[Code of Federal Regulations]
[Title 42, Volume 2]
[Revised as of October 1, 2002]
From the U.S. Government Printing Office via GPO Access
[CITE: 42CFR424.13]

[Page 935-936]
 
                         TITLE 42--PUBLIC HEALTH
 
                             HUMAN SERVICES
 
PART 424--CONDITIONS FOR MEDICARE PAYMENT--Table of Contents
 
       Subpart B--Certification and Plan of Treatment Requirements
 
Sec. 424.13  Requirements for inpatient services of hospitals other than psychiatric hospitals.

    (a) Content of certification and recertification. Medicare Part A 
pays for inpatient hospital services of hospitals other than psychiatric 
hospitals only if a physician certifies and recertifies the following:
    (1) The reasons for either--
    (i) Continued hospitalization of the patient for medical treatment 
or medically required inpatient diagnostic study; or
    (ii) Special or unusual services for cost outlier cases (under the 
prospective payment system set forth in subpart F of part 412 of this 
chapter).
    (2) The estimated time the patient will need to remain in the 
hospital.
    (3) The plans for posthospital care, if appropriate.
    (b) Certification of need for hospitalization when a SNF bed is not 
available. (1) A physician may certify or recertify need for continued 
hospitalization if the physician finds that the patient could receive 
proper treatment in a SNF but no bed is available in a participating 
SNF.
    (2) If this is the basis for the physician's certification or 
recertification,

[[Page 936]]

the required statement must so indicate; and the physician is expected 
to continue efforts to place the patient in a participating SNF as soon 
as a bed becomes available.
    (c) Signatures. (1) Basic rule. Except as specified in paragraph 
(c)(2) of this section, 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.
    (2) Exception. If the intermediary requests certification of the 
need to admit a patient in connection with dental procedures, because 
his or her underlying medical condition and clinical status or the 
severity of the dental procedures require hospitalization, that 
certification may be signed by the dentist caring for the patient.
    (d) Timing of certifications and recertifications: Cases not subject 
to the prospective payment system (PPS). (1) For cases that are not 
subject to PPS, certification is required no later than as of the 12th 
day of hospitalization. A hospital may, at its option, provide for the 
certification to be made earlier, or it may vary the timing of the 
certification within the 12-day period by diagnostic or clinical 
categories.
    (2) The first recertification is required no later than as of the 
18th day of hospitalization.
    (3) Subsequent recertifications are required at intervals 
established by the UR committee (on a case-by-case basis if it so 
chooses), but no less frequently than every 30 days.
    (e) Timing of certification and recertification: Cases subject to 
PPS. For cases subject to PPS, certification is required as follows:
    (1) For day-outlier cases, certification is required no later than 
one day after the hospital reasonably assumes that the case meets the 
outlier criteria, established in accordance with Sec. 412.80(a)(1)(i) of 
this chapter, or no later than 20 days into the hospital stay, whichever 
is earlier. The first and subsequent recertifications are required at 
intervals established by the UR committee (on a case-by-case basis if it 
so chooses) but not less frequently than every 30 days.
    (2) For cost-outlier cases, certification is required no later than 
the date on which the hospital requests cost outlier payment or 20 days 
into the hospital stay, whichever is earlier. If possible, certification 
must be made before the hospital incurs costs for which it will seek 
cost outlier payment. In cost outlier cases, the first and subsequent 
recertifications are required at intervals established by the UR 
committee (on a case-by-case basis if it so chooses).
    (f) Recertification requirement fulfilled by utilization review. (1) 
At the hospital's option, extended stay review by its UR committee may 
take the place of the second and subsequent physician recertifications 
required for cases not subject to PPS and for PPS day-outlier cases.
    (2) A utilization review that is used to fulfill the recertification 
requirement is considered timely if performed no later than the seventh 
day after the day the physician recertification would have been 
required. The next physician recertification would need to be made no 
later than the 30th day following such review; if review by the UR 
committee took the place of this physician recertification, the review 
could be performed as late as the seventh day following the 30th day.
    (g) Description of procedures. The hospital must have available on 
file a written description that specifies the time schedule for 
certifications and recertifications, and indicates whether utilization 
review of long-stay cases fulfills the requirement for second and 
subsequent recertifications of all cases not subject to PPS and of PPS 
day outlier cases.