DEPARTMENT: Governmental Operations Support / POLICY DESCRIPTION: Physician Certification and Recertification for Post Acute Services
PAGE:1 of 6 / REPLACES POLICY DATED: 4/1/2000; 8/1/2000; 5/1/2002; 9/1/2002; 1/1/2004
EFFECTIVE DATE: March 1, 2004 / REFERENCE NUMBER: GOS.APS.001
SCOPE: All Company-affiliated facilities, Corporate Departments, Groups and Divisions, and particularly the following Departments and individuals:

Post Acute Services Service Centers

Health Information Management Revenue Integrity
Business Office Medical Staff

Nursing Allied Health Practitioners

Utilization/Case Management
PURPOSE: To outline the Medicare requirements for physician certification and recertification for post acute services.
Definition: For purposes of this policy, “Post Acute Services” shall include Inpatient Psychiatric hospitals and distinct part units (DPU), Inpatient Rehabilitation Facilities (IRF) and DPU, Skilled Nursing Facility (SNF), Swing Bed, Outpatient Physical Therapy (PT), Occupational Therapy (OT) and Speech Pathology (SP) and Partial Hospitalization Program (PHP).
POLICY: The medical necessity of post acute services must be certified and if applicable, recertified as required by the applicable statutes, regulations and manual provisions in order to obtain Medicare reimbursement.
Certification and recertification statements are not submitted to the Medicare program. By signing the hardcopy of the UB92 or by submitting the UB92 electronically, the facility states that the certifications and recertifications have been obtained pursuant to applicable regulatory requirements.

