CMS Pub. 100-02, ch. 1, § 10.2

The order to admit as an inpatient (“practitioner order”) is a critical element in clarifying

when an individual is considered an inpatient of a hospital, including a critical access

hospital (CAH), and is therefore required for all hospital inpatient cases for hospital

inpatient coverage and payment under Part A. As a condition of payment for hospital

inpatient services under Medicare Part A, according to section 1814(a) of the Social

Security Act, CMS is requiring, only for long-stay cases and outlier cases, separate

physician certification of the medical necessity that such services be provided on an

inpatient basis. The signed physician certification is considered, along with other

documentation in the medical record, as evidence that hospital inpatient service(s) were

reasonable and necessary.

The following guidance applies to all inpatient hospital and CAH services unless

otherwise specified. For the remainder of this guidance, references to hospitals includes

CAHs. The complete requirements for the physician certification are found in 42 CFR

Part 424 subpart B, and requirements for admission orders are found at 42 CFR 412.3.

A. Physician Certification. Physician certification of inpatient services is required

for cases that are 20 inpatient days or more (long-stay cases), for outlier cases of

hospitals other than inpatient psychiatric facilities and for cases of CAHs. (See

CY 2015 Outpatient Prospective Payment System Final Rule, 79 FR 66997 and

42 CFR 412 Subpart F, 42 CFR 424.13 and 42 CFR 424.15):

1. Content: The physician certification includes the following information:

a. Reason for inpatient services: The physician certifies the reasons for

either— (i) Continued hospitalization of the patient for inpatient medical

treatment or medically required inpatient diagnostic study; or (ii) Special

or unusual services for outlier cases under the applicable prospective

payment system for inpatient services. For example, documentation of an

admitting diagnosis could fulfill this part of the certification requirement.

b. The estimated (or actual) time the beneficiary requires or required in the

hospital: The physician certifies the estimated time in the hospital the

beneficiary requires (if the certification is completed prior to discharge) or

the actual time in the hospital (if the certification is completed at

discharge). Estimated or actual length of stay is most commonly reflected

in the progress notes where the practitioner discusses the assessment and

plan. For the purposes of meeting the requirement for certification,

expected or actual length of stay may be documented in the order or a

separate certification or recertification form, but it is also acceptable if

discussed in the progress notes assessment and plan or as part of routine

discharge planning.

If the reason an inpatient is still in the hospital is that they are waiting for

availability of a skilled nursing facility (SNF) bed, the regulations at 42

CFR 424.13(c) and 424.14(e) provide that a beneficiary who is already

appropriately an inpatient can be kept in the hospital as an inpatient if the

only reason they remain in the hospital is they are waiting for a post-acute

SNF bed. The physician may certify the need for continued inpatient

admission on this basis.

c. The plans for posthospital care, if appropriate, and as provided in 42 CFR

424.13.

d. For inpatient CAH services only, 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.

Time as an outpatient at the CAH does not count towards the 96 hour

certification requirement. The clock for the 96 hour certification

requirement only begins once the individual is admitted to the CAH as an

inpatient. Time in a CAH swing-bed also does not count towards the 96

hour certification requirement.

The 96-hour certification requirement is based on an expectation at the

time of admission. If a physician certifies in good faith that an individual

may reasonably be expected to be discharged or transferred to a hospital

within 96 hours after admission to the CAH, and something unforeseen

occurs that causes the individual to stay longer at the CAH, the CAH

would be paid for that unforeseen extended inpatient stay as long as that

individual’s stay does not cause the CAH to exceed its 96-hour annual

average condition of participation requirement. However, if a physician

cannot in good faith certify that an individual may reasonably be expected

to be discharged or transferred within 96 hours after admission to the

CAH, the CAH will not receive Medicare reimbursement for any portion

of that individual’s inpatient stay. This would be determined based on a

medical review of the case.

All certification requirements must be completed, signed, and documented

in the medical record no later than 1 day before the date on which the

claim for payment for the inpatient CAH service is submitted, as provided

in the FY15 IPPS Final Rule and 42 CFR 424.11 and 42 CFR 424.15.

e. Inpatient Rehabilitation Facilities (IRFs): The documentation that IRFs

are already required to complete to meet the IRF coverage requirements

(such as the preadmission screening (including the physician review and

concurrence), the post-admission physician evaluation, and the required

admission orders) may be used to satisfy the certification and

recertification statement requirements.

