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Medicare 101: Know your documentation

March 1, 2007
by RETA UNDERWOOD, ADC
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Basic knowledge of Medicare's skilled care criteria has been historically considered a “must-know” for skilled nursing facility (SNF) admission coordinators. Now it's become a New Age “must-know” for nursing home survival involving all departments and all staff. Nurses, social workers, physicians, and even activity directors and nursing assistants must be Medicare-savvy in order to reap the benefits of the Medicare programs’ Prospective Payment System (PPS). Failure to follow Medicare eligibility guidelines and fulfill documentation needs can result in denials of payment, regulatory sanctions within the survey process, and worse. Even if you’re confident of your performance in this area, a little review can’t hurt.

Who Signs Certification

Certification Time Frame

Recertification Time Frame

Hospital Inpatient

Attending physician or another physician with knowledge of the case with authorization from attending physician, or a member of hospital's medical staff with knowledge of the case

No later than the 12th day of hospitalization

Interval between recertification is not to exceed 30 days

SNF

Attending physician or physician on staff at SNF with knowledge of case

Obtain at time of admission or shortly thereafter

First recertification no later than the 14th day of inpatient extended care services. Sub-sequent at intervals not exceeding 30 days

Home HealthAgency

Attending physician

Obtain at time POC is established or shortly thereafter

Physician must certify at least once every 60 days

Hospice

For initial 90-day period, must obtain written certification statements from medical director of hospice or physician member of the hospice interdisciplinary group and the attending physician

If written certification is not obtained within 2 calendar days of the initiation of hospice care, a verbal certification must be obtained

Must be obtained for each period of hospice care; written certification by hospice medical director or physician member of interdisciplinary group

Medicare 101.A—The Who, What, and When of Physician Certification

Who is responsible?Like all certified Medicare providers, the SNF is responsible for obtaining the required physician certification and recertification statements and for retaining them on file for verification by the intermediary, if needed.

Who can sign?A certification or recertification statement must be signed by the attending physician or a physician on the SNF's staff who has knowledge of the case, or by a nurse practitioner or clinical nurse specialist who does not have a direct or indirect employment relationship with the facility but is working in collaboration with the physician.

What is required and when for recertification?The recertification statement must be completed no later than the 14th day of a stay and at each subsequent 30-day interval. This statement must contain an adequate written record of the reason(s) 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, when appropriate, for home 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 notes. 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 reporting only that continued extended care services are medically necessary is not, in and of itself, sufficient. See the table for allotment of responsibility on this. For more information on physician certification, please refer to Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, available at http://www.cms.hhs.gov/Manuals/IOM/list.asp.

Medicare 101.B–Qualifying Stay Criteria

It is important to recognize that eligibility requirements did not change upon implementation of the Medicare PPS. Qualifying stay criteria still consist of four focus points, each of which should be reviewed and addressed before accepting a patient for admission:

  1. A medically necessary three-day hospital stay must have occurred. This does not include emergency room hours; rather, the clock starts ticking at the time the patient is admitted to an acute care bed. The hospital discharge must have occurred on or after the first day of the month in which the individual attains age 65 or becomes entitled to health insurance benefits under the disability or chronic renal disease provisions of the Medicare law. The three consecutive calendar days’ requirement can be met by stays totaling three consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day.

  2. The patient must receive Part A care within 30 days of the qualifying hospital stay. Customarily, this is not a problem unless the patient is returning after being discharged home or is being readmitted from another setting. In such cases, it is very important to determine the reason for the return service, how it relates to the original qualifying stay, and whether a Medical Predictability Order was written.

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