Can Any Physician Enter an Inpatient Order?

Let’s talk about the term “attending physician.”  The simplest definition is the physician primarily responsible for a hospitalized patient’s care. 

While there may be many physicians and other practitioners involved in the hospital care of a single patient, there is only one designated “attending physician.”  This individual generally owns the responsibility of creating the initial documentation about the patient’s hospitalization – the History and Physical, or H&P – in addition to the final Discharge Summary. 

Many times, they also are considered the ringleaders of the patient’s care – deciding when specialists need to be involved and if specific investigations, testing, or imaging must take place during the hospitalization or if they can wait until after discharge in the outpatient setting. 

While there’s one attending physician listed on a patient’s record, clearly, that physician isn’t working 24 hours a day, seven days a week.  They have at least one peer designated as a covering physician while they are not available.  This is almost always a member of their practice team or medical group. 

Generally, this individual is “covering” multiple patients of more than one attending physician during overnight or other hours when the attendings are not on service.  Their work shift in the hospital starts with a report of some sort whereby the attending physician briefly describes the patients’ reasons for hospitalization, gives a brief update of their current condition, lists specific concerns which might materialize over the coverage timeframe, and so on. 

Commonly referred to as a “sign-out,” this report from the attending physician to the covering physician serves to give the covering physician a basic introduction to the patients they may be called about by nurses or others on the medical team during the coverage period. 

A call about a patient generally requires the covering physician to at least review the most recent documentation if not also physically examining and speaking with the patient to make appropriate decisions about how to address new situations or assess changes in condition.  On the flip side, the covering physician might not hear anything about most of the patients signed out to them from the attending physicians and therefore, won’t even review the charts.  Despite this, they are considered the point-person for the medical team and the physician to call in place of the attending physician.  But does this include questions about patient status?

Per the Code of Federal Regulations, Title 42, Chapter IV, Subchapter B, Part 412, Subpart A, Section 412.3, “…an inpatient admission is generally appropriate for payment under Medicare Part A when the admitting physician expects the patient to require hospital care that crosses two midnights…The expectation of the physician should be based on such complex medical factors as patient history and comorbidities, the severity of signs and symptoms, current medical needs, and the risk of an adverse event.”  Similarly, per the Medicare Benefit Policy Manual, Chapter 1, Section 10.2, “The order must be furnished by a physician or other practitioner (“ordering practitioner”) who is…knowledgeable about the patient’s hospital course, medical plan of care, and current condition at the time of admission.”

Granted, the Medicare Benefit Policy Manual also states, “CMS considers only the following practitioners to have sufficient knowledge about the beneficiary’s hospital course, medical plan of care, and current condition to serve as the ordering practitioner: the admitting physician of record (“attending”) or a physician on call for him or her, primary or covering hospitalists caring for the patient in the hospital, the beneficiary’s primary care practitioner or a physician on call for the primary care practitioner, a surgeon responsible for a major surgical procedure on the beneficiary or a surgeon on call for him or her, emergency or clinic practitioners caring for the beneficiary at the point of inpatient admission, and other practitioners qualified to admit inpatients and actively treating the beneficiary at the point of the inpatient admission decision.”  However, it’s important to note this extensive list of physicians and practitioners involves those who could “have sufficient knowledge about the beneficiary’s hospital course, medical plan of care, and current condition” and does not indicate all these individuals fit the bill as a provider who can compliantly assign the patient to Inpatient status.

Let’s get back to the covering physician who is working in the hospital overnight.  They have a baseline, relatively minimal understanding of the patients in their charge from the attending physicians who were working during the day.  If they are called from someone on the medical team with a question about a patient, that covering physician will undoubtedly perform at least a cursory review of the day’s documentation from the attending and consultant physicians.  They might also review the latest radiological reports and lab values before making any decisions about next steps in the assessment of the patient or changes to the plan of care.  In this instance, if the covering physician completes their assessment of the patient and documents how they are addressing the question posed to them, it could be considered appropriate for them to address the issue of patient status.  Their more thorough review of the patient’s hospital course, current condition, and plan of care would meet the description outlined in the Code of Federal Regulations and the Medicare Benefit Policy Manual.

Now, let’s think about the covering physician’s knowledge of and involvement with the patient before anyone on the care team asks them to assess or intervene.  Remember, the sign-out they received from the attending physician was likely minimal, with only the most high-level points shared in the event an emergency developed.  Does the covering physician have the breadth of knowledge about the patient’s hospital course, current condition, and plan of care to qualify them for placement of an Inpatient status order? 

If the patient is about to cross a second midnight or has already crossed a second midnight and clearly, they’re still receiving medically necessary hospital services, the answer seems to be yes. The Centers for Medicare and Medicaid Services already indicated in the Fiscal Year 2014 Inpatient Prospective Payment System Final Rule, “the decision to admit becomes easier as the time approaches the second midnight, and beneficiaries in medically necessary hospitalizations should not pass a second midnight prior to the admission order being written.”  Therefore, even if a covering physician isn’t intimately knowledgeable about a patient’s hospitalization or plan of care, they would likely be able to identify the patient continues to require hospital services and appropriately enter an Inpatient order if asked to do so. 

In contrast, if a covering physician is asked about a patient who has passed zero or only one midnight, the patient details allowing valid determination of Inpatient assignment likely will not be known.  As such, a utilization manager contacting a covering physician in the evening hours for an Inpatient order in this scenario is unlikely to be a compliant practice.  Similarly, a physician working for a medical group who scans all of their practice’s hospitalized patients in the electronic health record and enters Inpatient orders for each patient who is about to or has passed a second midnight would not be compliant. 

Keep in mind, neither of these scenarios are specifically called out in the formal Medicare rules or regulations.  It’s advised you take time to consider this situation and talk it through with your own hospital utilization management and compliance teams to come to a final decision on practice within your institution.