2. Timing: Outlier cases must be certified and recertified as provided in 42 CFR

424.13. Under extenuating circumstances, delayed initial certification or

recertification of an outlier case may be acceptable as long as it does not

extend past discharge. For all other long stay cases, the certification must be

signed and documented no later than 20 days into the inpatient portion of the

hospital stay.

3. Authorization to sign the certification: The certification or recertification

may be signed only by one of the following:

(1) A physician who is a doctor of medicine or osteopathy.

(2) A dentist in the circumstances specified in 42 CFR 424.13(d).

(3) A doctor of podiatric medicine if his or her certification is consistent

with the functions he or she is authorized to perform under state law.

Certifications and recertifications must be signed by the physician responsible

for the case, or by another physician who has knowledge of the case and who

is authorized to do so by the responsible physician or by the hospital’s

medical staff (or by the dentist as provided in 42 CFR 424.11 and 42 CFR

424.13). CMS considers only the following physicians, podiatrists or dentists

to have sufficient knowledge of the case to serve as the certifying physician:

the admitting physician of record (“attending”) or a physician on call for him

or her; a surgeon responsible for a major surgical procedure on the beneficiary

or a surgeon on call for him or her; a dentist functioning as the admitting

physician of record or as the surgeon responsible for a major dental procedure;

and, in the specific case of a non‐physician non‐dentist admitting practitioner

who is licensed by the state and has been granted privileges by the facility, a

physician member of the hospital staff (such as a physician member of the

utilization review committee) who has reviewed the case and who also enters

into the record a complete certification statement that specifically contains all

of the content elements discussed above. The admitting physician of record

may be an emergency department physician or hospitalist. CMS does not

require the certifying physician to have inpatient admission privileges at the

hospital.

4. Format: As specified in 42 CFR 424.11, no specific procedures or forms are

required for certification and recertification statements. The provider may

adopt any method that permits verification. The certification and

recertification statements may be entered on forms, notes, or records that the

appropriate individual signs, or on a special separate form. Except as

provided for delayed certifications, there must be a separate signed statement

for each certification or recertification. If all the required information is

included in progress notes, the physician's statement could indicate that the

individual's medical record contains the information required and that hospital

inpatient services are or continue to be medically necessary.

B. Inpatient Order: A Medicare beneficiary is considered an inpatient of a hospital

if formally admitted as an inpatient pursuant to an order for inpatient admission

by an ordering practitioner. As stated in the FY 2014 IPPS Final Rule, 78 FR

50908 and 50941, and as conveyed in 42 CFR 482.24, if the order is not properly

documented in the medical record prior to discharge, the hospital should not

submit a claim for Part A payment. Meeting the two midnight benchmark does

not, in itself, render a beneficiary an inpatient or serve to qualify them for

payment under Part A. Rather, as provided in Medicare regulations, a beneficiary

is considered an inpatient (and Part A payment may only be made) if they are

formally admitted as such pursuant to an order for inpatient admission by an

ordering practitioner.

With regard to the time of discharge, a Medicare beneficiary is considered a

patient of the hospital until the effectuation of activities typically specified by the

ordering practitioner as having to occur prior to discharge (e.g., “discharge after

supper” or “discharge after voids”). Thus, discharge itself can but does not

always coincide exactly with the time that the discharge order is written, rather it

occurs when the ordering practitioner’s order for discharge is effectuated.

1. Content: The ordering practitioner’s order contains the instruction that the

beneficiary should be formally admitted for hospital inpatient care. The order

must specify admission for inpatient services. Inpatient rehabilitation

facilities (IRFs) must adhere to the admission requirements specified in 42

CFR 412.622. The two midnight benchmark does not apply in IRFs.

2. Qualifications of the ordering/admitting practitioner: The order must be

furnished by a physician or other practitioner (“ordering practitioner”) who is:

(a) licensed by the state to admit inpatients to hospitals, (b) granted privileges

by the hospital to admit inpatients to that specific facility, and (c)

knowledgeable about the patient’s hospital course, medical plan of care, and

current condition at the time of admission. See section (B)(3) for a discussion

of the requirements to be knowledgeable about the patient’s hospital course.