InpatientHospital and Distinct Part Psychiatric Services

  1. Certifications must be obtained at the time of admission, or as soon thereafter as reasonable and practical. The initial certification must state that inpatient psychiatric services were required:
  2. For treatment that could reasonably be expected to improve the patient’s condition; or
  3. For diagnostic study.
  1. The first recertification is required no later than the 12th day of hospitalization; the second recertification is required no later than the 18th day of hospitalization. Subsequent recertifications must be made at intervals established by the hospital’s Utilization Review (UR) committee, but in no event may the interval exceed 30 days.
  1. Recertifications for inpatient psychiatric services must include the following:
  2. Inpatient psychiatric services furnished since the previous certification or recertification were, and continue to be, medically necessary for either treatment that could reasonably be expected to improve the patient’s condition, or for diagnostic study;
  3. The hospital records must show that the services furnished were intensive treatment services, admission and related services necessary for diagnostic study, or equivalent services;
  4. The estimated time an individual will require active treatment as an inpatient; and
  5. Plans for post-discharge care.
Certifications and recertifications for inpatient psychiatric facilities and distinct part units must be signed by a physician who is either the admitting physician or a medical staff member with knowledge of the case.
Inpatient Rehabilitation Facilities (Hospitals and DPU)
1.The initial certification is required no later than the 12th day of hospitalization. An IRF or DPU must meet certain requirements in order to be excluded from the prospective payment system. The unit must have a preadmission screening procedure in effect under which each prospective patient’s condition and medical history are reviewed to determine whether the patient is likely to benefit significantly from an intensive inpatient program or assessment. A physician’s signature concurring with the prescreening assessment qualifies as the initial certification.
2.IRFs must have a plan of treatment for each inpatient that is reviewed at least every two weeks. The recertification requirement can be met with a physician’s statement on the treatment plan that justifies appropriateness of treatment. The first recertification is required no later than the 18th day of hospitalization. Subsequent recertifications must be made at intervals established by the UR committee, but in no event may the interval exceed 30 days.
3.Certifications and recertifications for inpatient rehabilitation facilities and distinct part units must be signed by a physician who is either the admitting physician or a medical staff member with a knowledge of the case.
NOTE: A hospital level of care is required by a patient needing rehabilitative services if that patient needs a relatively intense rehabilitation program that requires a multidisciplinary coordinated team approach to upgrade his or her ability to function. There are two basic requirements which must be met for inpatient hospital stays for rehabilitation care to be covered:
  • The services must be reasonable and necessary (in terms of efficacy, duration, frequency and amount) for the treatment of the patient’s condition; and
  • It must be reasonable and necessary to furnish the care on an inpatient hospital basis, rather than in a less intensive setting such as a SNF, a SNF level of care in a swing bed hospital, or on an outpatient basis.
Skilled Nursing Facility Services and Swing Bed
  1. Certifications must be obtained at the time of admission or as soon thereafter as is reasonable and practicable. The certification must state that post-hospital skilled nursing care is or was required because:
  2. The individual needs or needed, on a daily basis, skilled nursing care (furnished directly by or requiring the supervision of skilled nursing personnel) or other skilled rehabilitation services that, as a practical matter, can only be provided in a SNF or a swing-bed hospital on an inpatient basis;
  3. The skilled nursing care is or was needed for a condition for which the individual received inpatient care in a participating hospital or a qualified hospital, as defined in 42 C.F.R. §409.3; or
  4. The individual has been correctly assigned to one of the Resource Utilization Groups (RUGs) designated as representing the level of care, as provided in 42 C.F.R. §409.30.
  1. The first recertification is required no later than the 14th day of the post-hospital SNF care. Subsequent recertifications are required at least every 30 days after the first recertification.
  1. Recertifications must include:
  2. The reasons for the continued need for post-hospital services;
  3. The estimated time the individual will need to remain in the SNF;
  4. Plans for home care, if any; and
  5. If appropriate, the fact that the continued services are needed for a condition that arose after admission to the SNF and while the individual was still under treatment for the condition for which he or she had received inpatient hospital services.
  1. Certifications and recertifications for SNF and swing bed services must be signed by one of the following:
  2. The physician responsible for the case;
  3. A physician on the SNF staff or a physician who is available in case of an emergency and has knowledge of the case, and who acts with the authorization of the physician responsible for the case; or
  4. A nurse practitioner or clinical nurse specialist, neither of whom has a direct or indirect employment relationship with the facility, but who is working in collaboration with a physician.
Outpatient Physical Therapy, Occupational Therapy and Speech Pathology Services
  1. The certification statement must be obtained at the time the plan of treatment is established, or as soon thereafter as possible.
  1. The initial certification must state that:
  2. A written plan for furnishing such services is or was established by the physician, physical therapist, occupational therapist or speech pathologist and is periodically reviewed by the physician or Allied Health Practitioner (nurse practitioner, clinical nurse specialist or physician assistant);
  3. The services were furnished while the individual was under the care of a physician or Allied Health Practitioner; and
  4. The services are or were reasonable and necessary to the treatment of the patient’s condition.
  1. Recertification statements are required at least every 30 calendar days and must be signed by the physician or Allied Health Practitioner who reviews the plan of treatment. The content of the recertifications must include:
  2. The continuing need for therapy services; and
  3. An estimate of how much longer the services will be needed.
  1. Since the certification is closely associated with the plan of treatment, the same physician or Allied Health Practitioner who establishes or reviews the plan must certify the necessity of the services.
  1. If a physician or Allied Health Practitioner establishes the plan of treatment, that physician or Allied Health Practitioner must sign the certification. If a physical therapist, occupational therapist or speech pathologist establishes the plan of treatment, a physician or Allied Health Practitioner who has knowledge of the case must sign the certification.
6.Outpatient physical therapy, occupational therapy, or speech-language pathology services must be furnished to an individual who is under the care of a physician or AHPwho certifies the patient’s outpatient therapy services. If the therapy service continues past the 60th day, there must be evidence in the patient’s clinical record, which is a part of the therapy documentation, that a physician or AHP has seen him/her within 60 days after the therapy began and every 30 days past the 60th day. If the requirement is not met, the therapy services are not covered (reasonable andnecessary). The 60-day period begins with the therapist or pathologist initial encounter with the patient, i.e., the day when the evaluation is performed. In the event that an evaluation is not indicated the first treatment session begins the 60-day period. The therapist’s or pathologist’s first encounter with the patient should occur in a timely manner from the date of the physician or AHP therapy referral. For continuity of care the physician or AHP who certifies the patient’s need for outpatient therapy services is the same person who meets the visit requirements. In addition, timing of recertifications and the visit requirements should coincide. However, the physician or AHP still makes the necessary certifications.
Partial Hospitalization Program Services
  1. The initial certification establishing the need for PHP services must be received upon admission into the program.
  1. Coverage of partial hospitalization services is dependent on a physician certification that:
  2. The individual would require inpatient psychiatric care in the absence of such services;
  3. An individualized, written plan of care for furnishing such service has been established by a physician and periodically reviewed by a physician; and
  4. Such services are or were furnished while the individual is or was under the care of a physician.
  1. The first recertification is required as of the 18th calendar day of service and subsequent recertifications are required no less frequently than every 30 calendar days.
4.The recertification must specify that the patient would otherwise require inpatient psychiatric care in the absence of continued stay in the PHP and describe the following:
  1. The patient’s response to the therapeutic interventions provided by the PHP;
  2. The patient’s psychiatric symptoms that continue to place the patient at risk of hospitalization; and
  3. Treatment goals for coordination of services to facilitate discharge from the PHP.
5.Certifications and recertifications for partial hospitalization services must be signed by a physician who is treating the patient and has knowledge of the patient’s response to treatment.
PROCEDURE:
1.The facility must designate an appropriate person to obtain the physician certification/ recertification within the timelines defined by the Centers for Medicare and Medicaid Services (CMS) and/or Local Medical Review Policies (LMRP).
2.A facility-designated person must monitor that physician certification/recertifications are obtained concurrently and are completed within the timelines defined by CMS and/or LMRP.
3.The certification/recertification must be signed, dated, and completed by a physician or applicable allied health practitioner for SNF, swing bed and outpatient therapy services.
4.The physician certification/recertification must be part of the permanent post acute medical record.
5.Prior to releasing an account for final billing, the facility must designate an individual to review, on a case-by-case basis, the medical record documentation to ensure required certifications and recertifications have been obtained and are on file. The facility must not bill if the required certification and recertification statements have not been obtained.
6.The facility must conduct self-monitoring using resources provided by the Corporate Governmental Operations Support Department to determine whether certifications and recertifications have been obtained according to this policy.
The Facility Ethics and Compliance Committee is responsible for the implementation of this policy within the facility.
REFERENCES:
42 U.S.C. §§ 1395f(a)(3), 1395f(a)(2), 1395n(a)(2)(F)
42 C.F.R. §§ 412.29(b), 424.1(b)(1), 424.10, 424.11, 424.13, 424.14, 424.20, 424.24, 424.5(a)(4)
CMS, Medicare Pub 100-1, Chapter 4
CMS Pub -10 §§ 273, 273.1, 274, 275(C), 276, 277
CMS Pub. 9 §260.6.B.
CMS Manual System, Pun. 100-02, Transmittal 5, January 9, 2004

9/2004