(Medicare General Information, Eligibility, and Entitlement)

Medicare General Information, Eligibility, and Entitlement  Chapter 4 - Physician Certification and Recertification of Services   Table of Contents  (Rev. 12425; Issued:  12-21-23)  Transmittals for Chapter 4   10 - Certification and Recertification by Physicians for Hospital Services - General  10.1 - Failure to Certify or Recertify for Hospital Services  10.2 - Who May Sign Certification or Recertification  10.3 - Certification for Hospital Admissions for Dental Services  10.4 - Inpatient Hospital Services Certification and Recertification  10.5 - Selection by Hospital of Format and Method for Obtaining Statement  10.6 - Criteria for Continued Inpatient Hospital Stay  10.7 - Utilization Review (UR) in Lieu of Separate Recertification Statement 10.8 - Timing of Certifications and Recertifications  10.8.1 - Admissions on or after January 1, 1970 for Non- PPS Hospitals  10.8.2 - Patients Discharged During Hospital Fiscal Years Beginning on or after October 1, 1983 Under PPS  10.9 - Inpatient Psychiatric Facility Services Certification and Recertification  10.9.1 - Delayed/Lapsed Certification and Recertification  20 - Certification for Hospital Services Covered by the Supplementary Medical Insurance Program  20.1 - Delayed Certifications and Recertifications  20.2 - Timing for Certification and Recertification for A Beneficiary Admitted Before Entitlement  30 - Certification and Recertification by Physicians and Allowed Practitioners for Home Health Services  30.1 - Content of the Physician's Certification  30.2 - Method and Disposition of Certifications for Home Health Services  30.3 - Recertifications for Home Health Services  40 - Certification and Recertification by Physicians for Extended Care Services  40.1 - Who May Sign the Certification or Recertification for Extended Care Services  40.2 - Certification for Extended Care Services  40.3 -  Recertifications for Extended Care Services  40.4 -  Timing of Recertifications for Extended Care Services  40.5 -  Delayed Certifications and Recertifications for Extended Care Services  40.6 -  Disposition of Certification and Recertifications for Extended Care Services  50 - Physician's Certification and Recertification for Outpatient Physical Therapy, Occupational Therapy and Speech -Language Pathology 60 - Certification and Recertification by Physicians for Hospice Care  70 - DME Certification  80 - Summary Table for Certifications/Recertifications  10 - Certification and Recertification by Physicians for Hospital Services  General  (Rev. 1, 09-11-02)  Payments may be made for covered hospital services only if a physician certifies and recertifies to the medical necessity for the services at designated intervals of the hospital inpatient stay. Appropriate supporting material may be required. The physician certification or recertification statement must be based on a current evaluation of the patient's condition.  For patients admitted to a general hospital, regardless of whether the patients are under PPS, a physician certification is not required at the time of admission for patient services. For services continued over a period of time or for a day outlier case ( i.e., an appropriately admitted case results in an extraordinarily long stay) or for a PPS cost outlier case (i.e., an appropriately admitted case results in the expenditure of extraordinary resources), a physician must certify or recertify the continued need for the services at specified intervals. (See  80 for timing of physician certification and recertification.) Psychiatric and tuberculosis hospitals (which are excluded from PPS) are required to obtain a physician certification on admission.  Hospitals do not transmit physician certification and recertification statements to the A/B MAC (A) or to CMS. The hospital must itself certify on the appropriate billing form that the required physician certification and recertification statements have be en obtained and are on file. The physician certification and recertification statements are retained in the hospital's file where they are available for verification if needed.   A hospital must also have available in its files a written description of the procedure it adopts on the timing of certifications and recertifications, i.e., the intervals at which the necessary certification statements are required and whether review of l ong stay cases by the utilization review committee may serve as an alternative to recertification by a physician in the case of the second or subsequent recertification.  10.1 - Failure to Certify or Recertify for Hospital Services  (Rev. 1, 09-11-02)  If a hospital fails to obtain the required certification or recertification statements in an individual case, program payments may not be made in that case.  If the hospital's failure to obtain a certification or recertification is not due to a question as to the necessity for the services, but rather to the physician's refusal to certify based on other grounds (e.g., he/she objects in principle to the concept of certification and recertification), the hospital may not bill the program or the beneficiary for covered items or services. The provider agreement precludes the hospital from charging the patient for covered items and services.    10.2 - Who May Sign Certification or Recertification  (Rev. 1, 09-11-02)  A certification or recertification statement must be signed by the attending physician responsible for the case or by another physician who has knowledge of the case and is authorized to do so by the attending physician, or by a member of the hospital's me dical staff with knowledge of the case.   Ordinarily for purposes of certification and recertification, a "physician" must meet the definition in Chapter 5, 70 and 70.3.  10.3 - Certification for Hospital Admissions for Dental Services  (Rev. 1, 09-11-02)  The attending doctor of dental surgery or of dental medicine is authorized to certify that the patient's underlying medical condition and clinical status or the severity of the dental procedure requires the patient to be admitted to the hospital for the pe rformance of the dental procedure; and to recertify the patient's continuing need for hospitalization when required.  This applies even if the dental procedure is not covered.  