The ordering practitioner makes the determination of medical necessity for

inpatient care and renders the admission decision. The ordering practitioner is

not required to write the order but must authenticate (sign, or in the case of an

initial order (under (B)(2)(a)) or a verbal order (under (B)(2)(b)), countersign)

the order reflecting that he or she has made the decision to admit the patient

for inpatient services.

The admission decision (order) may not be delegated to another individual

who is not authorized by the state to admit patients, or has not been granted

admitting privileges by the hospital's medical staff. However, a medical

resident, physician assistant, nurse practitioner, or other non-physician

practitioner may act as a proxy for the ordering practitioner provided they are

authorized under state law to admit patients and the requirements outlined

below are met (FY 14 IPPS Final Rule and 42 CFR 412.3(b)).

a. Residents and non-physician practitioners authorized to make initial

admission decisions - Certain non-physician practitioners and residents

working within their residency program are authorized by the state in

which the hospital is located to admit inpatients, and are allowed by

hospital by-laws or policies to do the same. The ordering practitioner may

allow these individuals to write inpatient admission orders on his or her

behalf, if the ordering practitioner approves and accepts responsibility for

the admission decision by authenticating (countersigning) the order prior

to discharge. (See (A)(2) for guidance regarding the definition of

discharge time and (B)(3) for more guidance regarding knowledge of a

patient’s hospital course). In authenticating (countersigning) the order, the

ordering practitioner approves and accepts responsibility for the admission

decision. This process may also be used for practitioners (such as

emergency department physicians) who do not have admitting privileges

but are authorized by the hospital to issue temporary or “bridge” inpatient

admission orders.

b. Verbal orders- At some hospitals, individuals who lack the authority to

admit inpatients under state laws and hospital by‐laws (such as a

registered nurse) may nonetheless enter the inpatient admission order as a

verbal order. In these cases, the ordering practitioner directly

communicates the inpatient admission order to staff as a verbal (not

standing) order, and the ordering practitioner need not separately record

the order to admit. Following discussion with and at the direction of the

ordering practitioner, a verbal order for inpatient admission may be

documented by an individual who is not qualified to admit patients in his

or her own right, as long as that documentation (transcription) of the order

for inpatient admission is in accordance with state law including; scope‐

of‐practice laws, hospital policies, and medical staff bylaws, rules, and

regulations. In this case, the staff receiving the verbal order must

document the verbal order in the medical record at the time it is received.

The order must identify the ordering practitioner and must be

authenticated (countersigned) by the ordering practitioner promptly and

prior to discharge. Example: “Admit to inpatient per Dr. Smith” would

be considered an acceptable method of identifying the ordering

practitioner and would meet the verbal order requirement if the verbal

order (1) is appropriately documented in the medical record by the

individual receiving the verbal order when the order is received; and (2) is

authenticated (countersigned) by Dr. Smith promptly, prior to discharge.

c. Standing orders and protocols - The inpatient admission order cannot be

a standing order. While Medicare’s rules do not prohibit use of a protocol

or algorithm that is part of a protocol, only the ordering practitioner, or a

resident or other practitioner acting on his or her behalf under section

(B)(2)(a) can make and take responsibility for the inpatient admission

decision.

d. Commencement of inpatient status - Inpatient status begins at the time

of formal admission by the hospital pursuant to the order, including an

initial order (under (B)(2)(a)) or a verbal order (under (B)(2)(b)) that is

authenticated (countersigned) timely, by authorized individuals, as

required in this section. If the practitioner responsible for authenticating

(countersigning) an initial order or verbal order does not agree that

inpatient admission was appropriate or valid (including an unauthorized

verbal order), he or she should not authenticate (countersign) the order and

the beneficiary is not considered to be an inpatient. The hospital stay may

be billed to Part B as a hospital outpatient encounter.

