This includes certification that inpatient services are reasonable and necessary and in the case of services not specified as inpatients. The decision to admit a patient is a complex medical judgment that can only be made after the doctor has considered a number of factors, including the patient's medical history and current medical needs, the types of facilities available for inpatients and outpatients, the hospital's admission regulations and policies, and the relative suitability of treatment in each setting. In general, the decision to admit a patient should be based primarily on the severity of the illness and the intensity of the services provided. The medical need at the time of admission to the hospital must be clearly documented in the medical record. Without concomitant medical conditions, factors that would only inconvenience the beneficiary or the beneficiary's family in terms of time and money do not justify a continuous hospital stay.
This includes, but is not limited to, continued hospitalization when the patient's condition justified discharge home or when the patient could have been discharged for admission to a nursing home. If the patient is not discharged when appropriate, the discharge will be delayed and denied if it is not necessary for medical reasons. Observation services should be patient-specific and not part of the center's standard operating procedures. For example, post-procedure recovery and monitoring would not be billed as observation.
In some cases, specific clinical situations may arise and additional outpatient services or hospitalization may be medically necessary. However, this would have to be outside the standard periods of recovery and control of the procedure performed. Observation services are not considered medically necessary when the patient's current state of health does not justify observation, or when there is no expectation of a significant deterioration in the patient's health status in the near future. Is your documentation complete? Will it be kept in a review of the medical record? Do not add late signatures to the medical record, other than the brief delay that occurs during the transcription process.
If there is no signature or the signature is unreadable, the signature authentication process can be used. A signature certification statement or a record of signatures can be used for any illegible or unsigned signature. The certification statement is signed and dated by the author of the medical record and contains information sufficient to identify the beneficiary. Did you know that illegible signatures or vendor initials are allowed? The signature or initials must be directly above the written or typed name.
A record of signatures that matches the signing of the documentation can also be submitted along with the medical records. The decision to hospitalize a patient is a complex medical decision based on the doctor's judgment and your need for medically necessary hospital care. Hospitalization is generally appropriate when you are expected to need 2 or more nights of medical hospital care necessary. However, your doctor must order such admission and the hospital must formally admit you so that you can be hospitalized.
