Updated on: November 29, -0001

Three Requirements to Meet Outlier Certification

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Original story posted on: January 28, 2015

Recently I reported here on RACmonitor about all the uncertainty regarding the new requirements for outlier certification that replaced the admission certification requirements.

As you may recall, the Centers for Medicare & Medicaid Services (CMS) view was much more liberal than the interpretation from one of the Medicare Administrative Contractors (MACs). Fortunately, I have been able to follow up with CMS and have some good news – CMS does not have any onerous requirements for outlier certification, nor does it want another form for physicians to complete.

Here is my interpretation of how CMS envisions the three elements involved. First, as I discussed last week, CMS only wants to pay for medically necessary hospital care, so be sure that the physician notes justify continuing hospitalization. That meets the first requirement. The second requirement involves “the plans for post-hospital care, if appropriate.” To quote the CMS representative I spoke with, “If discharge plans are not yet being determined for long-stay cases, we would not expect those to be elements of the certification.” If the patient is near discharge, the plans will be in the record, and if discharge is not even on the radar at day 20, this element of certification can be ignored.

That leaves expected length of stay as the only element in question. Here the CMS representative indicated that physicians are likely already documenting this, but I am not so sure. So I would recommend that at about day 18 or 19, someone ask the physician to make a wild guess on how long the patient will remain hospitalized and note that in their progress note. There is no requirement that the estimate be precise or even accurate, nor is there a penalty for being wrong. So simply ask the doctor to document their estimate, i.e. “I expect x more days or weeks of hospitalization,” and the requirement is met. And with routine clinical documentation and these five or so words, the three elements of certification required by of 42 CFR 424.13 are met.

It should also be noted that the regulation refers to cost outlier status as being another trigger for certification; specifically, it reads that “certification is required no later than the date on which the hospital requests cost outlier payment.” And since payment for an admission is only requested after the patient has been discharged, by that time all the required elements will be in the medical record through the course of normal physician documentation.

Let me add that in my many discussions with CMS about certification, the general impression I got was that both for the 2014 IPPS requirement for admission certification and the 2015 requirement for outlier certification, the agency felt that the provider community was making a mountain out of a molehill (although I could never get them to admit it in writing). But their intent really is simple: to ensure that Medicare trust fund money is spent wisely.

Finally, Jackie Birmingham, one of the masters of case management, reminded all that the requirement for physician documentation of discharge plans is not the same as the hospital’s requirement for discharge planning.

Discharge planning by the case management staff should be ongoing, beginning at admission with reevaluation throughout the hospital stay.

About the Author

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the American Case Management Association and a Fellow of the American College of Physicians.

Contact the Author

RHirsch@accretivehealth.com

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