Skilled Nursing Facility Probe And Educate Review Results - JE Part A

The Jurisdiction E, Part A Medical Review Department is conducting a 5-Claim Probe and Educate review of Skilled Nursing Facility (SNF) PPS claims. The findings of the claims reviewed from July 1, 2024 through September 30, 2024 are as follows:

Review Results

• 1277 claims were reviewed with 7.28% error rate

Top Trending Errors

• Documentation did not support the required certifications and/or recertifications for the SNF stay.
• Documentation did not support that SNF services were medically reasonable and necessary.
• Documentation submitted did not support that skilled services were provided at a frequency to meet the definition of "daily."
• The HIPPS was recoded to reflect MDS changes supported by the documentation submitted.

Educational Resources

• CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 8
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 70
• Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual
• Skilled Nursing Facility Documentation Requirements
• Skilled Nursing Facility

Education

Physician Certification/Recertification

Physician certifications and recertifications are required for SNF PPS payment. No specific form is required to fulfill this requirement; however, complete certification statements must be found in the documentation. A statement that continued extended care services are medically necessary would not be sufficient.

Initial certifications

• Due as soon as possible after admission to SNF.
• Must include:
• Physician determination that skilled services are necessary
• Indication that posthospital services were given on an inpatient basis due to beneficiary’s need for skilled care on a continuing basis
• Physician/NPP signature* and date to validate timeliness

Recertifications

• Due by 14th day after admission and every 30 days thereafter.
• Delayed certifications must include an explanation for the delay in the submitted documentation.
• Must include:
• Physician determination that skilled services are necessary
• Indication that posthospital services were given on an inpatient basis due to beneficiary’s need for skilled care on a continuing basis
• Reason for continuation of extended services
• Estimated time services will be required
• Discharge plans for home care if applicable
• Physician/NPP signature* and date to validate timeliness

* Per Medicare General Information, Eligibility, and Entitlement (MGIEE), Chapter 4, Section 40.1, "A certification or recertification statement must be signed by the attending physician or a physician on the staff of the skilled nursing facility who has knowledge of the case, or by a physician extender (that is, a nurse practitioner, a clinical nurse specialist or, effective with items and services furnished on or after January 1, 2011, a physician assistant) who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician."

Please reference Internet Only Manual (IOM), Publication 100-01 Medicare General Information, Eligibility and Entitlement Manual (MGIEE) Chapter 4, Section 40 and IOM, Publication 100-08, Medicare Program Integrity Manual (MPIM) Chapter 6, Section 6.3 for additional information.

Medical Necessity

The following should be considered when determining and billing either covered skilled services or demand billing of non-skilled levels of care. Per the Medicare Benefit Policy Manual (MBPM) Chapter 8 section 30, care in a SNF is covered if all of the following four factors are met:

• The patient requires skilled nursing services or skilled rehabilitation services:
• Services that must be performed by or under the supervision of professional or technical personnel (see section 30.2 – 30.4)
• Are ordered by a physician and the services are rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services
• The patient requires these skilled services on a daily basis (see section 30.6); and
• As a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (See section 30.7.)
• The services must be reasonable and necessary for the treatment of a patient’s illness or injury, i.e., be consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice. The services must also be reasonable in terms of duration and quantity.

If any one of these four factors is not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered. For example, payment for a SNF level of care could not be made if a patient needs an intermittent rather than daily skilled service.

Coverage Criteria

For a beneficiary to receive coverage in a SNF the following criteria must be met:

• The beneficiary must be entitled to receive Medicare Part A
• There must be a medically necessary 3-day qualifying hospital stay
• Transfer or admission to the SNF must occur within 30 days at a skilled level of care
• Benefit days must be available to the beneficiary
• The patient requires skilled nursing services or skilled rehabilitation services, i.e.:
• Services must be performed by or under the supervision of professional or technical personnel (see section 30.2 - 30.4)
• Services must be ordered by a physician and rendered for a condition for which the patient received inpatient hospital services or for a condition that arose while receiving care in a SNF for a condition for which he received inpatient hospital services.
• The patient requires these skilled services on a daily basis (see section 30.6) and as a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. (see section 30.7.)
• The services must be reasonable and necessary for the treatment of a patient’s illness or injury, i.e.:
• Being consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs, and accepted standards of medical practice.
• The services must also be reasonable in terms of duration and quantity.
• The patient must be admitted to a SNF within 30-days of discharge from a hospital and require skilled care. (See exception to this criteria)

If any one of these factors is not met, a stay in a SNF, even though it might include the delivery of some skilled services, is not covered. For example, payment for a SNF level of care could not be made if a patient needs an intermittent rather than daily skilled service.

Documentation to Support MDS Coding

Documentation to support the SNF Patient Driven Payment Model (PDPM) Health Insurance Prospective Payment System (HIPPS) code(s) billed, including clinical notes and medical records related to the assessment reference date, documentation relating to the 7 day look back period under review (which may fall outside the billing period), and documentation related to the claim period billed are required for document submission to support the accuracy of the MDS reviewed. If documentation is missing, or a discrepancy is noted resulting in an inaccuracy of the MDS reviewed in the repository, MR is required to correct the MDS entry with the documentation available. This may result in a change in the HIPPS code billed.