(Medicare General Information, Eligibility, and Entitlement)

If ambulance service is furnished by a skilled nursing facility, an additional certification is required.  It may be furnished by any physician who has sufficient knowledge of the patient's case, including the physician who requested the ambulance or the physician who examined the patient upon his arrival at the facility.  The physician must certify that the ambulance service was medically required.   40.3 - Recertifications for Extended Care Services  (Rev. 1, 09- 11-02)  The recertification statement must contain an adequate written record of the reasons for the continued need for extended care services, the estimated period of time required for the patient to remain in the facility, and any plans, where appropriate, for h ome care.  The recertification statement made by the physician does not have to include this entire statement if, for example, all of the required information is in fact included in progress.   NOTE:   In such a case, the physician's statement could indicate that the individual's medical record contains the required information and that continued posthospital extended care services are medically necessary.  A statement reciting only that continued extended care services are medically necessary is not, in and of itself, sufficient.  If the circumstances require it, the first recertification and any subsequent recertifications must state that the continued need for extended care services is for a condition requiring such services which arose after the transfer from the hospital and whi le the patient was still in the facility for treatment of the condition(s) for which he/she had received inpatient hospital services.   40.4 - Timing of Recertifications for Extended Care Services  (Rev. 1, 09- 11-02)  The first recertification must be made no later than the l4th day of inpatient extended care services.  A skilled nursing facility can, at its option, provide for the first recertification to be made earlier, or it can vary the timing of the first recertif ication within the l4 -day period by diagnostic or clinical categories. Subsequent recertifications must be made at intervals not exceeding 30 days.  Such recertifications may be made at shorter intervals as established by the utilization review committee a nd the skilled nursing facility.  At the option of the skilled nursing facility, review of a stay of extended duration, pursuant to the facility's utilization review plan (if a UR review plan is in place), may take the place of the second and any subsequent physician recertifications.  The  skilled nursing facility should have available in its files a written description of the procedure it adopts with respect to the timing of recertifications.  The procedure should specify the intervals at which recertifications are required, and whether review of long- stay cases by the utilization review committee serves as an alternative to recertification by a physician in the case of the second or subsequent recertifications.  40.5 - Delayed Certifications and Recertifications for Extended Care Services  (Rev. 1, 09- 11-02)  Skilled nursing facilities are expected to obtain timely certification and recertification statements.  However, delayed certifications and recertifications will be honored where, for example, there has been an isolated oversight or lapse.   In addition to complying with the content requirements, delayed certifications and recertifications must include an explanation for the delay and any medical or other evidence which the skilled nursing facility considers relevant for purposes of explaining the delay.  The facility will determine the format of delayed certification and recertification statements, and the method by which they are obtained.  A delayed certification and recertification may appear in one statement; separate signed statements for each certification and recertification would not be required as they would if timely certification and recertification had been made.   40.6 - Disposition of Certification and Recertifications for Extended Care Services  (Rev. 1, 09- 11-02)  Skilled nursing facilities do not have to transmit certification and recertification statements to the A/B MAC (A); instead, the facility must itself certify, in the admission and billing form that the required physician certification and recertification statements have been obtained and are on file.   50 - Physician's Certification and Recertification for Outpatient Physical Therapy Occupational Therapy and Speech- Language Pathology  (Rev. 28; Issued:  08- 12-05; Effective/Implementation:  09 -12-05)  For certification and recertification of outpatient physical therapy, occupational therapy and speech -language pathology services see Pub. 100- 02, Chapter 15, 220.1.3.  60 - Certification and Recertification by Physicians for Hospice Care  (Rev. 68, Issued: 04- 22-11, Effective: 01 -01-11, Implementation: 05- 12-11))  The hospice must obtain written certification of terminal illness for each period of hospice care received by an individual.  For the initial 90- day period, the hospice must obtain written certification statements from the medical director of the hospice o r the physician member of the hospice interdisciplinary group, and the individual's attending physician (if the individual has one). The certification must specify that the individual's prognosis is for a life expectancy of 6 months or less if the terminal  illness runs its normal course.  Recertification for subsequent periods only requires the written certification by the hospice medical director or the physician member of the hospice interdisciplinary group.  Certifications and recertifications must be da ted and signed by the physician and must include the benefit periods to which they apply.  Certifications and recertifications must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less.  