01-026 Skilled Nursing Facility (SNF) Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for Medicare Part A Skilled Nursing Facility (SNF) services billed on dates of service from January 1, 2018 through December 31, 2018. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

The SNF benefit has been a topic that was reviewed by the Office of the Inspector General (OIG). In 2014 and 2016, SNF medical review projects were done by the Supplemental Medical Review Contractor (SMRC). The results of the SNF medical review projects supported additional evaluation, review, and education on the SNF benefit.

Medicare covers SNF care under the Part A benefit under certain conditions for up to 100 days. The admission must meet medical necessity requirements to qualify for payment. The SNF patient requires skilled nursing or skilled rehab services, are ordered by a physician, and services rendered are for a condition which the patient received inpatient hospital services, or for a condition that arose while receiving care in a SNF for a condition they received inpatient hospital services; The patient required the skilled services on a daily basis; and as a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. The services are reasonable and necessary and must be reasonable and necessary in terms of duration and quantity.

Reason for Review

CMS tasked the SMRC, to perform data analysis and conduct medical review. The SMRC will complete medical record review on claims in accordance with applicable statutory, regulatory and sub-regulatory guidance.

Claim Sample Detail

Revenue Code TOB HIPPS
  • 0022: SNF PPS
  • 18X: Swingbed
  • 21X: SNF Inpatient
  • RUA10: Ultra-high Rehab with 4-8 ADLS – 5-day Assessment
  • RUA20: Ultra-high Rehab with 4-8 ADLS – 14-day Assessment
  • RUB10: Ultra-high Rehab with 9-15 ADLS – 5-day Assessment
  • RUB20: Ultra-high Rehab with 9-15 ADLS – 14-day Assessment
  • RUC10: Ultra-high Rehab with 16-18 ADLS – 5-day Assessment
  • RUC20: Ultra-high Rehab with 16-18 ADLS – 14-day Assessment

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Minimum Data Sheet (MDS) Assessments (5-day, 14-day, if applicable)
    1. Documentation to support the period of time when the beneficiary’s condition is captured by the MDS assessment (look back period). The look back period may fall outside of the dates of service under review. The documentation requested may include documentation 30-45 days prior to the dates of service (DOS) under review.
  2. Physician or Non-Physician Practitioner (NPP) order for date of service
  3. Signed and dated physician certification (and recertification, if applicable) for skilled level of care
    1. If not signed and dated timely, letter of delay that is signed and dated by physician must be submitted
  4. Records of patient’s condition before, during and after this billing period to support medical necessity and reason the service was provided:
    1. Hospital discharge summary and transfer form
    2. Emergency room records
    3. Physician progress notes
    4. Operative reports
    5. Consultation reports
  5. Records supporting skilled level of care
    1. History and physical exam pertinent to patient’s care
    2. Skilled services provided and patient’s response
    3. Plan for future care based on rationale of prior results
    4. SNF progress notes and discharge summary
    5. Nursing notes including medication and treatment records detailing:
      1. Wound care
      2. Respiratory treatments
      3. Oxygen therapy records
    6. Care Plan
    7. ADL charting/logs
  6. Therapy progress notes (physical, occupational, speech/language, if applicable)
    1. Initial evaluation
    2. Plan of care
    3. Progress reports
    4. Treatment encounter notes
    5. Therapy minute logs
    6. Discharge summary
  7. Valid electronic and handwritten physician and/or clinician signatures
    1. Signature logs and signature attestation statement should be submitted when physician and/or clinician signatures are illegible
  8. Diagnostic procedure notes, if applicable
  9. Laboratory reports, if applicable
  10. Advance Beneficiary Notice (ABN) of Noncoverage, if applicable

