Pre-Payment Review Results for Skilled Nursing Facility (SNF) for July to September 2023

Pre-Payment Review Results for Skilled Nursing Facility (SNF) for Probe and Educate (P&E) for July to September 2023

The Centers for Medicare & Medicaid Services (CMS) implemented the Probe and Educate (P&E) process for Skilled Nursing Facilities (SNF). The reviews with edit effectiveness are presented here for North Carolina, South Carolina, Virginia and West Virginia.

Cumulative Results 

Probe One Findings

Risk Category
The categories for Skilled Nursing Facility are defined as:

Top Denial Reasons

Denial Reasons and Recommendations 

5D504/5H504 — Skilled Service

Reason for Denial
The claim was fully or partially denied due to the documentation submitted did not support that SNF services were medically reasonable and necessary for the treatment of the beneficiary's illness or injury. 

How to Avoid a Denial

• Documentation should support treatment of a condition for which the beneficiary was receiving inpatient hospital services or for a condition that arose while receiving care in a SNF for treatment of a condition for which the beneficiary was previously treated in the hospital
• Submit all documentation to support the services billed and the medical necessity of those services. Services must be medically reasonable and necessary and supported by documentation. 
• Submit a copy of the qualifying hospital stay transfer/discharge summary that relates to the services provided in the SNF
• Submit a physician certification and subsequent re-certifications of the need for continuing daily skilled SNF services
• Submit the corresponding MDS for each RUG code billed. If more than one RUG code is billed, an MDS for each RUG code must be submitted for review. This may include all MDS from the start of care through the dates of service billed.
• Submit all documentation used to complete each MDS. This includes the documentation to cover the look back periods for each MDS submitted. 
• Submit dated physician’s orders for all services billed, including services provided during the look back period(s). Orders for services rendered during the look back period(s), written prior to the look back period, must be submitted with the documentation.
• Include any separate forms used for documentation of medication, wound care, staging of wounds, therapy minutes, weights, vital signs, intake and output, enteral feedings, nutritional consults, percentage of meals consumed, bladder and bowel function with the submitted records
• Ensure any changes in condition or treatment that would warrant daily skilled care are documented and submitted for review. This documentation includes, but is not limited to, nurse’s notes, social worker notes, nutritional services, activity reports, progress notes, consultations, laboratory and x-ray reports, treatment plans. 
• Documentation should include the beneficiary’s functional level and mental status, changes in treatment or medications, the skilled services provided in response to physician’s orders, and visits from the physician or other professional personnel
• Documentation in the form of checklists must include documentation of the beneficiary’s response to the services rendered
• Clinical documentation that furnishes a picture of the beneficiary’s care needs and response to treatment helps to establish the need for Part A services in a SNF

For more information, refer to:

• Social Security Act 1862(a)(1)(A)
• 42 CFR § 409.31
• 42 CFR 409.32
• Internet Only Manual (IOM), 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30
• Internet Only Manual (IOM), 100-08, Medicare Program Integrity Manual Chapter 3, Sections 3.4.1.3. 3.6.2.1 and 3.6.2.2
• Internet Only Manual (IOM), 100-08, MPIM Chapter 6, Section 6.1.4

5D505/5H505 — Certification / Recertification

Reason for Denial
The claim was fully or partially denied due to the certification was not obtained timely, and no documentation of delayed certification submitted. 

How to Avoid a Denial

• A certification or recertification statement must be signed by an attending physician or a physician on the staff of the SNF who has knowledge of the case or a nurse practitioner who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician, or a clinical nurse specialist who does not have a direct or indirect employment relationship with the facility, but who is working in collaboration with the physician. Initial certifications must be obtained at the time of admission, or as soon thereafter as is reasonable and practicable.
• The routine physician’s admission order is not a certification of the necessity for post-hospital extended care services for purposes of the Medicare program
• When responding to a request for copies of medical records, submit the initial certification and/or subsequent recertifications related to the look back periods and the dates of service under review

For more information, refer to:

• CFR § 424.20
• Internet Only Manual (IOM), 100-01 Chapter 4, Section 40.5

5D510 — 3 day qualifying inpatient stay

Reason for Denial
The claim was fully or partially denied due to there was insufficient documentation to support that there was a three-day inpatient qualifying stay prior to admission to the Skilled Nursing Facility, and no waiver is indicated. 

How to Avoid a Denial
The three consecutive calendar day stay requirement can be met by stays totaling three consecutive days in one or more hospitals. In determining whether the requirement has been met, the day of admission, but not the day of discharge, is counted as a hospital inpatient day. In addition, the qualifying hospital stay must be medically necessary.

For further information on the above Medicare coverage issue, references include, but are not limited to, this resource:

• Internet Only Manual (IOM), 100-02, Medicare Benefit Policy Manual Chapter 8, Section 20.1

5FFSG/5CFSG — Administrative / Other

Reason for Denial
The claim was fully or partially denied due to the documentation submitted is incomplete.

How to Avoid a Denial

• A legible signature is required on all documentation necessary to support orders and medical necessity
• A signature log or provider attestation must be submitted for review timely (within 20 calendar days) when requested. The 20-day timeframe begins once 1) the contractor makes an actual phone contact with the provider or 2) the date the request letter is received by the post office.
• Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or an electronic signature. Stamp signatures are not acceptable.

For more information, refer to:

• CMS Manual System, Pub 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4
• MLN Matters article # MM 6698 Revised

5D501/5H501 — MDS / Billing

Reason for Denial
The claim was fully or partially denied due to the documentation submitted does not support the level of service as shown on the claim. The HIPPS was recoded to reflect MDS changes supported by the documentation submitted. 

How to Avoid a Denial
Ensure that all charges for accuracy/timeliness prior to submitting the final bill to Medicare. Check to ensure that all documentation submitted in response to the ADR corresponds to the service(s) rendered and the dates of service(s) billed. 

For more information, refer to:

• Internet Only Manual (IOM), 100-08 Medicare Program Integrity Manual, Chapter 6, Section 6.1.4 (C-D)

Education
Palmetto GBA offers providers individualized education sessions to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations, or teleconferences. Other education methods may also be available. Providers do not have to be selected for PE to request education. If education is desired, please complete the Education Request Form (PDF).   
                  
Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of SNF Probe & Educate, will be placed under Targeted Probe & Educate.