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Documentation Updates

for Physicians

CMS IPPS 2014 Final Rule

1

Agenda

• Background

• FY2014 IPPS Compliance Requirements

– Physician order

– “2-Midnight Rule”

– Medical Necessity Documentation and Physician

Certification

• Summary

2

IPPS Key

Requirements/Changes

• The Time the patient is expected to stay in

the hospital (2 midnights is guide)

• The Order to “admit to inpatient” or “refer

for observation/outpatient”

• The Documentation & Certification of

medical necessary to support the patient’s

inpatient admission.

3












Time: 2 Midnight

Expectation

4

• “Benchmark of 2 midnights”

– “the decision to admit the beneficiary should be based on the cumulative time

spent at the hospital beginning with the initial outpatient service. In other

words, if the physician makes the decision to admit after the beneficiary arrived

at the hospital and began receiving services, he or she should consider the

time already spent receiving those services in estimating the beneficiary’s

total expected length of stay.”

0946, IPPS

• “Presumption of 2 midnights”

– “Under the 2-midnight presumption, inpatient hospital claims with lengths of

stay greater than 2 midnights after formal admission following the order

will be presumed generally appropriate for Part A payment and will not be

the focus of medical review efforts absent evidence of systematic gaming,

abuse or delays in the provision of care…”

Page 50949, IPPS

Benchmark vs. Presumption

5

Exceptions to the

2 Midnight Rule

• Medicare Inpatient only Surgical List

• AMA

• Transfers

• Death

• Other Rare exceptions

6

Expectation/Certification

• Physician must document if they expect the patient’s

hospital care to span more or less than 2 midnights

– Treatment time spent in the ED can be counted towards

2 midnights

• Guidelines:

– If you believe the patient will be discharged same day

or the day following hospitalization, consider

ordering Outpatient or Observation

– If you believe the patient will NOT be ready for

discharge the day after hospitalization, consider

ordering Inpatient

7












Physician Orders

8

• For payment of hospital inpatient services under

Medicare Part A, the order must specify the

admitting practitioner’s recommendation to admit

“to inpatient,” “as an inpatient,” “for inpatient

services,” or similar language specifying his or

her recommendation for inpatient care

Page 50942, IPPS

• “Admit to Tower 7” or “Admit to Dr. Smith” are

not recommended

Physician Order

9

Some commenters commented that their current processes provide for admission “to case management” or “to utilization

review” rather than specifying inpatient admission.

Response: “As we discussed above, many public comments from physicians indicated that they believed the physician should be involved in the determination of patient status, and we agree. To reinforce this policy and reduce confusion among hospitals, beneficiaries, and physicians on the differences between outpatient observation and inpatient services, we are providing in this final rule that the order for inpatient admission must specify admission “to or as an inpatient.”

Page 50942, IPPS

Physician must be involved in

Order Determination

10

Physician Order Clarification

• Qualifications of the ordering/admitting practitioner: – At some hospitals, practitioners who lack the authority to admit inpatients under either

State laws or hospital by‐laws may nonetheless frequently write the sets of admitting orders that define the initial inpatient care of the patient. In these cases, the ordering practitioner need not separately record the order to admit ….. the order must identify the qualified “ordering practitioner”, and must be authenticated by the ordering practitioner (or by another practitioner with the required admitting qualifications) prior to discharge.

• Verbal orders: – A verbal or telephone inpatient admission order must be authenticated (signed, dated

and timed) by the ordering practitioner (or by another practitioner with the required admitting qualifications in his or her own right) in the medical record prior to discharge, unless the hospital or the State requires an earlier timeframe

• Timing: – The order must be furnished at or before the time of the inpatient admission.

Sept 5 CMS Update Memo

11

• Inpatient Cases: must include the words “Admit” and

“Inpatient” to be a valid inpatient order

• Observation/Outpatient Cases: Should include the phrase

“refer for Observation Services” or “outpatient status”

– Avoid using “admit” and “Observation or Outpatient” in the same

order. CMS considers this to be contradictory

– “Admit to Tower 7” or “Admit to Dr. Smith” are not recommended

Physician Order Guidelines

12












Physician

Documentation and

Certification

Requirements

13

Certification Requirements

• CMS requires physician certification of the patient’s inpatient admission in

the medical record. The certification must include:

– Order for inpatient admission (as discussed)

– Diagnosis and rationale for hospitalization/ inpatient medical treatment

– Documentation of the estimated time the patient will need to remain in the hospital (as

discussed)

– Plans for post-hospital care, if appropriate

– May be entered on forms, notes, or records that the appropriate individual signs, or on a

special separate form.

– If information is in different places (i.e. progress notes, H+P) [certification] statement should

indicate where it may be found

– Certification must be signed and documented in the medical record prior to the hospital

discharge

• CFR §424.13

14

Sept 5 CMS Update:

Physician Certification

Timing: The certification must be completed, signed, dated and documented in the medical record

prior to discharge

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

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 verification.

The certification and recertification statements may be entered on forms, notes, or records

that the appropriate individual signs, or on a special separate form.

• Sept 5 CMS Update Memo

15

Guidelines for

Documentation/Certification

• Excellent patient care should continue to be the

top priority.

• Clearly document and sign the diagnosis,

medical rationale, plan of care and anticipated

discharge.

• Sign the admission order and certification (if

appropriate) prior to discharge.

16

Medical Documentation Takeaways

6 key pieces of documentation for medical necessity

• Past Medical History

Comorbidities

• Severity of signs and symptoms

Pertinent positives on physical exam

• Current Medical needs Plan of care and orders

• Facilities available for adequate care

• Predictability of an adverse outcome

Suspected diagnosis and rational

• Expectation Length of Stay

17

Surgical Takeaways

• Medicare's Inpatient Only List should be reviewed at the

time the procedure is scheduled

– For procedures that are on the Medicare IP only list,

• the order for Inpatient must be on the chart PRIOR

to the surgery

– If the procedure changes during surgery to an Inpatient

only case

• ensure the IP order is put on the chart ASAP after

the procedure

18

Summary

• Changes go into effect October 1, 2013

• Order must be written and signed by

attending

• Time Expectation of LOS AND medical

necessity drives Inpatient or Outpatient

status

• Certification must be signed by attending

physician

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