In skilled nursing facilities, in accordance with CMS manual guidance, CMS will only make payment for covered post-hospital extended care services if a physician makes the required certification and, where applicable, the required re-certification regarding the services furnished. Skilled nursing facilities are responsible for obtaining the required physician certification and recertification statements. Such certification must clearly note that that post-hospital inpatient extended care services are required because of the individual’s need for skilled care on a continuing basis for any of the conditions for which he/she was receiving inpatient hospital services, including services of an emergency hospital.
Who can sign certification and recertification statements? Clearly, the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case may sign. A nurse practitioner or clinical nurse specialist may sign the certifcation as well, but only if the nurse is working in collaboration with the physician and such nurse does NOT have a direct or indirect employment with the skilled nursing facility. In accordance with 42 C.F.R. 424.20, an indirect relationship exists when the nurse is a direct employee of an entity other than the skilled nursing facility, and that entity has an agreement with the facility for the provision of nursing services.
Under a lesser-known provision of the PPACA, as of January 2011, a physician assistant may also sign a certification or recertification. The physician assistant is also bound by the same constraints as nurses; the physician assistant must be working in collaboration with the physician and may not have a direct or indirect relationship with the skilled nursing facility.
