Closely related to the “2-Midnight Rule” (discussed in the December 17 edition of this newsletter), Physician Certification requires that a provider document the patient’s “medical necessity that such services be provided on an inpatient basis.”1 However, the Centers for Medicare and Medicaid Services (CMS) states that “no specific procedures or forms are required for certifications and recertification statements.”1
To meet these requirements, each patient should have an inpatient admit order placed by the provider (or created by another user and signed by the provider). The new Admit Data Order collection screen, available in the NextGen® Inpatient Clinicals (NGC) KBM version 2.0.3, (Figure 1) will meet all the required CMS criteria. If the inpatient order has not been properly documented, then the hospital will not be eligible to submit a Part A repayment claim.1
With this order collections screen, and through other normal uses of the NGC application, all of the required Physician Certification requirements will be captured. This prevents providers from being required to complete additional documentation to prove repayment eligibility. Below are requirements put forth by CMS, and how the NGC application will meet those requirements:
-The authentication requirement for the provider is met when the signature (or countersignature) is captured on the inpatient admission order.
-Certification of reasons for admission will be captured by entering the patient’s diagnosis on any physician documentation, such as the Admitting H&P form or the Progress Notes form.
– The estimated time requirement will be met by the Inpatient Admission Order (in the CPOE tab) written in accordance with the 2‐Midnight benchmark, supplemented by the physician notes and discharge planning instructions.
– The post-hospital care plan requirement will be met either by physician notes or by discharge planning instructions.
– The CAH 96-hour expectation requirement will be met either by physician notes or by actual discharge within 96 hours.
All of the above requirements are frequently part of the clinician’s normal workflow and no changes need to occur. Please ensure that your facility is up to date on the latest NextGen® Hospital KBM release to ensure that all information is being captured at the point of order entry.
Additional information can be located at:
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