What Does Continued Stay Psychiatric Hospitalization Mean Continued Stay Medical Meaning

• The physician certification or recertification statement must be based on a current evaluation of the patient's condition.
• There is no requirement that the certification or recertification be

  

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  entered on any specific form or handled in any specific way

• For services continued over a period of time or for a day outlier case, or for a PPS cost outlier case a physician must certify or recertify the continued need for the services at specified intervals.
• If a hospital fails to obtain the required certification or recertification statements in an individual case, program

  

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  payments may not be made in that case.

• If the hospital'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/she objects in principle to the concept of certification and recertification), the hospital may not bill the program or the beneficiary for covered items or services. The providers agreement precludes the hospital from charging the patient for covered items and services.
• A certification or recertification statement must be signed by the attending physician responsible for the case or by another physician who has knowledge of the case and is authorized to do so by the attending physician, or by a member of the hospital's medical staff with knowledge of the case.

Criteria for continued stay and documentation should reflect:

• Medical necessity
• Availability of out-of-hospital facilities and services which will assume continuity of care.  Where the basis for the certification or recertification is the need for continued inpatient care because of the lack of SNF accommodations, the certification or recertification should so state.
• Estimated time patient will need to remain in the hospital.

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It is sufficient for UR committee to review three things for certification or recertification

1. Consideration was given to the need for special or unusual care in cost outlier status under prospective payment system [PPS]
2. Estimated time the patient will need to remain in the hospital and
3. Plans for post-hospital care

Patients Discharged During Hospital Fiscal Years Beginning On or After October 1, 1983 Under PPS

• Outlier cases certification was required no later than1 day after the hospital reasonably assumes that the case meets the established outlier criteria, or no later than 20 days into the hospital stay, whichever is earlier.
• The first and subsequent recertification/s are required at intervals established by the utilization review committee, on a case-by-case basis if it so chooses, but not less than every 30 days.
• For cost outlier cases The first and subsequent recertification/s  are required at intervals established by the utilization review committee, on a case-by-case basis if it so chooses, but not less than every 30 days.

Delayed Certifications and Recertification

o   Delayed certifications and recertification will be honored: Oversight or lapse must include an explanation for the delay and any medical or other evidence which the hospital considers relevant for purposes of explaining the delay.

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o   Hospital will determine the format of delayed certification and recertification statements, and the method by which they are obtained.

o   Separate signed statements for each certification and recertification would not be required as they would if timely certification and recertification had been made.

Psychiatric and tuberculosis hospitals (which are excluded from PPS) are required to obtain a physician certification on admission.

Hospitals do not transmit physician certification and recertification statements to the intermediary or to CMS.

The hospital must itself certify on the appropriate billing form that the required physician certification and recertification statements have been obtained and are on file. Made available for verification when requested.

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Source: https://www.hospitalcasemanagement.net/en/?p=599

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