CMS Pub. 100-02, ch. 8, § 40

Services

(Rev. 10880, Issued: 08-06-21, Effective: 11-08-21, Implementation: 11-08-21)

Payment for covered posthospital extended care services may be made only if a physician

(or, as discussed in §40.1 of this chapter, a physician extender) makes the required

certification, and where services are furnished over a period of time, the required

recertification regarding the services furnished.

The SNF must obtain and retain the required certification and recertification statements.

The A/B MAC (A) may request them to assist in determining medical necessity when

necessary. The SNF will determine how to obtain the required certification and

recertification statements. There is no requirement for a specific procedure or form as

long as the approach adopted by the facility permits verification that the certification and

recertification requirement is met. Certification or recertification statements may be

entered on or included in forms, notes, or other records that would normally be signed in

caring for a patient, or on a separate form. Except as otherwise specified, each

certification and recertification is to be separately signed.

If the SNF’s failure to obtain a certification or recertification is not due to a question of

the necessity for the services, but to the physician’s or physician extender’s refusal to

certify on other grounds (e.g., an objection in principle to the concept of certification and

recertification), the SNF cannot charge the beneficiary for covered items or services. Its

provider agreement precludes it from doing so.

If a physician or physician extender refuses to certify, because, in his/her opinion, the

patient does not, as a practical matter, require daily skilled care for an ongoing condition

for which he/she was receiving inpatient hospital services (or for a new condition that

arose while in the SNF for treatment of that ongoing condition), the services are not

covered and the facility can bill the patient directly. The reason for the refusal to make

the certification must be documented in the SNF’s records.

Certifications must be obtained at the time of admission, or as soon thereafter as is

reasonable and practicable (see Pub.100-04, Medicare Claims Processing Manual,

Chapter 6, §120.2, regarding the circumstances under which a resumption of SNF care

following a temporary break in SNF coverage would be considered a new “admission”

under the SNF PPS’s interrupted stay policy). The routine admission order established

by a physician is not a certification of the necessity for post-hospital extended care

services for purposes of the program. There must be a separate signed statement

indicating that the patient will require on a daily basis SNF covered care.

In addition, only physicians may certify outpatient physical therapy and outpatient

speech-language pathology services.