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Physician Certification

Critical Access Hospital Alert - CAH Physician Certification Requirements

CMS finalized policies related to inpatient admission and review criteria, including physician certification and admission order requirements, for the fiscal year 2014 hospital inpatient prospective payment system final rule.

On Sept. 5, CMS issued guidance further clarifying physician certification and order requirements for inpatient admissions. CMS specifically sets forth the following condition of payment for inpatient CAH services:

  • For inpatient Critical Access Hospital (CAH) services, the physician must certify that the beneficiary may reasonably be expected to be discharged or transferred to a hospital within 96 hours after admission to the CAH.

  • The CAH 96 hour expectation requirement will be met either by physician notes or by actual discharge within 96 hours.

However, there is some confusion regarding payment on the basis of the physician's certification of admission. If the physician should have or could have reasonably known that the stay would be in excess of 96 hours, then the contention is that the patient should not have been admitted to a Critical Access Hospital without a plan of action to transfer that patient to a tertiary facility.

Therefore, the question arises (per CMS' interpretation) as to whether the hospital should be reimbursed in accordance with a cap at the 4th day or even if the CAH should receive any reimbursement at all.

This results in many unanswered questions:

  • Will this result in fewer Inpatient admissions to Critical Access Hospitals?

  • Will this lead to refund requests?

  • Will this retrospectively impact any stay meeting the qualification since program inception?

  • How is this situation avoided?

Although this will not affect overall participation with CMS (as long as the average hospital stay is 96 hours or less) it appears that the reimbursement for individual cases will be impacted.


For more information, contact Medical Recovery Services

(816) 229-4887

Medical Recovery Services is a full-service revenue cycle company assisting

hospitals and surgical centers in achieving their full earning potential since 2004.

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