Hospital Inpatient Admission Guidance

With the recent emphasis on and marketplace discussions concerning hospital inpatient admission criteria, The Centers for Medicare and Medicaid Services (CMS) has released additional guidance on inpatient order and certification requirements. 

The organizations that are affected by and to whom the requirements apply are all inpatient hospitals and critical access hospitals. For reimbursement under Medicare Part A, regulations require that physicians must provide certification that the inpatient admission is medically necessary in order to treat the respective patient’s condition, and that it is medically necessary to provide these services in the inpatient setting.

In conjunction with this release, The Centers for Medicare and Medicaid Services (CMS) also issued guidelines for the initial physician admission order and certification for each stay, as well as the requirements for additional certification and recertification for outlier cases (See CMS’s website, specifically 42 CFR Part 424, Subpart B and 42 CFR 412.3

  1. Authentication of the practitioner order,
  2. Reason for inpatient services, including the patient’s specific needs for inpatient medical treatment,
  3. The estimated time the patient requires in the hospital,
  4. The plans for post-hospital care, if appropriate, and
  5. That the physician reasonably expects the patient to be discharged or transferred to a hospital within 96 hours after admission.

Medicare Inside recently published a complete listing of these requirements. You can read the article here: CMS issues guidance on hospital inpatient admission order and certification requirements, Part I: Physician certification

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