Physician Certification and Recertification of Extended Care

40 - Physician Certification and Recertification of Extended Care 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.