References/Resources

  • Social Security Act (SSA), Title XVIII, §§1812 (a)(2)(A). Scope of Benefits
  • SSA, Title XVIII, §§1813(3). Deductibles and Coinsurance
  • SSA, Title XVIII, §1814(2)(B). Conditions of Payment and Limitationon Payment for Services
  • SSA, Title XVIII, §§1815. Payment to Provider of Services
  • SSA, Title XVIII, §§1819(a) – (d) and (f). Requirements for, and Assuring Quality of Care In, Skilled Nursing Facilities
  • SSA, Title XVIII, §§1861(aa)(5). Non-Physician Providers
  • SSA, Title XVIII, §§1862. Exclusions from Coverage and Medicare as Secondary Payer
  • SSA, Title XVIII, §§1879(a)(1).Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
  • SSA, Title XVIII, §§1888 (e). Prospective Payment
  • 42 Code of Federal Regulations (C.F.R.) §409.30. Basic Requirements
  • 42 C.F.R. §409.31. Level of Care Requirements
  • 42 C.F.R. §409.32. Criteria for Skilled Services and the Need for Skilled Services
  • 42 C.F.R. §409.33. Examples of Skilled Nursing and Rehabilitation Services
  • 42 C.F.R. §409.34. Criteria for “Daily Basis”
  • 42 C.F.R. §409.35. Criteria for “Practical Matter”
  • 42 C.F.R. §409.36. Effect of Discharge from Posthospital SNF Care
  • 42 C.F.R. §411.15(k)(1) . Particular services excluded from coverage
  • 42 C.F.R. §413.330. Basis and Scope
  • 42 C.F.R. §413.333. Definitions
  • 42 C.F.R. §413.335. Basis of Payment
  • 42 C.F.R. §413.337. Methodology for Calculating the Prospective Payment Rates
  • 42 C.F.R. §413.338. Skilled Nursing Facility Value-based Purchasing
  • 42 C.F.R. §413.340. Transition Period
  • 42 C.F.R. §413.343. Resident Assessment Data
  • 42 C.F.R. §413.345. Publication of Federal Prospective Payment Rates
  • 42 C.F.R. §413.348. Limitation on Review
  • 42 C.F.R. §413.360. Requirements under the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
  • 42 C.F.R. §424.20. Requirements for Posthospital SNF Care
  • 42 C.F.R. §424.5(a)(6) . Sufficient Information
  • 42 C.F.R. §483.1. Basis and scope
  • 42 C.F.R. §483.5. Definitions
  • 42 C.F.R. §483.20. Resident Assessment
  • 42 C.F.R. §483.21. Comprehensive Person-Centered Care Planning
  • 42 C.F.R. §483.24. Quality of Life
  • 42 C.F.R. §483.25. Quality of Care
  • 42 C.F.R. §483.30. Physician Services
  • 42 C.F.R. §483.35. Nursing Services
  • 42 C.F.R. §483.40. Behavioral Health Services
  • 42 C.F.R. §483.65. Specialized Rehabilitative Services
  • 42 C.F.R. §483.315. Specification of Resident Assessment Instrument
  • CMS Internet Only Manual (IOM), Publication 100-01, Medicare General Information, Chapter 1, Section 20. Administration of the Medicare Program
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 10. Requirements General
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 20. Prior Hospitalization and Transfer Requirements
  • CMS, IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30. Skilled Nursing Facility Level of Care General
  • CMS, IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 40. Physician Certification and Recertification of Extended Care Services
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 50. Covered Extended Care Services
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 60. Covered Extended Care Days
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 70. Medical and Other Health Services Furnished to SNF Patients
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 10. General Exclusion from Coverage
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20. Services not Reasonable and Necessary
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110. Custodial Care
  • CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 170. Inpatient Hospital or SNF Services Not Delivered Directly or Under Arrangement by the Provider
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 10. Skilled Nursing Facility (SNF) Prospective Payment System (PPS) and Consolidated Billing Overview
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 20. Services Included in Part A PPS Payment Not Billable Separately by the SNF
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 30. Billing SNF PPS Services
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 130. A/B MAC (A) and (HHH) Specific Instructions for Application of Limitation on Liability
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, § 130.2. A Three-Day Prior Hospitalization
  • CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, § 130.2.B. Transfer Requirements
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3. Verifying Potential Errors and Taking Corrective Actions
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6. Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Bills
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, § 6.1. Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Bills
  • CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, § 6.3. Medical Review of Certification and Recertification of Residents in SNFs
  • CMS, Minimum Data Set Manual, CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual, Version 1.15, Effective 10/01/2017 to 09/30/2018
  • Program for Evaluating Payment Patterns Electronic Report (PEPPER). National-level Data Reports. National Target Area Analysis. https://pepper.cbrpepper.org/Data external website icon. April 10, 2019
  • CMS, Medicare Learning Network (MLN) ICN 006846 (SNF Billing Reference). Effective December 2018
  • CMS, MLN ICN 909067 (Medicare-Required SNF PPS Assessment). Effective October 2017

Last Updated Nov 26, 2019