(Medicare Benefit Policy Manual)

Any request by the patient (or relative or other person responsible for his or her affairs) for ward accommodations must be obtained by the provider in writing and kept in its files.   10.1.6.1 - Assignment Co nsistent With Program Purposes  (Rev. 1, 10-01-03) A3-3101.1.F.1, HO-210.1.F.1  It is considered to be consistent with the program's purposes to assign the patient to ward accommodations if all semiprivate accommodations are occupied, or the facility has no semiprivate accommodations.  However, the patient must be moved to semiprivate accommodations if they become available during the stay.   Some hospitals have a policy of placing in wards all patients who do not have private physicians.  Such a practice may  be consistent with the purposes of the program if the A/B MAC (A) determines that the ward assignment inures to the benefit of the patient.  In making this determination, the principal consideration is whether the assignment is likely to result in better medical treatment of the patient (e.g., it facilitates necessary medical and nursing supervision and treatment).  The A/B MAC (A) should ask a provider having this policy to submit a statement describing how the assignments are made, their purpose, and the effect on the care of patients so assigned.   If the A/B MAC (A) makes a favorable determination on a practice affecting all ward assignments of Medicare patients in the institution, a reference should be made on the appropriate billing form for patients to whom the hospital assigned a ward pursuant to such practice.   10.1.6.2 - Assignment Not Consistent With Program Purposes  (Rev. 1, 10-01-03) A3-3101.1.F.2, HO-210.1.F.2  It is not consistent with the purposes of the law to assign a patient ward accommodation based on their social or economic status, their national origin, race, or religion, or their entitlement to benefits as a Medicare patient, or any other such discriminatory reason.  It is also inconsistent with the purposes of the law to assign patients to ward accommodations merely for the convenience or financial advantage of the institution.  Additionally, under DRGs, there no longer is a reduction to payment or an adjustment to the end of year settlement.   10.1.7 - Charges  (Rev. 1, 10-01-03) A3-3101.1.G, HO-210.1.G  Customary charges means  amounts which the hospital or skilled nursing facility is uniformly charging patients currently for specific services and accommodations.  The most prevalent rate or charge is the rate that applies to the greatest number of semiprivate or private beds in the institution.   10.2  Hospital Inpatient Admission Order and Certification  (Rev.  234, Issued: 03-10-17, Effective: 01-01-16, Implementation: 06-12-17)  The order to admit as an inpatient (practitioner order) is a critical element in clarifying when an individual is considered an inpatient of a hospital, including a critical access hospital (CAH), and is therefore required for all hospital inpatient case s for hospital inpatient coverage and payment under Part A.  As a condition of payment for hospital inpatient services under Medicare Part A, according to section 1814(a) of the Social Secu rity Act , CMS is requiring, only for long -stay cases and outlier cases, separate physician certification of the medical necessity that such services be provided on an inpatient basis.  The signed physician certification is considered, along with other documentation in the medical record, as evidence that hospital inpatient service(s) were reasonable and necessary.   The following guidance applies to all inpatient hospital and CAH services unless otherwise specified.  For the remainder of this guidance, refer ences to hospitals includes CAHs.  The complete requirements for the physician certification are found in 42 CFR Part 424 subpart B , and requirements for admission orders are found at 42 CFR 412.3 .  A. Physician Certification.  P hysician certification of inpatient services is required for cases that are 20 inpatient days or more (long -stay cases), for outlier cases of hospitals other than inpatient psychiatric facilities and for cases of CAHs.  (See CY 2015 Outpatient Prospective Payment System Final Rule, 79 FR 66997 and 42 CFR 412 Subpart F , 42 CFR 424.13 and 42 CFR 424.15 ):  1. Content:  The physician certification includes the following information:   a. Reason for inpatient services:  The physician certifies the reasons for either  (i) Continued hospitalization of the patient for inpatient medical treatment or medically required inpatient diagnostic study; or (ii) Special or unusual services for outlier cases under the applicable prospective payment system for inpatient services.  For example, documentation of an admitting diagnosis could fulfill this part of the certification requirement.   b. The estimated (or actual) time the beneficiary requires or required in the hospital:  The physician certifies the estimated time in the hospital the beneficiary requires (if the certification is completed prior to discharge) or the actual time in the hospital (if the certification is completed at discharge).  Estimated or actual length of stay is most commonly reflected in the progress notes where the practitioner discusses the assessment and plan.  For the purposes of meeting the requirement for certification, expected or actual length of stay may be documented in the order or a separate certification or recertification form, but it is also acceptable if discussed in the progr ess notes assessment and plan or as part of routine discharge planning.   If the reason an inpatient is still in the hospital is that they are waiting for availability of a skilled nursing facility (SNF) bed, the regulations at 42 CFR 424.13(c)  and 424.14(e)  provide that a beneficiary who is already appropriately an inpatient can be kept in the hospital as an inpatient if the only reason they remain in the hospital is they are waiting for a post -acute SNF bed.  The physician may certify the need for continued inpa tient admission on this basis.   c. The plans for posthospital care, if appropriate, and as provided in 42 CFR 424.13 .  d. For inpatient CAH services only, the physician must certify that the beneficiary may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH.  Time as an outpatient at the CAH does not count towards the 96 hour certification requirement.  The clock for the 96 hour certification requirement only begins once the individual is admitted to the CAH as an inpatient.  Time in a CAH swing -bed also does not count towards the 96 hour certification requirement.  The 96- hour certification requirement is based on an expectation at the time of admission.  If a physician certifies in good faith that an individual may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH, and something unforeseen occurs that causes the individual to stay longer at the CAH, the CAH would be paid for that unforeseen extended inpatient stay as long as that individuals stay does not cause the CAH to exceed its 96- hour annual average con dition of participation requirement.  However, if a physician cannot in good faith certify that an individual may reasonably be expected to be discharged or transferred within 96 hours after admission to the CAH, the CAH will not receive Medicare reimbursement for any portion of that individuals inpatient stay.  This would be determined based on a medical review of the case.   All certification requirements must be completed, signed, and documented in the medical record no later than 1 day before the date on which the claim for payment for the inpatient CAH service is submitted, as provided in the FY15 IPPS Final Rule  and 42 CFR 424.11 and 42 CFR 424.15.  e. Inpatient Rehabilitation Facilities (IRFs):  The documentation that IRFs are already required to complete to meet the IRF coverage requirements (such as the preadmission screening (including the physician review and concurrence), the post -admission  physician evaluation, and the required admission orders) may be used to satisfy the certification and recertification statement requirements.   2. Timing:  Outlier cases must be certified and recertified as provided in 42 CFR 424.13 .  Under extenuating circumstances, delayed initial certification or recertification of an outlier case may be acceptable as long as it does not extend p ast discharge.  For all other long stay cases, the certification must be signed and documented no later than 20 days into the inpatient portion of the hospital stay.   3. Authorization to sign the certification:  The certification or recertification may be signed only by one of the following:   (1) A physician who is a doctor of medicine or osteopathy.  (2) A dentist in the circumstances specified in 42 CFR 424.13(d). (3) A doctor of podiatric medicine if his or her certification is consistent with the functions he or she is authorized to perform under state law.   Certifications and recertifications must be signed by the physician responsible for the case, or by another physician who has knowledge of the case and who is authorized to do so by the responsible physician or by the hospitals medical staff (or by the dentist as provided in 42 CFR 424.11 and 42 CFR 424.13 ).  CMS considers only the following physicians, podiatrists or dentists to have sufficient knowledge of the case to serve as the certifying physician:  the admitting physician of record (attending) or a physician on call for him or her; a surgeon responsible for a major surgical procedure on the beneficiary or a surgeon on call for him or her; a dentist functioning as the admitting physician of record or  as the surgeon responsible for a major dental procedure; and, in the specific case of a non physician non dentist admitting practitioner who is licensed by the state and has been granted privileges by the facility, a physician member of the hospital staff  (such as a physician member of the utilization review committee) who has reviewed the case and who also enters into the record a complete certification statement that specifically contains all of the content elements discussed above.  The admitting physic ian of record may be an emergency department physician or hospitalist.  CMS does not require the certifying physician to have inpatient admission privileges at the hospital.  4. Format:  As specified in 42 CFR 424.11 , no specific procedures or forms are required for certification and recertification statements.  The provider may adopt any method that permits verifica tion.  The certification and recertification statements may be entered on forms, notes, or records that the appropriate individual signs, or on a special separate form.  Except as provided for delayed certifications, there must be a separate signed stateme nt for each certification or recertification.  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 hospital inpatient servic es are or continue to be medically necessary.   B. Inpatient Order:  A Medicare beneficiary is considered an inpatient of a hospital if formally admitted as an inpatient pursuant to an order for inpatient admission by an ordering practitioner.  As stated in  the FY 2014 IPPS Final Rule, 78 FR 50908 and 50941, and as conveyed in 42 CFR 482.24 , if the order is not properly documented in the medical record prior to discharge, the hospital should not submit a claim for Part A payment.  Meeting the two midnight benchmark does not, in itself, rende r a beneficiary an inpatient or serve to qualify them for payment under Part A.  Rather, as provided in Medicare regulations, a beneficiary is considered an inpatient (and Part A payment may only be made) if they are formally admitted as such pursuant to a n order for inpatient admission by an ordering practitioner.   With regard to the time of discharge, a Medicare beneficiary is considered a patient of the hospital until the effectuation of activities typically specified by the ordering practitioner as havi ng to occur prior to discharge (e.g., discharge after supper or discharge after voids).  Thus, discharge itself can but does not always coincide exactly with the time that the discharge order is written, rather it occurs when the ordering practitioner s order for discharge is effectuated.   1. Content:  The ordering practitioners order contains the instruction that the beneficiary should be formally admitted for hospital inpatient care.  The order must specify admission for inpatient services.  Inpatient rehabilitation facilities (IRFs) must adhere to th e admission requirements specified in 42 CFR 412.622 .  The two midnight benchmark does not apply in IRFs.