On July 14, 2014, the Centers for Medicare & Medicaid Services (“CMS”) issued the Outpatient Prospective Payment System Proposed Rule for Calendar Year 2015 (“Proposed Rule”), but the Proposed Rule also addresses issues unrelated to OPPS. Among other changes, the Proposed Rule eliminates the physician certification statement requirement for most inpatient stays paid under Medicare Part A (currently a requirement of the “2-Midnight Rule”). Under the Proposed Rule, CMS will continue to require, for example, a physician admission order as a condition of payment for inpatient services, but a physician certification statement would only be required for inpatient stays of 20 days or more and outlier cases.
However, even though CMS proposes to remove the physician certification requirement for most inpatient stays, it still expects to see adequate and appropriate documentation of the medical necessity for the inpatient admission. Specifically, CMS stated “we believe that, in most cases, the admission order, medical record and progress notes will contain sufficient information to support the medical necessity of an inpatient admission without a separate requirement of additional, formal physician certification.” Therefore, physicians and hospitals should continue to ensure that the medical record contains adequate justification for the inpatient stay, including the reason for hospitalization, the estimated time the patient will need to remain in the hospital and the plan of post-hospital care, if applicable.
It is important to note that the changes in the Proposed Rule would not affect the critical access hospital (“CAH”) requirement for inpatient admissions that a physician certify the beneficiary may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH. The Proposed Rule is available here, and the proposed changes to the physician certification requirements are addressed at pages 41056 through 41058 of the Proposed Rule.