As the Medicare Administrative Contractors’ (MACs’) probe-and-educate audit program winds down, hospitals may be breathing a sigh of relief. Many institutions received denials under the program, with denial rates for some contractors being recorded as high as 60 percent or more. These denials generally have fallen into three categories – denials for lack of medical necessity of the inpatient stay, lack of support for a reasonable expectation of a two-midnight length of stay, or lack of certification. 

Hospitals are statutorily required under Section 1814(a)(3) of the Social Security Act to certify inpatient services for payment under Medicare Part A. The 2014 IPPS (Inpatient Prospective Payment System), effective Oct. 1, 2013, elaborated on this statutory requirement by mandating that specific elements of certification be present in the inpatient medical record and signed by the responsible physician prior to discharge. These elements were to be contained in an inpatient admission order with unambiguous wording (“admit to inpatient” or some close variant of that phrase), an estimated length of stay, a statement of reasons the Medicare beneficiary required either a) inpatient medical treatment, or b) a medically required inpatient diagnostic study; and lastly, a plan for post-discharge care, if required under the relevant regulations. The absence of any of these elements prior to discharge, or the absence of a certifying physician’s signature under these elements prior to discharge, was grounds for a denial of the inpatient claim during the probe-and-educate audit program.

Many hospitals made significant changes to electronic order sets, instituted separate certification forms, placed hard or soft stops on discharges, and designated or hired personnel to perform chart checks for missing certification elements prior to discharge. All of this was in addition to the daunting task of educating physicians and UM staff on the certification requirements.

The Centers for Medicare & Medicaid Services (CMS) chose to alter the required elements of inpatient certification in the 2015 OPPS (Outpatient Prospective Payment System) regulations. This rule was released on Oct. 31, 2014 and became effective Jan. 1, 2015. Although at a first reading, it might seem that CMS has largely removed the certification requirements, hospitals still remain at risk for denial due to poor or inadequate documentation. Additionally, CMS specifically states in the rule that the two-midnight policy instituted in the 2014 IPPS is unrelated and unchanged.

CMS stated that it was looking “to achieve our policy goals with the minimum administrative requirements necessary … and we believe that, in the majority of cases, the additional benefits (for example, as a program safeguard) of formally requiring a physician certification may not outweigh the associated administrative requirements placed on hospitals.”

However, despite that welcome news, CMS has made it clear that there remain specific documentation and medical records requirements. An inpatient admission order is no longer an element of certification, but remains a condition of payment under Part A. The order must be present in the chart for payment: “We continue to believe that an order from a physician or other qualified practitioner in order to trigger an inpatient hospital admission as specified in 42 CFR 412.3 is necessary for all inpatient admissions.” The inpatient admission order has the same timeliness requirements as under the previous rules:  “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.”

CMS now requires additional certification elements in the record triggered by the beneficiary’s length or cost of stay, as indicated by its stance that “evidence of additional review and documentation by a treating physician beyond the admission order is necessary to substantiate the continued medical necessity of long or costly inpatient stays.”

The Social Security Act requires physician certification at no later than 20 days. CMS notes that the regulations at CFR Section 424.13(f)(2) remain unchanged, triggering certification upon either identification of a cost outlier or 20 days, whichever occurs first. The elements of certification required on or before day 20 for outlier cases are: a) the reasons for either – i) continued hospitalization of the patient for medical treatment or medically required diagnostic study or (ii) special or unusual services for cost outlier cases; b) the estimated time the patient will need to remain in the hospital; and c) the plans for post-hospital care, if appropriate.

Additionally, all the other elements of certification under the 2014 IPPS, including a reasonable and supportable estimated length of stay, along with a plan for post-hospital care, still must be present in the medical record to support the medical necessity of the inpatient admission. It is clear that documentation for medical necessity of the inpatient admission is still mandatory under the relaxed certification requirements.

Despite the changes in formal certification under the 2015 OPPS, many hospitals have chosen to continue with their certification programs to ensure that at least a bare minimum of the required elements will always be present. However robust physician documentation is, discussing the beneficiary’s risks, comorbidities, acuity, and reasonable length of stay will continue to be the best protection going forward.

The modification of certification requirements is good news for acute-care and critical access hospitals. No longer should a hospital receive a technical denial of Part A payment simply because a certification statement was not signed by the responsible physician prior to discharge. Hospitals and physicians must realize, however, that thorough documentation covering the same concepts – particularly medical necessity and a supportable estimated length of stay – remain as important as ever.

About the Author

Kurt Hopfensperger, MD, JD, is the Senior Director of Audit, Compliance and Education at Executive Health Resources. He is board-certified in Neurology with the American Board of Psychiatry and Neurology and a Diplomate of the National Board of Medical Examiners and a member of the Health Law Section of the American Bar Association.

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