Proper documentation of certification forms for extended care

You've heard it a million times before: if it isn't documented, it isn't done. This adage is applicable to many aspects of healthcare, including documentation of extended stay certification under Medicare Part A.

Covering procedure services and supplies, Medicare Part A encompasses hospital care, skilled nursing facility care, nursing home care, hospice, and home health services. Getting the most from Medicare is dependent upon proper documentation. Compliance with the certification documentation requirements for extended care services can be challenging and Medicare auditors can deny reimbursement for extended care facilities if complete certification documentation is lacking.

“The worst-case scenario would be when the certification is not completed,” says Deanna Peterson, MHA, RHIA, CHPS, vice president of health consulting services at First Class Solutions, Inc., in Maryland Heights, Missouri. “While best practice is to capture all certification and re-certification documentation on one form, there is not a specific form that must be utilized.”

Recertification for extended care by the physician or physician extender must be completed by day 14 and every subsequent 30 days from the last re-certification. According to Peterson, proper documentation must include the following information:  

• Reasons for continued skilled care.
• Estimated length of stay.
• Any plans for home care.
• If the circumstances require it, the first recertification and any subsequent re-certifications must state that the continued need for extended care services is for a condition requiring such services which arose after the transfer from the hospital and while the patient was still in the facility for treatment of the condition(s) for which he/she had received inpatient hospital services.
• Any reason for delay if the provider has not signed the re-certification in a timely manner.

Despite the necessity for proper documentation, mistakes are common. According to Peterson, some common documentation errors with Medicare A certification for extended care include:

• Missing signature dates by the provider.
• Missing re-certification elements. All elements must be documented with a provider’s signature. Any missing element means Medicare can deny for an improper re-certification.
• Missing reasons for delay for late certification and re-certifications.

If any of these errors arise when reviewing extended care certifications, there are a few solutions. In isolated circumstances, delayed certification is an option. Otherwise, look to provider documentation including H&Ps, progress notes and orders, advises Peterson.

“If a facility finds themselves in a situation where the certification or re-certification may not have been completed, they can always look to provider documentation, such as progress notes, that may have captured components of the certification or re-certification,” says Peterson. “As long as they can piece together all of the components, and they were documented timely, they will meet the requirements.”

To prevent errors from occurring in the first place, establish a set of best practices for proper documentation at your organization. Below are a few considerations from First Class Solutions, Inc., that Peterson relies on when reviewing Medicare A certification and re-certification documentation for extended care:

1. Keep the certification and re-certification all on one form.  Make it as easy as possible to prove you are compliant with certifications and re-certifications.
2. Create a “hard stop” at weekly Medicare A or utilization review meetings for validating the certification and re-certification are complete.
3. Consider completing the re-certification requirements before the provider signs the form.  This will ensure a blank re-certification is not signed.