Beginning January 1, 2015, physicians will no longer need to provide certification for an inpatient admission unless the admission is expected to last for 20 days or longer or the case is an outlier.
CMS proposed removing the requirement for physician certification in the 2015 OPPS proposed rule. As part of the 2015 OPPS final rule, released October 1, CMS finalized the change.
CMS reiterated its requirement for an inpatient admission order as a condition of payment under Medicare Part A.
In the final rule, CMS stated that it believes “the admission order, medical record, and progress notes will contain sufficient information to support the medical necessity of an inpatient admission without a separate requirement of an additional, formal, physician certification.”
However, CMS stated that costly or long-stay care requires evidence of additional review and documentation by a treating physician beyond the admission order to substantiate the continued medical necessity of the care.
CMS goes on to define long-stay care as an admission lasting 20 days or more. In those situations, the physician must complete an inpatient certification by day 20 of the patient’s stay.
In addition, physicians must also certify the medical necessity for high-cost outlier care.
In the 2015 OPPS final rule, CMS states that most commenters agreed with the proposal to remove the certification, because it would reduce administrative burden and improve efficiency.
Some commenters asked CMS to provide additional guidance or clarification of the format and structure of the physician certification. CMS stated it does not require that a physician certification comply with a specific standard or format, adding:
If the medical record adequately describes the reasons for continued hospitalization, the estimated time the patient is expected to require inpatient care, and discharge planning (where appropriate), and the medical record is signed by a physician involved with and responsible for the patient’s care, this would satisfy certification requirements.
CMS also reminded providers that they must continue to meet the current certification requirements until the provisions of the OPPS become effective January 1, 2015.