DEPARTMENT: Governmental Operations Support / Acute and Post Acute Services / POLICY DESCRIPTION: Physician Certification and Recertification for Post Acute Services
PAGE:1 of 6 / REPLACES POLICY DATED:
APPROVED: February 2, 2000 / RETIRED:
EFFECTIVE DATE: April 1, 2000 / REFERENCE NUMBER: GOS.APS.001
SCOPE: All Companyaffiliated facilities and all Corporate Departments, Groups and Divisions, and particularly the following Departments and individuals:

Post Acute Services

Health Information Management
Business Office
Nursing Services
Utilization Review
PURPOSE: To outline the Medicare requirements for physician certification and recertification for post acute services.
Definition: For purposes of this policy, “Post Acute Services” shall include Inpatient Psychiatric distinct part unit (DPU), Inpatient Rehabilitation DPU, Skilled Nursing Facility (SNF), Swing Bed, Outpatient Physical Therapy, Occupational Therapy, Speech Pathology and Partial Hospitalization Program (PHP)/Outpatient Psychiatric services.
POLICY:
1.To obtain Medicare reimbursement for inpatient psychiatric DPU, SNF, swing bed, outpatient physical therapy, occupational therapy, speech pathology services, PHP and inpatient rehabilitation DPU services, certifications and recertifications for the services must be obtained as required by the applicable statutes, regulations and manual provisions.
2.Certifications and recertifications must be signed, dated, and completed by a physician who is a doctor of medicine or osteopathy and is responsible for the case or by another physician who has knowledge of the case and who also is authorized to do so by the responsible physician or by the hospital’s medical staff bylaws, rules and regulations.
3.Certification and recertification statements are not submitted to the Medicare program. By signing the hardcopy of the UB92 or by submitting the UB92 electronically, the facility states that the certifications and recertifications have been obtained pursuant to regulatory requirements.

