In federal fiscal year 2014, concurrently with the implementation of the Two Midnight Rule, CMS adopted a new regulation (the "Admissions Regulation") making the inpatient admission order an express condition of Medicare payment. Among other requirements, the Admissions Regulation addresses the issue of who may furnish a valid order for inpatient admission. One question that arises periodically in the context of this regulation is whether medical residents may admit Medicare patients, and under what circumstances.

The Admissions Regulation requires that the admission order must be furnished by a "qualified and licensed practitioner who has admitting privileges at the hospital as permitted by State law," and who is "knowledgeable about the patient's hospital course, medical plan of care, and current condition." The regulation emphasizes that the admission decision may not be delegated to someone who is not so qualified. (42 C.F.R. § 412.3(b).) In subregulatory guidance posted on the CMS website, the agency adds that such an ordering practitioner "must sign the order reflecting that he or she has made the decision to admit the patient for inpatient services."

Thus, the practitioner who makes the admission decision and furnishes and signs the admission order must, in addition to being knowledgeable about the patient's condition and treatment, be state-licensed to admit hospital inpatients and have hospital-granted privileges to do so. Whether a given medical resident is able to meet each element to be a qualified ordering practitioner requires a case-by-case determination. First, it is necessary to understand the particular resident's medical licensure status, as some states offer restricted medical licenses that permit residents to perform certain activities in the hospital, but may not authorize admission decisions. Second, a properly licensed resident must also be granted admitting privileges by the hospital's medical staff, so an understanding of the institution's medical staff bylaws is essential. Third and finally, a properly licensed resident with admitting privileges must also be appropriately knowledgeable about the particular patient's condition and treatment plan.

In sum, per Medicare admission order guidelines, some residents likely will be able to function in their own right as the ordering practitioner, but many will not. Notably, the Medicare guidance linked above specifically contemplates a situation where a resident—rather than being the ordering practitioner himself or herself—may admit an inpatient on behalf of another ordering practitioner. The guidance provides that the resident may act as a "proxy" for the qualified ordering practitioner, provided the ordering practitioner "approves and accepts responsibility for the admission decision by countersigning the order prior to discharge."