November 21, 2013

Validating Certification through the UR Process

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CMS’ long-standing requirement that physicians must “certify” that admissions are appropriate with a valid order and necessary supporting documentation in the medical record are not only outlined in the Code of Federal Regulations (42 CFR Section 424.13), but have been further emphasized in the September 5, 2013 CMS Memorandum, “Hospital Inpatient Admission Order and Certification.”

As a condition of payment for hospital inpatient services under Medicare Part A, Section 1814(a) of the Social Security Act requires that physicians certify the medical necessity of an inpatient admission.

A physician’s certification of inpatient services must include:

  • Authentication of the practitioner order
  • Reason for inpatient services
  • Estimated time the beneficiary requires or required in the hospital
  • Plans for post hospital care

Certification must be documented, dated, and signed in the medical record prior to discharge. While certification is required, no specific forms are required, and hospitals may adopt any method that permits verification. Certification or recertification statements may be captured on forms, notes or records that the appropriate individual signs or on a special separate form.

In light of the renewed emphasis on certification in the FY2014 IPPS, it is vital that hospitals ensure UR processes are designed to validate all of the elements of certification in the medical record for each inpatient admission. I anticipate that CMS contractors will closely scrutinize cases for the “technical” elements of certification, including presence of a valid order, expectation of a length of stay, as well as a reasonable expectation of a lengthier hospitalization based on “accepted standards of care.”

Meeting Certification Requirements

In reviewing the UR process to ensure that it produces medical records that comply with regulations and will withstand scrutiny, hospitals should pay particular attention to the following areas:

Valid Order – Certification begins with a valid order for inpatient admission. 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” (September 5, 2013 CMS Memorandum). Verbal orders are permitted but must be authenticated in the medical record prior to discharge.

While the September 5 memo softened CMS’ position documented in the FY2014 IPPS, it is evident that the requirements are most clearly met with orders which specify a recommendation to admit ‘to inpatient,’ ‘as an inpatient,’ or ‘for inpatient services.’ Ambiguous orders should be avoided to prevent the risk of subsequent denial.

Reason for Inpatient Services – Physician documentation should explain the reasons for the beneficiary’s hospitalization for inpatient medical treatment or medically required inpatient diagnostic studies. Effective documentation will capture the rationale and support that the hospitalization was consistent with accepted standards of care.

Length of Stay – CMS directs admitting physicians to assess the likelihood of a length of stay greater than two midnights when considering a potential inpatient admission. The physician’s expectation should be captured in the record and fully supported by the rationale for inpatient services.

Discharge Plan – If a patient requires post-hospital care (including rehabilitation services, a Skilled Nursing Facility stay, home health, etc.), the rationale and plan should be clearly noted in the discharge summary.

An effective admission screening and UR process, utilizing evidence-based clinical standards, can help ensure that these requirements are satisfied.

Completing Certification

Under 42 CFR 424.13(d)(1), “certifications and recertifications 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.” Certification must be completed before the patient is discharged from the hospital. The 2014 IPPS Final Rule creates a new paragraph at 42 CFR 424.13(b), which states, “For all hospital inpatient admissions, the certification must be completed, signed, and documented in the medical record prior to discharge.”

As previously noted, CMS does not require that the physician certification take any particular form in order to be valid. The Final Rule states, “The certification and recertification statements may be entered on forms, notes, or records that the appropriate individual signs, or on a special separate form.” (2014 IPPS, p50940) 

If information is in different places (i.e., progress notes, history and physical) the certification statement should indicate where it may be found within the record. Except as provided for delayed certifications, there must be a separate signed statement for each certification or recertification.” (2014 IPPS, p50940)

About the Author

Dr. Ralph Wuebker serves as Chief Medical Officer of Executive Health Resources (EHR). In this role, Dr. Wuebker provides clinical leadership within EHR and works closely with hospital leaders to ensure strong utilization review and compliance programs. Additionally, Dr. Wuebker oversees EHR's Audit, Compliance and Education (ACE) physician team, which is focused on providing on-site education for physicians, case managers, and hospital administrative personnel and on helping hospitals identify potential compliance vulnerabilities through ongoing internal audit.

Contact the Author

Ralph.wuebker@ehrdocs.com

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Ralph Wuebker, MD, MBA

Dr. Ralph Wuebker serves as Chief Medical Officer of Executive Health Resources. In this role, Dr. Wuebker provides clinical leadership within the company and works closely with hospital leaders to ensure strong utilization review and compliance programs. Additionally, Dr. Wuebker oversees Executive Health Resources’ Client Services teams, who provide onsite education for physicians, case managers, and hospital administrative personnel and help hospitals identify potential compliance vulnerabilities through ongoing internal audit.

An expert in CMS regulations, medical necessity compliance, utilization review, denials management, and program integrity efforts, Dr. Wuebker also serves as an industry thought leader and editorial advisor to the media, as well as a highly respected and distinguished industry speaker.

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