Physician Certification/Recertifications in Skilled Nursing Facilities (SNFs) Manual Instructions and Supporting Regulation in 42 CFR 424.20
CMS-R-5 (OCN 0938-0454)
Background
The Medicare program requires, as a condition for Medicare Part A payment for posthospital skilled nursing facility (SNF) services that a physician or other authorized practitioner must certify and periodically recertify that a beneficiary requires an SNF level of care. The physician certification and recertification is intended to ensure that the beneficiary’s need for services has been established and then reviewed and updated at appropriate intervals. The documentation is a condition for Medicare Part A payment for post-hospital SNF care.
Need and Legal Basis
Section 1814(a) of the Social Security Act (the Act) requires specific certifications in order for Medicare payments to be made for certain services. Before the enactment of the Omnibus Budget Reconciliation Act of 1989 (OBRA1989, Public Law 101-239), section 1814(a)(2) of the Act required that, in the case of posthospital extended care services, a physician certify that the services are or were required to be given because the individual needs or needed, on a daily basis, skilled nursing care (provided directly by or requiring the supervision of skilled nursing personnel) or other skilled rehabilitation services that, as a practical matter, can only be provided in a SNF on an inpatient basis.
The physician certification requirements were included in the law to ensure that patients require a level of care that is covered by the Medicare program and because the physician is a key figure in determining the utilization of health services.
A final rule with comment period was published in the Federal Register on July 26, 1995 (60 FR 38266), which authorized nurse practitioners and clinical nurse specialists, working in collaboration with a physician, to certify and recertify that extended care services are needed or continue to be needed. In
addition, it set forth qualification requirements that a nurse practitioner or clinical nurse specialist must meet in order to sign certification or recertification statements (these requirements were later revised in the Balanced Budget Act of 1997). This final rule was necessary to implement section 6028 of OBRA 1989. Effective with items and services furnished on or after January 1, 2011, section 3108 of the Affordable Care Act added physician assistants to the existing authority for nurse practitioners and clinical nurse specialists. Regulations implementing this provision were promulgated in in the calendar year (CY) 2011
Medicare Physician Fee Schedule (MPFS) final rule with comment period (75 FR 73387, 73602, 73626-27, November 29, 2010).
The requirements at 42 CFR 424.20(a) and (b) concern the initial certification of a beneficiary’s need for a SNF level of care, which must be made upon admission or as soon as possible thereafter. The requirements at 42 CFR 424.20(c) and (d) concern recertification of a beneficiary’s need for continued SNF level of care, and also require an estimate of the time the individual will need to remain in the SNF, plans for home treatment, and whether the need is for a condition that occurred after transfer to the SNF and while still receiving treatment in the SNF for a prior condition for which he or she was hospitalized. These sections require recertification at specific intervals (the initial recertification must occur no later than the 14th day of SNF care, with subsequent recertification at least every 30 days thereafter) that posthospital SNF care is or was required because the individual needs or needed skilled care on a daily basis.
The following CMS Internet-Only Manuals provide more detailed instructions regarding the required certification and recertification of covered posthospital extended care services for a Medicare beneficiary: chapter 4, sections 40ff. and 80 in the Medicare General Information, Eligibility, and Entitlement Manual (CMS Pub. 100-01), chapter 8, sections 40ff. in the Medicare Benefit Policy Manual (CMS Pub. 100-02), and chapter 6, section 6.3 in the Medicare Program Integrity Manual (CMS Pub. 100-08).
The certification and recertification documentation is used by physicians and other authorized practitioners attending to Medicare patients in an SNF only on an “as needed” basis. Medical or other personnel employed by the SNF can review the said documentation only on an “as needed” basis.
The information being certified and recertified varies with each individual and requires signature. Therefore, it does not lend itself to automation.
There is no duplication of information or similar information being collected.
There is no requirement for a specific procedure or form as long as the approach permits verification that the certification and recertification requirement is met.
CMS does not collect this data. The record keeping involving "recertification" is on an "as-needed" basis.
There are no special circumstances.
The 60-day Federal Register notice published on July 22, 2016 (81FR47805). The 30-day Federal Register notice published on October 07, 2016 (81FR69828).
No payments or gifts are made to respondents.
CMS does not collect the recertifications and does not provide assurance of confidentiality.
Not applicable.
The requirements at 42 CFR 424.20(a) and (c) address the content of the initial certification and subsequent recertification statements for posthospital SNF care. A physician or other authorized practitioner must initially certify the need for services, and subsequently recertify the continued need for services, explain why the services are still needed, give an estimate of how long the person will need to remain in the facility, and include plans for home care, if appropriate.
We estimate the physician/practitioner spends 5 minutes for the initial certification and 10 minutes for each recertification in completing this information, either in the patient's record/progress notes or by filling in the spaces of the check blocks on the facility's preprinted form. The first recertification is required no later than the 14th day of posthospital SNF care. Subsequent recertifications are required at least once every 30 days thereafter.
Claims data for calendar year 2014 (the most recent available) were utilized to show SNF stays as follows: there were 923,390 persons whose total length of stay per covered admission was less than 14 days; 1,314,273 had stays of 14 - 43 covered days;343,166 had stays of 44 - 73 covered days; and 130,307 had stays of 74 – 100 covered days. The first group would require only an initial
certification; the second, a certification and one recertification; the third, a certification and two recertifications; and the fourth, a certification and three recertifications. There is a total of 2,711,136 certifications and recertifications.
We estimate the number of hours for each is 76,949 (1/12 of an hour, or 923,390 divided by 12); 328,568 (1/4 of an hour, or 1,314,273 divided by 4);142,986 (5/12 of an hour, or 343,166 multiplied by 5/12); and 76,012 (7/12 of an hour, or 130,307 multiplied by 7/12), for a total of 624,515 hours. The total number of respondents is 2,711,136.
We estimate $6,245,150 as the cost to the SNFs pertaining to the required certification and recertification. It is calculated at the standard rate of $10 per hour multiplied by the total hours, 624,515 hours = $6,245,150.
There is no expense for any capital and start-up costs since these documentations are entered by hand in the patient’s medical records. There are no additional costs involved in maintaining or disclosing this information.
We estimate no Federal costs associated with this information collection requirement.
The change in burden is due to an increase in number of responses based on more current data utilized.
There will be no publication and tabulation data.
This collection does not lend itself to the displaying of an expiration date. We are seeking a three-year extension date.
There are no certification exceptions.
The use of statistical methods does not apply.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement – Part A Physician Certification/Recertifications in Skilled Nursing Facilities (SNFs) Manual Instructions |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |