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CMS Extends Time for Probe Audits of Inpatient Admissions, and Clarifies Inpatient Order and Certification Requirements [Ober|Kaler]

Probe and Educate Audits of Inpatient Admissions Extended

CMS announced on its Inpatient Hospital Review website on Friday that it was extending the probe and education audits of inpatient admissions for an additional six months. Medicare Administrative Contractors (MACs) will now have until September 30, 2014, to complete these audits and can review claims with admission dates from October 1, 2013 through September 30, 2014. As a CMS representative explained in the February 4, 2014 Special Open Door Forum call, the extension does not increase the number of audits that will be conducted, just the time in which they must be completed.

The website also states that: “Generally, Recovery Auditors and other Medicare review contractors will not conduct post-payment patient status review of inpatient hospital claims with dates of admission on or after October 1, 2013 through October 1, 2014.” During the Open Door Forum call, CMS explained that the statement incorporated the word “generally,” because although clams during this period cannot be targeted for review, they still may be reviewed in a random audit, such as one conducted in a Comprehensive Error Rate Testing (CERT) audit.

Ober|Kaler's Comments

CMS made it very clear that it had not delayed implementation of its new inpatient policy, despite media reports to the contrary, and that the 2-Midnight Rule applies to admissions beginning September 30, 2013. The extension of time granted for the completion of the audits raises concerns that hospitals will not get the results of the audits as soon as anticipated, which could lead to delays in complying with the new rule.


Inpatient Certifications and Admission Orders Clarified

CMS also issued a seven page document [PDF] late last week, clarifying its position on hospital inpatient certifications and orders, which included the following information.


  • Physician Certification of Time Beneficiary Requires/Required in Hospital: The certification must include either an estimated time the beneficiary requires in the hospital (if the certification is completed prior to discharge) or the actual time in the hospital (if the certification is complete at discharge). This requirement is met if there is documentation of time found in the order, a separate certification or recertification, the progress notes, or the discharge plan.
  • Critical Access Hospital (CAH) 96 Hour Requirement: The physician certification for a CAH patient must include an assertion that the beneficiary “may reasonably be expected” to be discharged or transferred to a hospital within 96 hours after admission to the CAH. Outpatient time is excluded from the 96 hour count.
  • Inpatient Rehabilitation Facility (IRF) Certifications: IRF documentation already required to meet IRF coverage requirements may be used to satisfy the certification and recertification statement requirements.
  • Timing of Discharge: Discharge can, but does not have to, coincide with the time the discharge order is written. For example, if a physician signs a discharge order stating that discharge is to occur after a future event, such as a meal, then the discharge occurs after that event, consistent with the order.
  • Certifying Physician: The certifying physician may be an emergency department physician or hospitalist, and does not need to have admitting privileges at the hospital.
  • Format: Except for delayed certifications, there must be a separate signed statement for each certification and recertification. However, the required content of the certification may be entered on forms, notes or other records. If the content is in the progress notes, the physician’s statement could indicate that.

Inpatient Orders

  • Delegated Authority: A medical resident, physician assistant, nurse practitioner or other non-physician practitioner may act as a proxy for the ordering practitioner if the proxy is authorized under state law to admit patients and the following requirements are met:
    • Proxy: The non-physician practitioner must be permitted by hospital by-laws or policies to admit patients or have authority by the hospital to issue temporary or “bridge” inpatient admission orders (e.g., emergency physicians). The ordering physician must accept the order by countersigning it prior to discharge.
    • Verbal Orders: Verbal orders may be accepted by individuals lacking authority to admit, if such is permitted by state law and hospital policy, and the order is countersigned by the admitting practitioner prior to discharge.
    • Standing Order/Protocols: Standing orders or protocols do not qualify as proper inpatient admission orders.
  • Knowledge of Patient’s Hospital Course, Plan of Care and Current Condition:Only a practitioner with knowledge of the patient’s course of treatment, plan of care and current condition may sign the admission order. Medicare considers only the following individuals to have such knowledge: admitting physician (“attending”) or physician on call for him/her, hospitalist caring for the patient, patient’s primary care practitioner or physician on call for him/her, surgeon responsible for the patient’s major surgical procedure or physician on call for him/her, or practitioner actively treating the patient at the time of admission. A utilization review committee member may not write the order unless he/she is directly involved with the care of the patient.
  • Timing: The order may be written in advance of admission, e.g., for pre-scheduled surgery.

Ober|Kaler's Comments

Although these clarifications do provide much needed guidance for hospitals, many issues still remain unclear, e.g., how to treat transfers and how to address MACs that are not abiding by CMS’s rules and clarifications in their reviews. CMS has stated that it will be issuing additional guidance and continues to urge providers to directly contact CMS with any questions or concerns via email at

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