----- Original Message -----
Sent: Thursday, December 11, 2003 4:44
PM
Subject: Re: cert's/700 forms
Cites from two places. I've bolded parts of
interest. I think this is the "in writing" you seek-Caralyn
40 - Certification and Recertification by
Physicians for Extended Care Services - (Rev. 1, 09-11-02)
Payment for
covered posthospital extended care services may be made only if a physician
makes the required certification and, where services are furnished over a
period of time, the required recertification regarding the services
furnished.
The skilled nursing facility
is responsible for obtaining the required physician certification and
recertification statements and for retaining them in file for verifications,
if needed, by the intermediary. The skilled nursing facility determines the
method by which the physician certification and recertification statements
are to be obtained. There is no requirement that a specific procedure or
specific forms be used, as long as the approach adopted by the facility
permits a verification to be made that the certification and recertification
requirements are in fact met. Certification and recertification statements
may be entered on or included in forms, NOTEs, or other records a physician
normally signs in caring for a patient, or a separate form may be used.
Except as otherwise specified, each certification and recertification
statement is to be separately signed by a physician.
If the facility's failure to
obtain a certification or recertification is not due to a question as to the
necessity for the services, but rather to the physician's refusal to certify
based on other grounds (e.g., he objects in principle to the concept of
certification and recertification), the facility may not bill the program or
the beneficiary for covered items or services. The provider agreement which
the facility files with the Secretary precludes it from charging the patient
for covered items and services.
If a physician refuses to
certify because, in his/her opinion, the patient does not require skilled
care on a continuing basis for a condition for which he/she was receiving
inpatient hospital services, the services are not covered and the facility
can bill the patient directly. The reason for the physician's refusal to
make the certification must be documented in the facility records. For such
documentation to be adequate, there must be some statement in the facility's
records, signed by a physician or a responsible facility official,
indicating that the patient's physician feels that the patient does not
require skilled care on a continuing basis for any of the conditions for
which he/she was hospitalized.
40.1 - Who May Sign the Certification or
Recertification for Extended Care Services - (Rev. 1, 09-11-02)
A certification or
recertification statement must be signed by the attending physician or a
physician on the staff of the skilled nursing facility who has knowledge of
the case or by a nurse practitioner or clinical nurse specialist who does
not have a direct or indirect employment relationship with the facility, but
who is working in collaboration with the physician.
Ordinarily, for purposes of
certification and recertification, a "physician" must meet the definition
contained in Chapter 5, �70 of this
manual.
40.2 - Certification for Extended Care Services
- (Rev. 1, 09-11-02)
The certification must
clearly indicate that posthospital extended care services were required to
be given on an inpatient basis because of the individual's need for skilled
care on a continuing basis for any of the conditions for which he/she was
receiving inpatient hospital services, including services of an emergency
hospital (see Chapter 5, �20.2 prior to transfer
to the SNF. Certifications must be obtained at the time of
admission, or as soon thereafter as is reasonable and practicable.
The routine admission procedure followed by a physician would not be
sufficient certification of the necessity for posthospital extended care
services for purposes of the program.
If ambulance service is furnished by a skilled
nursing facility, an additional certification is required. It may be
furnished by any physician who has sufficient knowledge of the patient's
case, including the physician who requested the ambulance or the physician
who examined the patient upon his arrival at the facility. The physician
must certify that the ambulance service was medically
required.
40.3 - Recertifications for Extended Care
Services - (Rev. 1, 09-11-02)
The recertification
statement must contain an adequate written record of the reasons for the
continued need for extended care services, the estimated period of time
required for the patient to remain in the facility, and any plans, where
appropriate, for home care. The recertification statement made by the
physician does not have to include this entire statement if, for example,
all of the required information is in fact included in progress NOTEs. In
such a case, the physician's statement could indicate that the individual's
medical record contains the required information and that continued
posthospital extended care services are medically necessary. A statement
reciting only that continued extended care services are medically necessary
is not, in and of itself, sufficient.
If the circumstances require it, the first
recertification and any subsequent recertifications must state that the
continued need for extended care services is for a condition requiring such
services which arose after the transfer from the hospital and while the
patient was still in the facility for treatment of the condition(s) for
which he/she had received inpatient hospital services.
40.4 - Timing of Recertifications for Extended
Care Services - (Rev. 1, 09-11-02)
The first
recertification must be made no later than the l4th day of inpatient
extended care services. A skilled nursing facility can, at its
option, provide for the first recertification to be made earlier, or it can
vary the timing of the first recertification within the l4-day period by
diagnostic or clinical categories. Subsequent recertifications must be made
at intervals not exceeding 30 days. Such recertifications may be made at
shorter intervals as established by the utilization review committee and the
skilled nursing facility.