10.4 - Inpatient Hospital Services Certification and Recertification  (Rev. 1, 09-11-02)  A certification or recertification statement must contain the following information:   An adequate written record of the reason for either;  o Continued hospitalization of the patient for medical treatment or for medically required inpatient diagnostic study, or   o Special or unusual services for cost outlier cases for hospitals under the prospective payment system (PPS);   The estimated period of time the patient will need to remain in the hospital and, for cost outlier cases, the period of time for which the special or unusual services will be required; and    Any plans for posthospital care.  10.5 - Selection by Hospital of Format and Method for Obtaining Statement (Rev. 1, 09-11-02)  The individual hospital determines the method by which certifications and recertifications are to be obtained and the format of the statement.  Thus, the medical and administrative staffs of each hospital may adopt the form and procedure they find most convenient and appropriate.   There is no requirement that the certification or recertification be entered on any specific form or handled in any specific way, as long as the approach adopted by the hospital permits the A/B MAC (A) to determine that the certification and recertificatio n requirements are, in fact, met.  The certification or recertification could, therefore, be entered or preprinted on a form the physician already has to sign; or a separate form could be used.  If all the required information is included in progress NOTEs , the physician's statement could indicate that the individual's medical record contains the information required and that continued hospitalization is medically necessary.   10.6 - Criteria for Continued Inpatient Hospital Stay  (Rev. 94, Issued: 10- 16-15, Effective: 11 -16-15, Implementation: 11- 16-15)  A physician who certifies or recertifies to the need for continued inpatient stay should use the same criteria that apply to the hospital's utilization review committee.  These criteria include not only medical necessity, but also the availability of out -of-hospital facilities and services which will assume continuity of care.  In accordance with the regulations at 42 CFR 424.13(c), a physician should certify or recertify need for continued hospitalization if the physician finds that the patient could recei ve treatment in a SNF but no bed is available in the participating SNF.  Where the basis for the certification or recertification is the need for continued inpatient care because of the lack of SNF accommodations, the certification or recertification should so state.  The physician is expected to continue efforts to place the patient in a participating SNF as soon as the bed becomes available.  Coverage of these additional, alternate placement days in the hospital can continue until the earliest of the following events occurs:    A bed becomes available in a participating SNF;   The beneficiarys care needs drop below SNF -level; or   The beneficiary has exhausted all of the available days of Part A inpatient hospital benefits in that benefit period.  10.7 - Utilization Review (UR) in Lieu of Separate Recertification Statement  (Rev. 1, 09- 11-02)  For cases not subject to PPS and for PPS day outlier cases, a separate recertification statement is not necessary where the requirements for the second or subsequent recertification are satisfied by review of a stay of extended duration, pursuant to the hospital's UR plan. However, it is necessary to satisfy the certification and recertification content standards. It would be sufficient if records of the UR committee show that consideration was given to the three items required for certifications and recert ifications: the reasons for continued hospitalization (e.g., consideration was given to the need for special or unusual care in cost outlier status under PPS), estimated time the patient will need to remain in the hospital (e.g., the time period during which such special or unusual care would be needed), and plans for posthospital care.   10.8 - Timing of Certifications and Recertifications  (Rev. 1, 09- 11-02)  The timing of certifications and recertifications is described in the following subsections.   10.8.1 - Admissions On or After January 1, 1970 for Non -PPS Hospitals (Rev. 1, 09- 11-02)  For services furnished to beneficiaries admitted on or after January 1, 1970, the initial certifications are required no later than as of the 12th day of hospitalization. A hospital may at its option, provide for the certification to be made earlier, or it  may vary the timing of the certification within the 12 -day period by diagnostic or clinical categories. The first recertification is required no later than as of the 18th day of hospitalization. Subsequent recertifications must be made at intervals establ ished by the UR committee (on a case- by-case basis), but in no event may the interval between recertifications exceed 30 days.   The UR committee will be reviewing long -stay cases and may be in the best position to decide when subsequent recertifications are needed.   A hospital can, if it wishes, coordinate its physician recertifications with the process of review by the UR committee of longstay cases not subject to PPS, and for PPS day-outlier cases. At the option of the hospital, review of a stay of extended duration under the hospital's utilization review plan may take the place of the second and any subsequent physician recertifications. (Such review may be the initial review, or a second or subsequent review of an extended case by the UR committee.)   Where review of an extended stay case by the UR committee is deemed to take the place of a physician recertification, it would be possible for the recertification to be made later than the specified day, because the review of an extended duration case may be made at any time within the 7 -day period following the last day of the period of extended duration defined in the utilization review plan. Such a recertification will be treated as a delayed recertification; however, no explanation for the normal delay is required.   10.8.2 - Patients Discharged During Hospital Fiscal Years Beginning On or After October 1, 1983 Under PPS  (Rev. 1, 09- 11-02)  For cases subject to the prospective payment system (PPS), certification is not required at the time of admission for inpatient services. The admission is reviewed by a hospital review organization upon discharge of the patient. For outlier cases certifica tion is required as follows:    For day -outlier cases (now discontinued), certification was required no later than 1 day after the hospital reasonably assumes that the case meets the established outlier criteria, or no later than 20 days into the hospital stay, whichever is earlier. The first and subsequent recertifications are required at intervals established by the utilization review committee, on a case -by-case basis if it so chooses, but not less than every 30 days.