, signed and dated and in the medical record prior to discharge. The challenge for hospitals will be to ensure that this must be completed prior to the patient’s discharge from the hospital.

There are two exceptions to this timing. First, for outlier cases certification and recertification must be completed as instructed in 42 CFR 424.13. Second, CAHs must complete the certification “no later than 1 day prior to the date on which the claim for payment for the inpatient CAH services is submitted (§424.15).”

Authentication to sign the certification:

The September 5th guidance answered two main questions on this topic which are who can sign the certification and who does Medicare consider to have enough knowledge about a specific case to certify the admission. CMS has indicated that “the physician responsible for the case, or another physician who had 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) is the physician that must sign certifications and re-certifications.” CMS also detailed who they consider to have sufficient knowledge about a case to sign the certification and includes:

  • The admitting physician of record (“attending”),
  • A physician on call for the attending,
  • A surgeon responsible for a major surgical procedure,
  • A surgeon on call for the operating surgeon,
  • A dentist functioning as the admitting physician of record or as the surgeon responsible for a major dental procedure; and
  • A physician member of the hospital staff, such as a physician member of the utilization review committee, when the patient is admitted by a non-physician practitioner. This certifying physician must review the case and enter a complete certification statement into the record.

Format:

There is no required form available to complete the certification or recertification and CMS has left it up to each hospital to decide whether to ensure the appropriate information is in the record or adopt a special separate form. In the September 5th guidance, they did however provide providers with what CMS and its contractors will be looking for in the medical record in the absence of a separate form. As we work through the elements you will see that with sufficient documentation by the physician supporting the medical necessity of the inpatient admission all of the elements are already in the record.

  • First, to meet the authentication requirement the certifying physician must sign or countersign the admission order. If the admitting physician meets CMS’s requirements to be the certifying physician, then the signed admission order meets this requirement. If your hospital allows ER physicians to “admit” patients, the ER physician’s admission order would have to be countersigned by a physician with knowledge of the case as defined above in order to meet the certification requirements.
  • Second, certifying the need for inpatient admission will be met either by the diagnosis and plan documented in the admission assessment or by inpatient admission diagnosis and orders. (This sounds a lot like a History & Physical (H&P) that contains an assessment, diagnoses and plan of care for the patient and admitting order sets doesn’t it?)
  • Third, the estimated time requirement will be met by the inpatient admission order based on the 2-midnight benchmark supplemented by physician notes and discharge planning instructions. (This sounds a lot like an H&P and daily progress notes that demonstrate medical necessity of an inpatient admission, the plan of care and any identified discharge planning needs; are you seeing a pattern yet?)
  • Fourth, post hospital care planning requirement can be met by physician’s notes or by discharge planning instructions. (Don’t all patients already receive discharge planning instructions at the end of their inpatient stay?)

For CAHs the “96 hour expectation requirement will be met either by physician notes or by actual discharge within 96 hours.”

So, at the end of the day, a medical record needs:

  • An inpatient admission order authenticated (signed, dated and timed) by the certifying physician prior to discharge,
  • An H&P that clearly supports the medical necessity for admission, admitting diagnoses and a plan of care or an order set to include admitting diagnoses,
  • Physician progress notes; and
  • Documentation that the patient receives discharge planning instructions by physician notes or discharge planning instructions.

Again, there is no specific format requirement for the certification. Hospitals should be educating their medical staff, case management, utilization review, discharge planning and CDI specialists regarding the certification requirements. They should also assess what their current medical record documentation looks like and then decide if you need a separate form.

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-two 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 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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