evekhm/cms_iom_500 huggingface dataset:
(Medicare General Information, Eligibility, and Entitlement)
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;
(Medicare General Information, Eligibility, and Entitlement)
 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.
(Medicare General Information, Eligibility, and Entitlement)
Certifications must be obtained at the time the plan of care is established or as soon thereafter as possible.   The physician or allowed practitioner must sign and date the plan of care (POC) and the certification prior to the claim being submitted for payment; rubber signature stamps are not acceptable.  The plan of care may be signed by another physician or allowe d practitioner who is authorized by the certifying physician or certifying allowed practitioner who established the plan of care, to care for his/her patients in his/her absence. The HHA is responsible for ensuring that the physician or allowed non-physician practitioner who signs the plan of care and recertification statement was authorized by the physician or allowed practitioner who established the plan of care and completed the certification for his/her patient in his/her absence. While the regulations specify that documents must be signed, they do not prohibit the transmission of the POC, oral order, or certification via facsimile machine.  The HHA is not required to have the original signature on file.  However, the HHA is responsible for obtaining origi nal signatures if an issue surfaces that would require verification of an original signature.  Home health agencies that maintain patient records by computer rather than hard copy may use electronic signatures.  However, all such entries must be appropriately authenticated and dated.  Authentication must include signatures, written initials, or comp uter secure entry by a unique identifier of a primary author who has reviewed and approved the entry.  The HHA must have safeguards to prevent unauthorized access to the records and a process for reconstruction of the records upon request from the Medicare contractor, state surveyor, or other authorized personnel, in the event of a system breakdown.  See 10.1 for the effects of failure to certify or recertify.   30.2 - Method and Disposition of Certifications for Home Health Services  (Rev. 92, Issued: 04-22- 15, Effective: 01 -01-15, Implementation: 05-11-15)  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 Medicare contractor can determine, where necessary, that the certification and recertification requirements are met.  The certification by the physician must be retained by the HHA.  The following instructions pertain to required documentation of the certification and recertification period.
(Medicare General Information, Eligibility, and Entitlement)
The HHA enters the month, day, year, e.g., MMDDYYYY that identifies the period covered by the physician's POC. The "From" date for the initial certification must match the start of care (SOC) date.  The "through" date is up to and including the last day of the episode which is not the first day of the subsequent episode.  The "through" date can be up to, but never exceed a total of 60 days that includes the SOC date plus 59 days.  Example:  Initial certification "From" date 10012000; Initial certification "through" date 11292000; Re-certification "From" date 11302000; Re- certification "through" date 01282001.  NOTE:   Services delivered on 11292000 are covered in the initial certification episode.  30.3 - Recertifications for Home Health Services  (Rev. 92, Issued: 04- 22-15, Effective: 01 -01-15, Implementation: 05- 11-15)  Under both the hospital insurance and supplementary medical insurance programs, when services are continued past an initial 60- day episode of care, the physician must recertify at intervals of at least once every 60 days that there is a continuing need for services in accordance with requirements described in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 7, section 30.5.2.  The recertification should be obtained at the time the plan of care is reviewed since the same interval (at least once every 60 days) is required for the review of th e plan.   The physician must include an estimate of how much longer the skilled services will be required and must certify that:   1.  The home health services are or were needed because the patient is or was confined to the home as defined in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 7, section 30.1;
(Medicare General Information, Eligibility, and Entitlement)
1.  The home health services are or were needed because the patient is or was confined to the home as defined in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 7, section 30.1;   2.  The patient needs or needed skilled nursing services on an intermittent basis (other than solely venipuncture for the purposes of obtaining a blood sample), or physical therapy, or speech -language pathology services; or continues to need occupational therapy after the need for skilled nursing care, physical therapy, or speech- language pathology services ceased.  Where a patients sole skilled service need is for skilled oversight of unskilled services (management and evaluation of the care plan as defined in Pub. 100- 02, Medicare Benefit Policy Manual, chapter 7, section 40.1.2.2), the physician must include a brief narrative describing the clinical justification of this need as part of the recertification, or as a signed addendum to the recertification;   3.  A plan of care has been established and is periodically reviewed by a physician; and  4.  The services are or were furnished while the patient is or was under the care of a physician.  Recertifications must be signed by the physician who reviews the plan of care.  The form of the recertification and the manner of obtaining timely recertifications are up to the individual agency.   40 - Certification and Recertification by Physicians for Extended Care Services  (Rev. 101, Issued: 09- 16-16, Effective: 10 -18-16, Implementation: 10- 18-16)  Payment for covered posthospital extended care services may be made only if a physician (or, as discussed in 40.1 of this chapter, a physician extender) makes the required certification and, where services are furnished over a period of time, the required recertification regarding the services furnished.