If written certification is not obtained within 2 calendar days of the initiation of hospice care, a verbal certification must be obtained within the 2 days.  A written certification from the medical director of the hospice or the physician member of the i nterdisciplinary group must be on file in the beneficiary's record prior to the submission of a claim to the Medicare contractor.  If these requirements are not met, no payment may be made for the days prior to certification.   Instead  payment will begin with the day certification is obtained, i.e., the date verbal certification is obtained.  Certifications and recertifications may be completed up to 15 days before the next benefit period begins.   For recertifications on or after January 1, 2011, a hospice physician or hospice nurse practitioner must have a face- to-face encounter with each hospice patient prior to the beginning of the patients third benefit period, and prior to each subsequent bene fit period.  Failure to meet the face- to-face encounter requirements results in a failure by the hospice to meet the patients recertification of terminal illness eligibility requirement.  The patient would cease to be eligible for the benefit. See Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 9, Section 20.1, Timing and Content of Certification.  70 - DME Certification  (Rev. 1, 09- 11-02)  The DME supplier must retain a copy of the physician's order for DME in its files; and in some cases must furnish a Certificate of Medical Necessity to the DME MAC.   80 - Summary Table for Certifications/Recertifications  (Rev. 84, Issued: 04- 04-14, Effective: 05 -05-14, Implementation: 05- 05-14)  The following is a table summarizing the certification/recertification signature requirements and timeframes for various provider types.  Please review sections above for more detailed information on Certifications/Recertifications and their required conte nt:   Provider Type  Who Signs Certification  Certification Timeframe  Recertification  Hospital Inpatient  Attending physician or by another physician with knowledge of the case with authorization from attending physician or by a member of hospital's medical staff with knowledge of the case.  No later than the 12th day of hospitalization  Interval between recertifications not to exceed 30 days  SNF Attending physician or physician on staff at SNF with knowledge of case, or physician extender  as discussed in 40.1 of this chapter  Obtain at time of admission or shortly thereafter  First recertification no later than the 14th day of inpatient extended care services. Subsequent at intervals not exceeding 30 days.  HHA  Attending physician  Obtain at time POC is established or shortly thereafter  Physician must recertify at least once every 60 days  Hospice  For initial 90 -day period, must obtain written certification statements from medical director of hospice or physician member of the hospice interdisciplinary group and the attending physician.  If written certification is not obtained within 2 calendar days of the initiation of hospice care, a verbal certification must be obtained. Must be obtained for each period of hospice care; written certification by hospice medical director or physician member of interdisciplinary group.   Transmittals Issued for this Chapter   Rev #  Issue Date  Subject  Impl Date  CR#  R12425GI   12/21/2023  Enforcing Billing Requirements for Intensive Outpatient Program (IOP) Services with New Condition Code 92 - Additional Publication Update  01/02/2024  13496  R10757GI  05/11/2021  Physician Certification and Recertification of Services Manual Update to Incorporate Allowed Practitioners into Home Health Policy  08/11/2021  12222  R126GI  10/04/2019  Manual Updates for CR11152 Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)  11/05/2019  11454  R120GI  11/02/2018  Internet Only Manual Updates to Pub. 100 -01, 100-02 and 100-04 to Correct Errors and Omissions (SNF) (2018 Q4)  12/04/2018  11004  R114GI  03/16/2018  Internet Only Manual Updates to Pub. 100 -01, 100-02 and 100-04 to Correct Errors and Omissions (SNF) (2018)  06/19/2018  10512  R101GI  09/16/2016  Internet Only Manual Updates to Pub. 100 -01, 100-02 and 100-04 to Correct Errors and Omissions (SNF)  10/18/2016  9748  R98GI  05/13/2016  Clarification of Inpatient Psychiatric Facilities (IPF) Requirements for Certification, Recertification and Delayed/Lapsed Certification and Recertification  08/15/2016  9522  R94GI  10/16/2015  Internet Only Manual Updates to Pub. 100 -01, 100-02 and 100-04 to Correct Errors and Omissions (2015)  11/16/2015  9336  R92GI  04/22/2015  Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services  05/11/2015  9119  R91GI  04/10/2015  Manual Updates to Clarify Requirements for Physician Certification and Recertification of Patient Eligibility for Home Health Services   Rescinded and replaced by Transmittal 92  05/11/2015  9119  R84GI  04/04/2014  Internet Only Manual Updates to Pub. 100 -01, 100-02 and 100-04 to Correct Errors and Omissions  05/05/2014  8669  R76GI  01/13/2012  Allowing Physician Assistants to Perform Skilled Nursing Facility (SNF) Level of Care Certifications and Recertifications  02/13/2012  7701  R68GI  04/22/2011  Physician Certification and Recertification of Services Manual Changes  05/12/2011  7377  R50GI  12/21/2007  Revision to Certification for Hospital Services Covered by the Supplementary Hospital Insurance Program as it Pertains to Ambulance Services  01/07/2008  5833  R47GI  08/17/2007  Revision to Certification for Hospital Services Covered by the Supplementary Medical Insurance Program as it Pertains to Ambulance Services  09/17/2007  5684  R39GI  06/09/2006  Update -Inpatient Psychiatric Facilities Prospective Payment System (IPF PPS) Rate Year 2007  07/03/2006  5129  R28GI  08/12/2005  Conforming Changes for Change Request 3648 to Pub. 100 -01 09/12/2005  3912  R01MGI  09/11/2002  Initial Publication of Manual  NA NA  Back to top of Chapter