At the option of the skilled nursing facility,
review of a stay of extended duration, pursuant to the facility's
utilization review plan (if a UR review plan is in place), may take the
place of the second and any subsequent physician recertifications. The
skilled nursing facility should have available in its files a written
description of the procedure it adopts with respect to the timing of
recertifications. The procedure should specify the intervals at which
recertifications are required, and whether review of long-stay cases by the
utilization review committee serves as an alternative to recertification by
a physician in the case of the second or subsequent
recertifications.
40.5 - Delayed Certifications and
Recertifications for Extended Care Services - (Rev. 1,
09-11-02)
Skilled nursing facilities
are expected to obtain timely certification and recertification statements.
However, delayed certifications and recertifications will be honored where,
for example, there has been an isolated oversight or lapse.
In addition to complying
with the content requirements, delayed certifications and recertifications
must include an explanation for the delay and any medical or other evidence
which the skilled nursing facility considers relevant for purposes of
explaining the delay. The facility will determine the format of delayed
certification and recertification statements, and the method by which they
are obtained. A delayed certification and recertification may appear in one
statement; separate signed statements for each certification and
recertification would not be required as they would if timely certification
and recertification had been made.
40.6 - Disposition of Certification and
Recertifications for Extended Care Services - (Rev. 1,
09-11-02)
Skilled nursing
facilities do not have to transmit certification and recertification
statements to the intermediary; instead, the facility must itself certify,
in the admission and billing form, that the required physician certification
and recertification statements have been obtained and are on
file.
50 - Physician's Certification and
Recertification for Outpatient Physical Therapy - (Rev. 1,
09-11-02)
50.1 - Content of Physician's Certification -
(Rev. 1, 09-11-02)
No payment is made
for outpatient physical therapy, occupational therapy, or speech pathology
services unless a physician certifies that:
* The
outpatient physical therapy, occupational therapy, or speech pathology
services are or were furnished while the patient was under the care of a
physician;
* A
plan for furnishing such services is or was established by the physician,
physical therapist, occupational therapist, or speech pathologist and
periodically reviewed by the physician; and
*
Services are or were required by the patient.
Since the certification is
closely associated with the plan of treatment, the same physician who
establishes or reviews the plan must certify to the necessity for the
services. Providers obtain the certification at the time the plan of
treatment is established or as soon thereafter as possible. Physician means
a doctor of medicine, osteopathy (including an osteopathic practitioner), or
podiatric medicine legally authorized to practice by the State in which
he/she performs these services. In addition, physician certifications or
recertifications by doctors of podiatric medicine must be consistent with
the scope of the professional services provided by a doctor of podiatric
medicine as authorized by applicable State law.
50.2 - Recertificaton - (Rev. 1,
09-11-02)
When outpatient physical
therapy, occupational therapy, or speech pathology services are continued
under the same plan of treatment, the physician must recertify at intervals
of at least once every 30 days that there is a continuing need for such
services and estimate how long services are needed. Providers obtain the
recertification at the time the plan of treatment is reviewed since the same
interval (at least once every 30 days) is required for the review of the
plan. Recertifications are signed by the physician who reviews the plan of
treatment. The form and manner of obtaining timely recertification is up to
the provider.
NEW/REVISED MATERIAL - EFFECTIVE DATE: July 1, 2003
IMPLEMENTATION DATE: July 1, 2003
Medicare contractors only: these instructions should be implemented
within your
current operating budget.
The documentation that supports the Plan of
Care must be in the medical record.
Therefore, we will no longer mandate the use of the Plan of
Treatment for
Outpatient Rehabilitation (HCFA Form 700) or the Updated Plan
of Progress for
Outpatient Rehabilitation (HCFA Form 701) in Exhibit 24. We are
deleting the
forms, all Program Integrity Manual Chapter 9 references to the
forms, and table of
contents references to the forms. Instead, providers may use
any written format,
including a form resembling the HCFA Forms 700/701, to convey
the required
information.
----- Original Message -----
Sent: Thursday, December 11, 2003 5:45
PM
Subject: cert's/700 forms
I am trying to locate "in writing" the requirement
that we cannot bill the FI until the certs & recerts, 700 & 701s are
signed.
Can someone help me on this?
Thx in advance!