(Medicare General Information, Eligibility, and Entitlement)
The skilled nursing facility is responsible for obtaining the required certification and recertification statements and for retaining them in file for verifications, if needed, by the A/B MAC (A).  The skilled nursing facility determines the method by whic h the certification and recertification statements are to be obtained.  There is no requirement that a specific procedure or specific forms be used, as long as the approach adopted by the facility permits a verification to be made that the certification an d recertification requirements are in fact met.  Certification and recertification statements may be entered on or included in forms, NOTEs, or other records that would normally be signed in caring for a patient, or a separate form may be used.  Except as otherwise specified, each certification and recertification statement is to be separately signed.  See Pub. 100- 08, Medicare Program Integrity Manual, chapter 6, section 6.3 regarding medical review of certification and recertification in SNFs.   If the facility'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 or physician extenders refusal to certify based on other grounds (e.g., an objection in principle to the concept of certification and recertification), the facility may not bill the program or the beneficiary for covered items or services.  The provider agreement, which the facility files with the Secretary, precludes it from charging the patient for covered items and services.
(Medicare General Information, Eligibility, and Entitlement)
If a physician or physician extender refuses to certify because, in his/her opinion, the patient does not, as a practical matter, require daily skilled care for an ongoing condition for which he/she was receiving inpatient hospital services (or for a new c ondition that arose while in the SNF for treatment of that ongoing condition), the services are not covered and the facility can bill the patient directly.  The reason for the refusal to make the certification must be documented in the facility records.  F or such documentation to be adequate, there must be some statement in the facility's records, signed by a physician or a responsible facility official, indicating that the patient's physician or physician extender feels that the patient does not, as a prac tical matter, require daily skilled care for an ongoing condition for which he/she was receiving inpatient hospital services (or for a new condition that arose while in the SNF for treatment of that ongoing condition).  40.1 - Who May Sign the Certification or Recertification for Extended Care Services  (Rev. 120, Issued: 11- 02-18, Effective: 12 - 04-18, Implementation: 12-  04-18)
(Medicare General Information, Eligibility, and Entitlement)
A certification or recertification statement must be signed by the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or by a physician extender (that is, a nurse practitioner, a clinical nurse sp ecialist or, effective with items and services furnished on or after January 1, 2011, a physician assistant) who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician. See Pub. 100- 02, Medicare Benefit Policy Manual at chapter 8, 40.1, for a discussion of direct and indirect employment relationships in this context, and at chapter 15, 190.C (for physician assistants), 200.D (for nurse practitioners), and 210.D (for clinic al nurse specialists), regarding the required collaboration between the physician and the physician extender.   Ordinarily, for purposes of certification and recertification, a physician must meet the definition contained in Chapter 5, 70 of this manual.   40.2 - Certification for Extended Care Services  (Rev. 126, Issued: 10- 04-19, Effective: 11 -05-19, Implementation: 11- 05-19)
(Medicare General Information, Eligibility, and Entitlement)
The certification must clearly indicate that posthospital extended care services were required to be given on an inpatient basis because of the individual's need for skilled care on a daily basis for an ongoing condition for which he/she was receiving inpa tient hospital services prior to transfer to the SNF (or for a new condition that arose while in the SNF for treatment of that ongoing condition).  Alternatively, under the regulations at 42 CFR 424.20(a)(1)(ii), the initial certification can simply affirm that the individual has been correctly assigned one of the case -mix classifiers that CMS designates as representing the required SNF level of care, as provided in the regulations at 42 CFR 409.30 (see Pub. 100- 02, Medicare Benefit Policy Manual, chapter 8 , 30.1, for a discussion of the administrative level of care presumption under the SNF PPS).  Certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable (see Pub.100 -04, Medicare Claims Processing Manual, Chapter 6, 120.2, regarding the circumstances under which a resumption of SNF care followi ng a temporary break in SNF coverage would be considered a new admission under the SNF PPSs Interrupted Stay policy).  The routine admission procedure followed by a physician would not be sufficient certification of the necessity for posthospital extended care services for purposes of the program.  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.
(Medicare General Information, Eligibility, and Entitlement)
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.
(Medicare General Information, Eligibility, and Entitlement)
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))
(Medicare General Information, Eligibility, and Entitlement)
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.
(Medicare General Information, Eligibility, and Entitlement)
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: