The Centers for Medicare & Medicaid Services (CMS) 2014 Inpatient Prospective Payment System (IPPS) Final Rule became effective on October 1, 2013.(1) The 2014 IPPS Final Rule (a) established new requirements for inpatient hospital admission orders and certifications as a condition of Medicare Part A payment and (b) created guidelines to justify and document the medical necessity of inpatient hospital admissions.
Physician orders and certifications
1. Orders
In the 2014 IPPS Final Rule, CMS finalized its proposal to establish that, “For purposes of payment under Medicare Part A, an individual is considered an inpatient of a hospital, including a critical access hospital, if formally admitted as an inpatient pursuant to an order for inpatient admission by a physician or other qualified practitioner…”(2) The order must be present in the medical record and be supported by the admission notes and progress notes for a Medicare Part A claim to be paid.(3)
The order initiates a beneficiary’s inpatient “status” and may be completed by a physician or other practitioner who (a) is licensed by the state to admit inpatients to hospitals; (b) has privileges to admit inpatients to the particular facility; and (c) is knowledgeable about the patient’s medical condition at the time of admission, plan of care and/or hospital course.(4) An admission order may be made verbally (if subsequently authenticated) or in writing.(5)
In commentary to its 2014 IPPS Final Rule, CMS notes that an inpatient hospital admission order must expressly document the admitting physician’s intent to order admission “to or as an inpatient.”(6) CMS sub-regulatory guidance (published after the effective date of the 2014 IPPS Final Rule) backs off of this requirement and does not require inpatient hospital admission orders to include specific language; however, CMS recommends that “the admitting practitioner use language that clearly expresses intent to admit the patient as [an] inpatient…”(7)
2. Certifications
The 2014 IPPS Final Rule creates a new requirement for physician certifications of all inpatient hospital admissions as a condition of Medicare Part A payment.(8) Certification statements must be completed, signed and dated in the medical record prior to a patient’s discharge.(9)
The physician responsible for the admission or another physician who has knowledge of the case and who is authorized by the responsible physician or by the hospital’s medical staff must complete the certification.(10) A specific form is not required; however, the medical record must include signed and dated certification statements addressing each of the following elements: (a) authentication of the inpatient hospital admission order; (b) the reason for inpatient hospital services; (c) the estimated (or actual) time the beneficiary is expected to (or did) require hospital care; (d) any plans for post-hospital care; and (e) for critical access hospital services, a certification that the beneficiary reasonably may be expected to be discharged or transferred within 96 hours after admission.(11)
Commenters to the 2014 IPPS Proposed Rule objected to the requirement of certifications for all inpatient hospital admissions and argued that certifications for admissions other than extended hospital stays is not supported by law. CMS initially found these arguments unpersuasive.(12) However, recently, as part of its 2015 Outpatient Prospective Payment System (“OPPS”) Proposed Rule, CMS proposed removing the requirement for physician certification as a condition of Part A payment for all inpatient hospital admissions (maintaining the requirement for extended hospital stays).(13)
“2-Midnight Rule”: Establishing and documenting medical necessity
In its 2014 IPPS Final Rule, CMS also finalized criteria to establish and document the medical necessity of inpatient hospital admissions. In particular, CMS finalized its proposal that an inpatient admission would be generally deemed appropriate and payment made under Medicare Part A when the physician expects a patient to require a stay that crosses at least 2 midnights and admits the patient to the hospital based on that expectation, or if the patient is undergoing a procedure on the Inpatient-Only list (“the 2-midnight rule”).(14)
Note that the 2-midnight rule generally does not include exceptions based on the intensity of services rendered (e.g., even if care is rendered in an Intensive Care Unit): “[O]ur 2-midnight benchmark policy is not contingent on the level of care required.”(15)
In its new rules, CMS places great emphasis on the physician’s documentation regarding his or her expectation of a patient’s need for hospital care and anticipated length of stay. Therefore, it is essential that all hospital physicians are educated regarding the heightened importance of documentation within the medical record.
Compliance with the 2014 IPPS Final Rule may involve the adoption of new forms (e.g., Admission Order / Certification forms), and must involve thorough documentation of the need for inpatient hospital services, the physician’s expectations regarding length of stay, and rationale for the physician’s opinion.
NOTES
[1] 78 Fed. Reg. 50496 et seq. (August 19, 2013).
[2] 42 C.F.R. § 509.40, 78 Fed. Reg. at 50940.
[3] 78 Fed. Reg. at 50940.
[4] See Hospital Inpatient Admission Order and Certification, January 30, 2014, available at http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf. See also 78 Fed. Reg. at 50942.
CMS sub-regulatory guidance instructs that in cases where residents and non-physician practitioners are authorized by state law to admit inpatients, are authorized by hospital bylaws to admit inpatients and have knowledge of the patient’s medical condition at the time of admission, plan of care and/or hospital course – such orders still must be authenticated by another physician meeting eligibility requirements prior to the patient’s discharge. See Hospital Inpatient Admission Order and Certification, January 30, 2014, available at http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf.
[5] 78 Fed. Reg. at 50941 and Hospital Inpatient Admission Order and Certification, January 30, 2014, available at http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf.
[6] 78 Fed. Reg. at 50942.
[7] Hospital Inpatient Admission Order and Certification, January 30, 2014, available at http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf.
[8] 42 C.F.R. § 424.13.
[9] Id.
[10] See Hospital Inpatient Admission Order and Certification, January 30, 2014, available at http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf.
[11] 42 C.F.R. § 424.13 and 78 Fed. Reg. at 50940. In its 2014 IPPS Final Rule, CMS specifically noted, “We are not finalizing any new documentation requirements… The provider may adopt any method that permits verification. The certification and recertification statements may be entered on forms, notes, or records that the appropriate individual signs, or on a special separate form.” 78 Fed. Reg. at 50940.
See also Hospital Inpatient Admission Order and Certification, January 30, 2014, available at http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/IP-Certification-and-Order-01-30-14.pdf.
[12] 78 Fed. Reg. at 50939.
[13] 79 Fed. Reg. 40916 at 41056 et seq. (July 14, 2014).
[14] 42 C.F.R. § 412.3
[15] 78 Fed. Reg. at 50946. If a physician reasonably expects a patient to require hospital care for 2 midnights or more, but this expectation does not materialize based on unforeseen circumstances (e.g., a beneficiary’s transfer, death, departure against medical advice), an inpatient hospital admission would still be medically necessary. See Frequently Asked Questions (last updated 03/12/2013), available at http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/Questions_andAnswersRelatingtoPatientStatusReviewsforPosting_31214.pdf.
One notable exception to CMS’ statements that appropriate inpatient hospital admissions are tied to a physician’s expectation regarding the need for 2-midnights or more of hospital care (and not related to intensity of services provided) is the exception to the 2-midnight rule CMS created for newly-initiated mechanical ventilation (excluding anticipated intubations related to minor surgical procedures or other treatment). See Frequently Asked Questions (last updated 03/12/2013), available at http://cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/Questions_andAnswersRelatingtoPatientStatusReviewsforPosting_31214.pdf