A federal rule that some hospitalists feared would bar nonstaff physicians from writing admission orders for hospital inpatients has been clarified to extend those privileges to resident physicians and advanced practitioners.
On Aug. 19, the Centers for Medicare & Medicaid Services (CMS) published its fiscal 2014 hospital Inpatient Prospective Payment System (IPPS) Final Rule, which is effective Oct. 1. Although this document impacts a number of important areas for hospitals, including the use of inpatient admission and observation status, hospitalists also were left with the impression that resident physicians and advanced practitioners (NPs and PAs) were being barred from writing admission orders.
Medical residents, NPs, and PAs do not have admitting privileges in most hospitals, and their inability to write admission orders would pose significant logistical and financial hurdles for many hospitals and physician groups, including hospitalists.
In most academic centers, residents have the opportunity and responsibility to evaluate patients at the time of hospitalization, write initial hospitalization orders, and then discuss patients with the attending physician. The “staffing” of patients typically occurs either later the same day or the following morning. The provision requiring an attending physician knowledgeable of the case to furnish the admission order, and not allowing delegation of this order to their residents, could fundamentally change the way our physicians are trained.
Many hospitals rely on NPs and PAs for the care of hospitalized patients under the supervision of a staff physician. These nonphysician providers often care for hospitalized patients, admit patients, and provide overnight coverage. Requiring admission orders to be placed by physicians with admitting privileges would require a greater presence of staff physicians, which would increase costs.
Some of these concerns were voiced Aug. 15 on CMS’ Special Open Door Forum on CMS Rule 1599-F. While clarification was not offered, it was indicated that CMS did not intend to place such limitations on residents, NPs, and PAs. On Sept. 5, CMS released clarifications to some of these provisions in the IPPS Final Rule, and noted that admission orders may come from a physician or other practitioner.
This clarification suggests that when a resident, NP, or PA writes admission orders, they are doing so at the direction of a physician with admitting privileges. This may occur in the form of a verbal order, which requires documentation of the name of the admitting physician, as well as the date and time of the verbal order. This verbal order must then be countersigned by a qualified physician prior to patient discharge.
Failures to obtain appropriate orders co-signed by an appropriate physician are likely at high risk for Medicare payment denial. This clarification appears to address previously held concerns about this new rule.