Medical staff alert: New CMS admission rules

Bradley Bryan, M.D.
Medical director, Regional Utilization Management

Oct. 16, 2013

As of Oct. 1, the Centers for Medicare & Medicaid Services began requiring new documentation for inpatient hospital admissions. The new rules apply only to Medicare and Medicare Advantage plan members.

All medical staff members admitting to Providence hospitals must follow these guidelines:

Inpatient order. A physician order is required for all inpatient admissions. Residents, physician assistants and nurse practitioners may write the order in conjunction with the admitting/attending physician. This has always been a CMS requirement, but it will be audited more strictly now. For residents, PAs and NPs, a co-signature is not required for the inpatient order.

Two-midnight rule. For Medicare patients to qualify for inpatient admission, the patient’s hospitalization must be expected to exceed two midnights. Inpatient-only procedures are excluded. Hospitalizations expected to last fewer than two midnights should be managed in an observation or outpatient bed.

Physician certification. The attending physician must document the specific certification elements for all inpatient admissions. These elements must be completed and signed prior to discharge. If residents, physician assistants, or nurse practitioners complete the certification elements, then the attending/supervising physician must co-sign the note. The required certification elements are:

  1. Diagnosis. Documentation in the History and Physical or Progress Note is sufficient.
  2. Justification for inpatient services (medical necessity). Documentation in the History and Physical or Progress Note is sufficient.
  3. Two-midnight expectation. There must be documentation in the record that the hospitalization is expected to exceed two midnights. Inpatient-only procedures are exempt from this rule.
  4. Post-hospital plan. There must be documentation of the anticipated post-hospital plan.

Nos. 2 and 3 can be entered into an Epic note by using "Smart Text"-.ipcert. This will provide downdowns to complete the certification statement.

This new process may seem complicated and onerous, but only a few additional documentation elements are required. Not only will Smart Text make the process as easy as possible, we’ll develop some enhancements in the near future to minimize the workflow impact for the medical staff.