CMS Hospital Admission Rules

[slolar]

I work in an busy ED.  We are starting to receive notice that all admissions need a physician certification per CMS.  My boss is telling me that only MD's can do this and that our SP's will have to do all admission orders.  I found the following at AAPA:

 

http://www.aapa.org/the_pa_profession/federal_and_state_affairs/resources/item.aspx?id=6661

 

This seems to indicated that AAPA clarified with CMS that PA's CAN provide the certification.  However, the "guidance" seems to state that only Physician's, podiatrists and dentist's can do it.

 

Anyone have any insight?

 

Sara

[eddoc]

That is not my understanding of the new guidance.  PAs, NPs and medical residents can still write the admission orders The certification which includes a documentations including orders, anticipated LOS and in some cases discharge planning must be compiled and signed by the physician prior to discharge.

[slolar]

That is not my understanding of the new guidance.  PAs, NPs and medical residents can still write the admission orders The certification which includes a documentations including orders, anticipated LOS and in some cases discharge planning must be compiled and signed by the physician prior to discharge.

Thanks for that clarification.  So we can put in the order, but an MD needs to certify.  Got it.

How are your hospitals dealing with this?  Mine seems to be leaning towards the need to have the SP put in the order.  That way they can certify as they are doing it. This seems like an awful way to deal with it.  I can't imagine having to interrupt my SP everytime I admit someone to get them to do the order.

 

Sara

[LKPAC]

I write my own inpatient orders.  My SP co-signs (electronically) within 24 hours.  Outpatient orders don't require co-signature.  This is our hospital policy.

[Houstonian]

PA's can do an admission H&P and may write admission orders, as a delegated responsibility from the admitting/attending physician.  (If the hospital rules and regulations also permit this).   

 

Most hospitals limit admission privileges (i.e. the decision to admit) to physicians.  A physician must also serve as the attending physician for the patient.  (There may be a few hospitals that allow NP's to admit independently in states where NP's have independent authority). 

 

Sounds like CMS is asking that a physician "certify" the admission at some time prior to discharge. 

 

I frequently write orders to "Admit to Dr. ________".  That does not mean that I made the decision to admit.  It just means that Dr. _______________ wants the patient admitted and has agreed to be the attending physician. 

 

If you are in the ER, who is the attending physican for the patients you are admitting?  Or are these ER observation patients? 

 

In our hospital ER physicians do not admit patients, unless it is just an overnight ER observation. 

 

I work on the other side - inpatient medicine, rather than on the ER side. 

[True Anomaly]

Our group covers three hospitals, two of which have an attached ED Observation unit.  Both units are ultimately staffed by a physician, so when I work the observation side of things I admit the patients to the physician of the day.  The computerized order reads "Please patient in observation status on the service of Dr. _______".  I haven't heard of any change to this.

[burnpac]

You Hospital is misinterpreting the rule. Here at our hospital, PAs, NPs, and residents can put in order to admit the patient. Nearly all orders are automatically routed to the attending physician for electronic co-signature, so it hardly changed anything.

[JohnnyM2]

The problem here is that CMS has constructed a rule that is unclear to those that must implement it. The "Guidance" which was written after the fact, at the request of AAPA, remains unclear. Being naturally suspicious, I have to wonder if the AMA or some other lobby wasn't responsible for influencing CMS staffers to write a rule clearly designed to limit PA and NP authority. (Anyone who thinks primary care pysicians don't resent the growing influence of the PA and NP professions is naive IMO.) If hospitals don't understand the rule, they are likely to insist that the physician write the initital admission order even though the guidance state that this is unnecessary. This may turn out to be a real practice obstacle for PAs working relatively autonomously in satellite facilities. Will the SP be able to submit an electronic order remotely or will s/he have to travel to the facility and see the patient. The burden on the SP, and thereforethe resulting effect on PA autonomy, will depend on how the hospital interprets the rule more than what CMS may have attended. This rule needs to be rewritten with some statement of the intent of the rule and clear guidelines for hospitals and practitioners. PA's with an interest in this should contact AAPA.

[greenmood]

My company's solution is to give every NP and PA on our team admitting privileges in order to remain in compliance with the new rules. It doesn't sound like it is going to change much in our everyday routines.

 

 

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[ventana]

I had a very different read on this whole topic.... I thought that CMS was saying that PAs could and should have admitting privileges....  Just the hospital bylaws that did not empower us stood in the way.....