Inpatient Distinct Part Psychiatric Services

  1. At the time of admission, or as soon thereafter as it is reasonable and practical, a physician (the admitting physician or a medical staff member) with a knowledge of the case must certify the medical necessity of the inpatient psychiatric hospital services.
  1. The initial certification must state that inpatient psychiatric services were required:
a)For treatment that could reasonably be expected to improve the patient’s condition; or
b)For diagnostic study.
  1. Recertification is required no later than the 12th day of hospitalization; the second recertification is required no later than the 18th day of hospitalization. Subsequent recertifications must be made at intervals established by the hospital’s Utilization Review (UR) committee, but in no event may the interval exceed 30 days.
  1. Recertifications for inpatient psychiatric services must include the following:
a)Inpatient services furnished since the previous certification or recertification were, and continue to be, required for treatment that could reasonably be expected to improve the patient’s condition, or for diagnostic study;
b)The hospital records must show that the services were either intensive treatment services, admission and related services necessary for diagnostic study, or equivalent services;
c)The estimated time an individual will require active treatment as an inpatient; and
d)Plans for post-discharge care.
Inpatient Distinct Part Rehabilitation Services
1.A rehabilitation unit must meet certain requirements in order to be excluded from the prospective payment system. The unit must have a preadmission screening procedure in effect under which each prospective patient’s condition and medical history are reviewed to determine whether the patient is likely to benefit significantly from an intensive inpatient program or assessment. A physician’s signature concurring with the prescreening assessment qualifies as the initial certification. This initial certification is required no later than the 12th day of hospitalization.
2.The unit must have a plan of treatment for each inpatient that is reviewed at least every two weeks. The recertification requirement can be met with a physician’s statement on the treatment plan that justifies appropriateness of treatment. The first recertification is required no later than the 18th day of hospitalization. Subsequent recertifications must be made at intervals established by the UR committee, but in no event may the interval exceed 30 days.
Skilled Nursing Facility Services and Swing Bed
  1. To obtain Medicare reimbursement for post-hospital SNF care furnished by a SNF or a hospital with a swing-bed approval, certifications and recertifications for services must be obtained as required by the applicable regulations. Certifications and recertifications must be signed by one of the following:
a)The physician responsible for the case;
b)A physician on the SNF staff or a physician who is available in case of an emergency and has knowledge of the case, and who acts with the authorization of the physician responsible for the case; or
c)A nurse practitioner or clinical nurse specialist, neither of whom has a direct or indirect employment relationship with the facility, but who is working in collaboration with a physician.
  1. Certifications must be obtained at the time of admission or as soon thereafter as is reasonable and practicable. The certification must state that post-hospital skilled nursing care is or was required because:
a)The individual needs or needed, on a daily basis, skilled nursing care (furnished directly by or requiring the supervision of skilled nursing personnel) or other skilled rehabilitation services that, as a practical matter, can only be provided in a SNF or a swing-bed hospital on an inpatient basis;
b)The skilled nursing care is or was needed for a condition for which the individual received inpatient care in a participating hospital or a qualified hospital, as defined in 42 C.F.R. §409.3; and
c)The individual has been correctly assigned to one of the Resource Utilization Groups (RUGs) designated as representing the level of care, as provided in 42 C.F.R. §409.30.
  1. The first recertification is required no later than the 14th day of the post-hospital SNF care. Subsequent recertifications are required at least every 30 days after the first recertification.
  1. Recertifications must include:
a)The reasons for the continued need for post-hospital services;
b)The estimated time the individual will need to remain in the SNF;
c)Plans for home care, if any; and
d)If appropriate, the fact that the continued services are needed for a condition that arose after admission to the SNF and while the individual was still under treatment for the condition for which he or she had received inpatient hospital services.
  1. For those swing bed hospitals with more than 49 beds but fewer than 100 beds, the patient’s physician has 5 days (excluding weekends and holidays) beginning on the date a SNF bed becomes available to transfer the patient to the identified SNF bed or certify that the transfer of the patient is not medically appropriate.
Outpatient Physical Therapy, Occupational Therapy and Speech Pathology Services
  1. To obtain Medicare Part B reimbursement for outpatient physical therapy, occupational therapy and speech pathology services, a physician must certify that:
a)The individual needs, or needed, physical therapy, occupational therapy or speech pathology services;
b)The services were furnished while the individual was under the care of a physician; and
c)The services were furnished under a plan of treatment.
  1. The certification statement must be obtained at the time the plan of treatment is established, or as soon thereafter as possible.
  1. If a physician establishes the plan of treatment, a physician must sign the certification. If a physical therapist, occupational therapist or speech pathologist establishes the plan of treatment, a physician who has knowledge of the case must sign the certification.
  1. Recertification statements are required at least every 30 days and must be signed by the physician who reviews the plan of treatment. The content of the recertifications must include:
a)The continuing need for therapy services and
b)An estimate of how much longer the services will be needed.
Outpatient Psychiatric and Partial Hospitalization Program Services
  1. Coverage of partial hospitalization services is dependent on a physician certification that:
a)The individual would require inpatient psychiatric care in the absence of such services;
b)An individualized, written plan of care for furnishing such service has been established by a physician and periodically reviewed by a physician; and
c)Such services are or were furnished while the individual is or was under the care of a physician.
  1. Even though Health Care Financing Administration (HCFA) regulations do not specify timing requirements for obtaining the certification, the certification must be obtained prior to billing. Local Medical Review Policies (LMRP) may dictate the timing requirements. Please obtain and follow any LMRP that specifies timing for certifications and recertifications.

PROCEDURE:
1.The facility must designate an appropriate person to obtain the physician certification/recertification within the timelines defined by HCFA and/or LMRP.
2.A facility-designated person must monitor that certification/recertifications are obtained concurrently and are completed within the timelines defined by HCFA and/or LMRP.
3.The certification/recertification must be signed, dated, and completed by a physician. (Please see the attached standard certification forms. The facility is strongly encouraged to utilize these forms. The standard forms may be ordered through HealthTrust Purchasing Group Forms Standardization. If the facility chooses not to use the standard forms, it must ensure that the required certification/recertification specifications are identifiable within the medical record).
4.The certification/recertification must be part of the permanent post acute medical record.
5.Prior to releasing an account for final billing, the facility must designate an individual to review, on a case-by-case basis, the medical record documentation to ensure that required certifications and recertifications have been obtained and are on file.
6.It is the responsibility of the Chief Financial Officer to ensure that the processes are in place to ensure compliance with this policy.
7.The facility must conduct self-monitoring using resources provided by the Corporate Governmental Operations Support Department to determine whether certifications and recertifications have been obtained according to this policy. Each facility must begin conducting these self-reviews 30 days after the effective date of this policy.
REFERENCES:
42 U.S.C. §§ 1395f(a)(3), 1395f(a)(2), 1395n(a)(2)(F); 42 C.F.R. §§ 424.5 (a)(4), 424.2, 424.24, 420.20, 413.13(c), 412.29(b), 411.11(a)(3); HCFA Pub -10 §§ 276, 275(C), 274, 273.1, 273; HCFA Pub –12 § 220.