Critical access hospital “swing” bed certification

by Judith L. Kares, JD

Critical access hospitals (CAH) are a special category of hospitals created to provide reasonable access to inpatient and outpatient hospital services (including emergency care) to Medicare beneficiaries located in relatively remote areas. Under the Medicare Rural Hospital Flexibility Program, assuming that relevant criteria are met, each state can implement a program to create CAHs within its borders. Subject to certain exceptions and limitations, CAHs must generally comply with the same conditions of participation and other CMS guidelines as non-CAH hospitals. 

In the interest of maximum flexibility, the Social Security Act also allows CAHs and other small rural hospitals to enter into “swing bed” agreements with CMS. Under these arrangements, in addition to providing acute inpatient services, such hospitals are permitted to provide extended care services that would normally be furnished in a skilled nursing facility (SNF). When provided under a swing bed arrangement, SNF extended care services are referred to as “swing bed” services. In a swing bed hospital, an inpatient bed may actually swing from one level of care to another (e.g., acute to swing or swing to acute), depending upon a particular patient’s need. One of the limitations imposed on CAHs, however, is that CAHs may not have more than 25 inpatient beds occupied at any one time, including both acute and swing beds. 

During several recent MBC-CAH classes, participants asked a number of questions on certification and recertification requirements for CAH swing bed patients. Certification and recertification requirements are essentially the same, whether the patient is receiving inpatient extended care services in a swing bed CAH or a SNF. The remainder of this note will provide an overview of these requirements.

Certification and recertification requirements

Prerequisite to payment. Payment under Medicare Part A for covered inpatient extended care services (including CAH swing bed services) is only available upon certification (and recertification, if applicable), signed by one of the following practitioners with knowledge of the patient:

• The attending physician,
• A facility staff physician with knowledge of the case, or
• A non-physician practitioner (NPP) working in collaboration with the physician, with no direct or indirect employment relationship with the facility.

Form. No special form or process is required, so long as the certification/recertirication is maintained in the file for verification. Simply following the routine physician admission procedure, however, is insufficient. In particular, each certification/recertification must be signed separately.

Certifications must clearly indicate that post-hospital extended care services are required on an inpatient basis because of the individual's need for skilled care on a continuing basis for any conditions for which he or she was receiving inpatient hospital services. These certifications must be obtained at the time of admission, or as soon thereafter as reasonable and practicable. If ambulance services are furnished by a SNF in connection with the admission, additional separate certification supporting the medical necessity of the ambulance services is required.

To view the complete article that appeared on Medicare Compliance Watch, click here.