3. Knowledge of the patient’s hospital course: CMS considers only the

following practitioners to have sufficient knowledge about the beneficiary’s

hospital course, medical plan of care, and current condition to serve as the

ordering practitioner: the admitting physician of record (“attending”) or a

physician on call for him or her, primary or covering hospitalists caring for the

patient in the hospital, the beneficiary’s primary care practitioner or a

physician on call for the primary care practitioner, a surgeon responsible for a

major surgical procedure on the beneficiary or a surgeon on call for him or

her, emergency or clinic practitioners caring for the beneficiary at the point of

inpatient admission, and other practitioners qualified to admit inpatients and

actively treating the beneficiary at the point of the inpatient admission

decision. A utilization review committee physician functioning in that role

does not have direct responsibility for the care of the patient and is therefore

not considered to be sufficiently knowledgeable to order the inpatient

admission. The order must be written by one of the above practitioners

directly involved with the care of the beneficiary, and a utilization committee

physician may only write the order to admit if he or she is not acting in a

utilization review capacity and fulfills one of the direct patient care roles, such

as the attending physician. Utilization review may not be conducted by any

individual who was professionally involved in the care of the patient whose

case is being reviewed (42 CFR 482.30(d)(3)).

4. Timing: The order must be furnished at or before the time of the inpatient

admission. The order can be written in advance of the formal admission (e.g.,

for a pre‐scheduled surgery), but the inpatient admission does not occur until

hospital care services are provided to the beneficiary. Conversely, in the

unusual case in which a patient is admitted as an inpatient prior to an order to

admit and there is no documented verbal order, the inpatient stay should not

be considered to commence until the inpatient admission order is documented.

CMS does not permit retroactive orders. Authentication by the ordering

practitioner of the order (either by signature or, in the case of an initial order

under (B)(2)(a) or a verbal order under (B)(2)(b), countersignature) is required

prior to discharge for all inpatient cases.

5. Specificity of the Order: The regulations at 42 CFR 412.3 require that, as a

condition of payment, an order for inpatient admission must be present in the

medical record. The preamble of the FY 2014 IPPS Final Rule at 78 FR

50942 states, “the order must specify the admitting practitioner’s

recommendation to admit ‘to inpatient,’ ‘as an inpatient,’ ‘for inpatient

services,’ or similar language specifying his or her recommendation for

inpatient care. While CMS does not require specific language to be used on

the inpatient admission order, it is in the interest of the hospital that the

ordering practitioner use language that clearly expresses intent to admit the

patient as inpatient that will be commonly understood by any individual who

could potentially review documentation of the inpatient stay. CMS does not

recommend using language that may have specific meaning only to

individuals that work in a particular hospital (e.g., “admit to 7W”) that will

not be commonly understood by others outside of the hospital.

If admission order language used to specify inpatient or outpatient status is

ambiguous, the best course of action would be to obtain and document

clarification from the ordering practitioner before initial Medicare billing

(ideally before the beneficiary is discharged). Under this policy, CMS will

continue to treat orders that specify a typically outpatient or other limited

service (e.g., admit “to ER,” “to Observation,” “to Recovery,” “to Outpatient

Surgery,” “to Day Surgery,” or “to Short Stay Surgery”) as defining a non‐

inpatient service, and such orders will not be treated as meeting the inpatient

admission requirements.

The admission order is evidence of the decision by the ordering practitioner to

admit the beneficiary to inpatient status. In extremely rare circumstances, the

order to admit may be missing or defective (that is, illegible, or incomplete,

for example “inpatient” is not specified), yet the intent, decision, and

recommendation of the ordering practitioner to admit the beneficiary as an

inpatient can clearly be derived from the medical record. In these extremely

rare situations, contractors have been provided with discretion to determine

that this information constructively satisfies the requirement that the hospital

inpatient admission order be present in the medical record. However, in order

for the documentation to provide acceptable evidence to support the hospital

inpatient admission, thus satisfying the requirement for the order, there can be

no uncertainty regarding the intent, decision, and recommendation by the

ordering practitioner to admit the beneficiary as an inpatient, and no

reasonable possibility that the care could have been adequately provided in an

outpatient setting.

This narrow and limited alternative method of satisfying the requirement for

documentation of the inpatient admission order in the medical record should be extremely

rare, and may only be applied at the discretion of the contractor.