Throw the Forms Away: CMS Relaxes Inpatient Certification

By Steve Silverstein, MD, FACEP, Vice President, Chief Clinical Architect, McKesson Health Solutions

Have you heard the news? The Centers for Medicare & Medicaid Services (CMS) eliminated the need for two-midnight certifications at the time of inpatient admission as part of updates included in the final Outpatient Prospective Payment System (OPPS) Rule for calendar year 2015, effective January 1. A requirement for certification for prolonged inpatient stays of 20 days or more is also included in the rule but does not affect the now eliminated admission certification requirement.

While the requirement for a separate written certification at the time of inpatient admission has been shelved, the documentation of medical necessity in the medical record is still required in order for a hospital to be paid for inpatient services.

Providers are directed to use the patient’s medical record to document the medical necessity for an inpatient stay. The existing requirement for a signed inpatient admission orders before discharge remains. Previously, physicians were expected to predict how long patients would be in the hospital. They also had to certify the order and expectation of a hospital stay of two midnight periods or longer in order for the patient to qualify for inpatient reimbursement.

Here’s the relevant text from the final OPPS Rule (79 Federal Register 66998), which goes into effect on January 1, 2015:

We believe that, in most cases, 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, we believe that evidence of additional review and documentation by a treating physician beyond the admission order is necessary to substantiate the continued medical necessity of long or costly inpatient stays.

Thus, the physician order must be present in the medical record and be supported by the physician admission and progress notes in order for the hospital to be paid for hospital inpatient services.

This rule change validates the importance of documenting medical necessity in the medical record. The use of InterQual’s objective, evidence based clinical criteria can help to ensure that the medical record documentation supports medical necessity. The McKesson clinical team will continue to watch this and other CMS rulings, and share their impact with the payer and provider community.