With so much riding on appropriate admissions vs. observation stay designated services, it’s pretty critical that physicians and staff understand Conditions of Participation and the expectations of the admission order and the CERTIFICATION for reasonable and necessary care. CMS recently published a five page guideline that provides rationale and content specific to the Physician Certification requirements.
This document covers Physician Certification:
Authorization to sign certification
Format (non-specific – content related within any type of documentation)
Default Methodology for Initial Certification.
Qualifications of the ordering/admitting practitioner
Knowledge of the Patient
Specificity of the order
Although the two midnight rule Final Rule published with 1599-F seems to ‘simplify’ the understanding of reasonable expectation for admitted versus observation status; understanding that the above clarifications are still expected to be found within the documented record have not been replaced. That being said, CMS fully expects “…physicians should generally admit as inpatients, beneficiaries they expect will require 2 or more midnights of hospital services, and should treat most other beneficiaries on an outpatient basis. CMS officials believe that, with the exception of cases involving services on the inpatient-only list, only in rare and unusual circumstances would an inpatient admission be reasonable in the absence of a reasonable expectation of a medically necessary stay spanning at least two midnights.”
The FAQ document quoting the above and providing additional two midnight rule justifications further outlines other expectations by CMS. That includes the future possibility to add outpatient treatment time to an inpatient part A billing document to further justify the time a patient was in a physician’s care that substantiates a full two midnight encompassed care episode. Check out all these documents and stay tuned to further discussion on observation vs. admission criteria. With therapy services now requiring claims-based outcomes g-code use when not admitted to an inpatient level of care, all staff need to understand how to determine if a patient is being treated as an inpatient or outpatient level of service.
If you feel there may be a few discrepancies, such as the FAQ stating there will not be a required estimated time of hospitalization and that it should be inherent in the documentation (A6), the order and certification document clearly lists this in their expected content 1.c. Play it safe; include that expectation as part of the documentation!