Certification Requirements Clarification

After 15 months of hospitals working diligently and struggling to make sure that certifications were in place for all Medicare acute care inpatient admissions, in transmittal CMS 1613-FC CMS changed its interpretation of certification requirements for acute care admissions on and after January 1, 2015 to “require certification only for long-stay cases and outlier cases.” Please note that the requirement for a certification for long-stay cases is not new. Prior to the 2014 IPPS Final Rule that instituted the Two Midnights rule, hospitals were required to have a physician certify the need for a hospital stay to extend 20 days or more and to address outlier cases. Historically we have not seen audit and denial activity around certification compliance although CMS has always audited to determine whether services billed were medical necessary. The “certification” requirements are not entirely clear, but based on existing guidance the following may be a best practice:

  1. The certification should be signed by a physician who is actively engaged in the management of the patient and who is familiar with the patient’s course of treatment and of course, treatment plan necessitating the continued stay.
  2. The certification statement should be in the record prior to day 20 or as soon as a case is identified as a cost outlier. Ensure that the statement is dated.
  3. The certification statement should explain why continued acute care hospitalization is necessary. In addition the basis for the conclusion that additional services in the acute care facility are required should be supported by the medical evidence in the medical record. The statement should also specify the anticipated length of stay, and plans for the patient post discharge.

We expect additional clarification from CMS and the MACs and we will share definitive guidance when issued. Remember that your utilization review plan should set forth the process by which you monitor and review extended stays and outlier cases.   As always, ensuring clear and complete clinical documentation by the attending physician is critical to facilitate patient care, ensure billing integrity and to support compliance efforts.

When timely clinical documentation tells the story of why the patient is hospitalized, details the expectation of the length of stay (i.e. does the patient require hospital care for a time spanning at least two midnights) and describes the treatment plan (including plans for discharge), the “certification requirements” will be much less problematic.