CMS Pub. 100-01, ch. 4, § 20

Medical Insurance Program

(Rev. 12425, Issued: 12-21-23, Effective: 01-01-24, Implementation: 01-02-24)

A physician must certify that medical and other health services covered by medical

insurance which were provided by (or under arrangement made by) the hospital were

medically required.

Physician certification is not required for the following outpatient services furnished on

or after January 3, 1968:

• Hospital services and supplies incident to physicians' services rendered to

outpatients; and

• Diagnostic services furnished by a hospital or which the hospital arranges

to have furnished in other facilities operated by or under the supervision of the

hospital or its medical staff.

Hospitals must obtain a physician's certification with respect to other services furnished

to outpatients.

Primarily, this means that a certification statement is needed for diagnostic services

furnished under arrangements by a facility that is not operated by or under the

supervision of the hospital or its organized medical staff, e.g., services obtained from an

independent laboratory.

This certification requires a brief description of the services and the signature of the

physician. It needs to be made only once for a course of treatment. Where services are

provided on a continuing basis, such as a course of radium treatments, the physician's

certification may be made at the beginning or end of the course of treatment, or at any

other time during the period of treatment.

There is no requirement that the certification be entered on any specific form or handled

in any specific way, as long as the approach adopted by the hospital permits the A/B

MAC (A) to determine that the certification requirement is in fact met. Therefore, the

certification could be entered or pre-printed on a form the physician already has to sign;

or a separate certification form could be used.

In addition, physician's certifications are required for the rental and purchase of durable

medical equipment (see §70), outpatient therapy, i.e., physical therapy, occupational

therapy and speech-language pathology services (see Pub. 100-02, Chapter 15, §220),

partial hospitalization services (see Pub. 100-02, Chapter 6, § 70.3), and intensive

outpatient services (see Pub. 100-02, Chapter 6, § 70.4).

The Physician Certification Statement requirements for all ambulance providers

(hospital-owned and operated) and suppliers (independently-owned and operated) are

located at 42 CFR §410.40 (d) (2) and §410.40 (d) (3).