----- 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!
