evekhm/cms_iom_500 huggingface dataset:
(Medicare Benefit Policy Manual)
below concerning medical necessity not based on need for isolation).  In establishing the medical necessity for isolation, the date of the physician's written statement is not controlling, nor is the presence of a written statement.  The c rucial question is whether a private room was ordered by the physician because it is necessary for the health of the patient himself or herself or of other patients.  In the absence of such an order, a patient who requested the room with knowledge of the amount of the charge may be charged appropriately, even though a physician subsequently submits a statement that the room was medically necessary.  There may be cases in which the physician's written statement of medical necessity, though dated after admiss ion or even after discharge, merely confirms an order made informally at or before the time the beneficiary was admitted to the private room (e.g., the physician made arrangements by phone for the patient's admission, gave the diagnosis, and stated the beneficiary would need a private room).  In such cases, assuming that the private room was medically necessary, the lack of a written statement by the physician, or the fact that the written statement was prepared after discharge, would not be controlling.  T he patient may not be charged.   10.1.3 - Medical Necessity - Admission Required and Only Private Rooms Available  (Rev. 1, 10-01-03) A3-3101.1.C, HO-210.1.C  A private room is considered to be medically necessary even though the beneficiary's condition does not require isolation if he/she needs immediate hospitalization (i.e., the beneficiary's medical condition is such that hospitalization cannot be deferred) and the hospital has no semiprivate or ward accommodations available at the time of admission.   It need not be considered whether semiprivate or ward accommodations were available in some other accessible hospital.  Where medical necessity exists, the provider may not charge the beneficiary a private room differential until semiprivate or ward accommodations become available.  Thereafter the provider may transfer the patient to the nonprivate accommodations, or allow them to continue occupancy of the private room, subject to an appropriate differential charge (described in 10.1.1 above) if they request the private room with knowledge of the amount of the charge.
(Medicare Benefit Policy Manual)
above) if they request the private room with knowledge of the amount of the charge.  If the admission could be deferred until semiprivate or ward accommodations become available, the beneficiary should be informed of the amount of the differential he/she must pay for a private room if he/she wishes to be admitted immediately.  The beneficiary may be charged the specified differential if he/she has been admitted to the private room at their request (or at the request of their representat ive) with knowledge of the amount of the charge.  10.1.4 - Charges for Deluxe Private Room  (Rev. 1, 10-01-03) A3-3101.1.D, HO-210.1.D
(Medicare Benefit Policy Manual)
Beneficiaries found to need a private room (either because they need isolation for medical reasons or because they need i mmediate admission when no other accommodations are available) may be assigned to any of the provider's private rooms.  They do not have the right to insist on the private room of their choice, but their preferences should be given the same consideration as if they were paying all provider charges themselves.  The program does not, under any circumstances, pay for personal comfort items.  Thus, the program does not pay for deluxe accommodations and/or services.  These would include a suite, or a room substa ntially more spacious than is required for treatment, or specially equipped or decorated, or serviced for the comfort and convenience of persons willing to pay a differential for such amenities.  If the beneficiary (or representative) requests such deluxe accommodations, the provider should advise that there will be a charge, not covered by Medicare, of a specified amount per day (not exceeding the differential defined in the next sentence); and may charge the beneficiary that amount for each day he/she occupies the deluxe accommodations.  The maximum amount the provider may charge the beneficiary for such accommodations is the differential between the most prevalent private room rate at the time of admission and the customary charge for the room occupied.  Beneficiaries may not be charged this differential if they (or their representative) do not request the deluxe accommodations.  The beneficiary may not be charged such a differential in private room rates if that differential is based on factors other than personal comfort items.  Such factors might include differences between older and newer wings, proximity to lounge, elevators or nursing stations, desirable view, etc.  Such rooms are standard 1-bed units and not deluxe rooms for purposes of these instructions, even though the provider may call them deluxe and have a higher customary charge for them.  No additional charge may be imposed upon the beneficiary who is assigned to a room that may be somewhat more desirable because of these factors.   10.1.5 - All Private Room Providers (Rev. 1, 10-01-03) A3-3101.E, HO-210.1.E
(Medicare Benefit Policy Manual)
10.1.5 - All Private Room Providers (Rev. 1, 10-01-03) A3-3101.E, HO-210.1.E  If the patient is admitted to a provider which has only private accommodations, and no semiprivate or ward accommodations, medical necessity will be deemed to exist for the accommodations f urnished.  Beneficiaries may not be subjected to an extra charge for a private room in an all-private room provider.  10.1.6 - Wards  (Rev. 1, 10-01-03) A3-3101.1.F, HO-210.1.F  The law contemplates that Medicare patients should not be assigned to ward accommodations except at the patient's request or for a reason consistent with the purposes of the health insurance program.  When ward accommodations are furnished at the patient's request or for a reason determined to be consistent with the program's purposes, payment will be based on the average per diem cost of routine services (see 10.1.1 above).  Where ward accommodations are assigned for other reasons, the law provides what may be a substantial penalty.  (See 10.1.6.2  below).  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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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:
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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:
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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.
(Medicare Benefit Policy Manual)
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.   2. Qualifications of the ordering/admitting practitioner:  The order must be furnished by a physician or other practitioner (ordering practitioner) who is:  (a) licensed by the state to admit inpatients to hospitals, (b) granted privileges by the hospital to admit inpatients to that specific facility, and (c) knowledgeable about the patients hospital course, medical plan of care, and current condition at the time of admission.  See section (B)(3) for a discussion of the requirements to be knowledgeable about the patients hospital course.  The ordering practitioner makes the determination of medical necessity for inpatient care and renders the admission decision.  The ordering practitioner is not required to write the order but must authenticate (sign, or in t he case of an initial order (under (B)(2)(a)) or a verbal order (under (B)(2)(b)), countersign) the order reflecting that he or she has made the decision to admit the patient for inpatient services.
(Medicare Benefit Policy Manual)
The admission decision (order) may not be delegated to a nother individual who is not authorized by the state to admit patients, or has not been granted admitting privileges by the hospital's medical staff.  However, a medical resident, physician assistant, nurse practitioner, or other non- physician practitioner  may act as a proxy for the ordering practitioner provided they are authorized under state law to admit patients and the requirements outlined below are met ( FY 14 IPPS Final Rule  and 42 CFR 412.3(b)).  a. Residents and non- physician practitioners authorized to make initial admission decisions -  Certain non- physician practitioners and residents working within their residency program are authorized by the state in which the hospital is located to admit inpatients, and are allowed by hospital by -laws or policies to do the same.  The ordering practitioner ma y allow these individuals to write inpatient admission orders on his or her behalf, if the ordering practitioner approves and accepts responsibility for the admission decision by authenticating (countersigning) the order prior to discharge.  (See (A)(2) fo r guidance regarding the definition of discharge time and (B)(3) for more guidance regarding knowledge of a patients hospital course).  In authenticating (countersigning) the order, the ordering practitioner approves and accepts responsibility for the adm ission decision.  This process may also be used for practitioners (such as emergency department physicians) who do not have admitting privileges but are authorized by the hospital to issue temporary or bridge inpatient admission orders.