(Medicare General Information, Eligibility, and Entitlement)

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.   For cost -outlier cases, if possible, certification must be made before the hospital incurs cost for which it will seek cost outlier payment. However, certification is required no later than the date on which the hospital requests cost outlier payment or 20 days into the hospital stay, whichever is earlier. For cost-outlier cases, the first and subsequent recertifications are required at intervals established by the UR committee, on a case -by-case basis if it chooses.   As previously stated the UR committee will be reviewing long -stay cases and may be in the best position to decide when subsequent recertifications are needed. Review by the UR committee used in place of recertification for PPS day outlier cases is consider ed timely if performed within 7 days after the physician recertification would have been required.   10.9 - Inpatient Psychiatric Facility Services Certification and Recertification  (Rev. 98, Issued: 05 -13-16, Effective: 08 -15-16, Implementation: 08- 15-16)  The requirements for physician certification and recertification for inpatient psychiatric facility services are similar to the requirements for certification and recertification for inpatient hospital services.  However, there is an additional certification requirement.  In accordance with 42 CFR 424.14, all IPFs (distinct part units of acute care hospitals, CAHs, and psychiatric hospitals) are required to meet the following certification and recertification requirements.   At the time of admission or as soon thereafter as is reasonable and practicable, a physician (the admitting physician or a medical staff member with knowledge of the case) must certify the medical necessity for inpatient psychiatric hospital services.  The  first recertification is required as of the 12th day of hospitalization.  Subsequent recertifications will be required at intervals established by the hospitals utilization review committee (on a case- by-case basis), but no less frequently than every 30 days.   There is also a difference in the content of the certification and recertification.  In certification the physician is required to document that the inpatient psychiatric facility admission was medically necessary for either:  (1) treatment which could rea sonably be expected to improve the patient's condition, or (2) diagnostic study.  The physician's recertification should satisfy all of the requirements noted below:   1. That inpatient psychiatric hospital services furnished since the previous certification or recertification were, and continue to be, medically necessary for either:   a. Treatment which could reasonably be expected to improve the patient's condition; or,  b.  Diagnostic study;   2. The hospital records indicate that the services furnished were either intensive treatment services, admission and related services necessary for diagnostic study, or equivalent services, and   3. Effective July 1, 2006, physicians will also be required to recertify that the patient continues to need, on a daily basis, active treatment furnished directly by or requiring the supervision of inpatient psychiatric facility personnel.   The format of all certifications and recertifications and the method by which they are obtained is determined by the individual facility.  No specific procedures or forms are required.  The provider may adopt any method that permits verification of all the  IPFs requirements to continue treatment.  For example, the recertification may be entered on provider generated forms, in progress notes, or in the records (relating to the stay in question) and must be signed by a physician.   Claim denials may not be made for failure to use a certification or recertification form or failure to use particular language or format, provided that the medical record demonstrates that the content requirements given at Pub. 100- 02, Medicare Benefit Policy Manual, Chapter 2, 30.2.1 are met.   For convenience, the period covered by the physician's certification and recertification is referred to a period during which the patient was receiving active treatment.  If the patient remains in the hospital but the period of "active treatment" ends (e.g., because the treatment cannot reasonably be expected to improve the patient's condition, or because intensive treatment services are not being furnished), program payment can no longer be made even though the patient has not yet exhausted his/her benefit s.  Where the period of "active treatment" ends, the physician is to indicate the ending date in making his recertification.  If "active treatment" thereafter resumes, the physician should indicate, in making his recertification, the date on which it resum ed.  10.9.1 - Delayed/Lapsed Certification and Recertification  (Rev 98, Issued: 05- 13-16, Effective: 08 -15-16, Implementation: 08- 15-16)  IPFs are expected to obtain timely certifications and recertifications.  However, delayed certifications and recertifications will be honored where, for instance, there have been an oversight or lapse, and a legitimate reason for the delay as noted in Pub. 100- 01, 20.1.  Denial of payment for lack of the required certification and recertification is considered a technical denial, which means a statutory requirement has not been met.  Consequently, if an appropriate certification is later produced, the denial shall be overturned.  Reopenings of technical denial decisions may be initiated by the contractor or the pr ovider.   In addition to compliance with the appropriate certification and recertification content requirements, delayed certification and recertification must include an explanation for the delay and any medical or other evidence which the IPF considers relevant for purposes of explaining the delay.  The IPF will determine the format of the delayed certifications and recertifications, and the method by which they are obtained.  A delayed certification may be included with one or more recertifications on a single signed document.  Separate signed documents for each delayed certification and recertification are not required as they would be if timely certification and recertification had been completed.  For all IPF services, a delayed certification may not extend past  discharge.  IPF certification or recertification documentation may only be signed by a physician.   20 - Certification for Hospital Services Covered by the Supplementary Medical Insurance Program  (Rev. 12425, Issued: 12- 21-23, Effective: 01- 01-24, Implementation: 01- 02-24)    A physician must certify that medical and other health services covered by medical insurance which were provided by (or under arrangement made by) the hospital were medically required.    Physician certification is not required for the following outpatient services furnished on or after January 3, 1968:     Hospital services and supplies incident to physicians' services rendered to outpatients; and      Diagnostic services furnished by a hospital or which the hospital arranges to have furnished in other facilities operated by or under the supervision of the hospital or its medical staff.    Hospitals must obtain a physician's certification with respect to other services furnished to outpatients.    Primarily, this means that a certification statement is needed for diagnostic services furnished under arrangements by a facility that is not operated by or under the supervision of the hospital or its organized medical staff, e.g., services obtained from an independent laboratory.    This certification requires a brief description of the services and the signature of the physician.  It needs to be made only once for a course of treatment.  Where services are provided on a continuing basis, such as a course of radium treatments, the physician's certification may be made at the beginning or end of the course of treatment, or at any other time during the period of treatment.    There is no requirement that the certification 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 requirement is in fact met.  Therefor e, the certification could be entered or pre-printed on a form the physician already has to sign; or a separate certification form could be used.    In addition, physician's certifications are required for the rental and purchase of durable medical equipment ( see 70), outpatient therapy, i.e., physical therapy, occupational therapy and speech -language pathology services (see Pub. 100-02, Chapter 15, 220) , partial hospitalization services (see Pub. 100-02, Chapter 6,  70.3), and intensive outpatient services (see Pub. 100-02, Chapter 6,  70.4) .    The Physician Certification Statement requirements for all ambulance providers (hospital-owned and operated) and suppliers (independently- owned and operated) are located at 42 CFR 410.40 (d) (2) and 410.40 (d) (3).   20.1 - Delayed Certifications and Recertifications  (Rev. 1, 09-11-02)  Hospitals are expected to obtain timely certification and recertification statements. However, delayed certifications and recertifications will be honored where, for example, there has been an oversight or lapse.   In addition to complying with the appropriate content requirements, delayed certifications and recertifications must include an explanation for the delay and any medical or other evidence which the hospital considers relevant for purposes of explaining the delay.  The hospital 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.   20.2 - Timing for Certification and Recertification for a Beneficiary Admitted Before Entitlement  (Rev. 1, 09-11-02)  If an individual is admitted to a hospital (including a psychiatric hospital) before he/she is entitled to hospital insurance benefits (for example, before attainment of age 65), no certification is required as of the date of admission or entitlement.  Certifications and recertifications are required as of the time they would be required if the patient had been admitted to the hospital on the day he/she became entitled.  (The time limits for certification and recertification are computed from the date of en titlement instead of the date of admission.)   30 - Certification and Recertification by Physicians and Allowed Practitioners  for Home Health Services  (Rev. 10757; Issued: 05- 11-21; Effective: 03 -01-20; Implementation: 08 -11-21)  In addition to the content below, refer to Pub. 100 -02, Medicare Benefit Policy Manual, chapter 7, section 30.5 for a complete description of the requirements that must be met in order to certify and recertify patient eligibility for Medicare home health s ervices.   30.1 - Content of the Physician Certification  (Rev. 10757; Issued: 05- 11-21; Effective: 03 -01-20; Implementation: 08 -11-21)  Under both the hospital insurance and the supplementary medical insurance programs, no payment can be made for covered home health services that a home health agency (HHA) provides unless a physician or allowed practitioner certifies that:    Home health services are needed because the individual is confined to his/her home;    The individual needs intermittent skilled nursing care, physical therapy and/or speech -language pathology services.  Where a patients sole skilled service need is for skilled oversight of unskilled services, the physician or allowed practitioner must include a brief narrative describing the clinical justification of this need as part of the certification, or as a signed addendum to the certification;    A plan for furnishing such services to the individual has been established and is periodically reviewed by a physician or allowed practitioner;    The services are or were furnished while the individual was under the care of a physician or allowed practitioner; and   The individual had a face -to-face encounter with a physician or an allowed non-physician practitioner no more than 90 days prior to or within 30 days after the start of home health care and the encounter was related to the primary reason the patient requir es home health services in accordance with requirements described in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 7, section 30.5.1.1.  The certifying physician or allowed practitioner must also document the date of the encounter.   Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible.