Denial 1: Certification or Recertification Statement (Missing/ Lacked Information)
From 2012-2014 the percentage rate of improper payments to SNF almost doubled all stemming from failure to obtain certification or recertification.
General Guidelines:
The Certification Statement must include that the individual requires skilled nursing (furnished directly by or requiring supervision of skilled nursing personnel) or skilled rehabilitation services on a daily basis in an SNF or swing-bed hospital as an inpatient. Important to note: services must be related to an ongoing condition in which the individual received inpatient care in the hospital. An example of this: admit to a hospital for CVA then transfer to SNF for Aftercare of CVA. This statement must be signed and dated by the certifying physician or NPP at the time of admission or as soon it is reasonable or practicable. This signature and date must appear in the same ink/writing – you cannot date this form for them, this has been a reason for denial.
The certification statement must support the following:
- The individual needs skilled services on a daily basis. (nursing or other rehabilitation services)
- The daily skilled services can only practically be provided in an SNF
- Reason for skilled services
- Dated signature by attending physician or physician on staff at SNF with knowledge of the case, or physician extender
The recertification statement must include the following:
- Reasons for the continued need for extended care services
- The estimated period of time required for the patient to remain in the facility
- Any plans, where appropriate, for home care
- Dated signature by attending physician or physician on staff at SNF with knowledge of the case, or physician extender
Denial for certification or recertification will occur in case of the following scenarios:
- Certifications must be obtained at the time of admission or as soon thereafter as is reasonable and practicable.
- The first recertification must be made no later than the 14th day of post-hospital inpatient extended care.
- Subsequent re-certifications must be made at intervals not exceeding 30 days.
- Delayed certifications and re-certifications must include an explanation for the delay and any medical or other evidence relevant for the purposes of explaining the delay.
How to avoid this denial:
- Certifications must be obtained at the time of admission or as soon thereafter as is reasonable and practicable.
- The first recertification must be made no later than the 14th day of post-hospital inpatient extended care.
- Subsequent re-certifications must be made at intervals not exceeding 30 days.
- Delayed certifications and re-certifications must include an explanation for the delay and any medical or other evidence relevant for the purposes of explaining the delay.
Denial 2: Insufficient Documentation (To Support the Services Provided)
The majority of SNF service improper payments were from insufficient documentation.
Denial for insufficient documentation will occur in case of the following scenarios:
- Actual therapy minutes documented in the treatment record did not equal the minutes reported on the MDS for physical therapy (PT), occupational therapy (OT), and/or speech-language pathology (SLP) services.
- Documented skilled services provided did not support the Resource Utilization Group-III (RUG-III) level billed.
How to avoid this denial:
Claims for skilled care coverage need to include sufficient documentation to enable a reviewer to determine the following:
- The beneficiary requires skilled involvement for the services in question to be furnished safely and effectively.
- The services themselves are reasonable and necessary for the treatment of a resident’s illness or injury. For example, the services must 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 documentation in the beneficiary’s medical record must be accurate and avoid vague or subjective descriptions of the resident’s care that would not be sufficient to indicate the need for skilled care. The documentation must also show that the services are appropriate in terms of duration and quality and promote the documented therapeutic goals. Beneficiary goals must be routinely assessed and documented to provide a sufficient basis for determining Medicare coverage. Therefore, the resident’s medical record must document as appropriate:
- The history and physical exam pertinent to the resident’s care (including the response or changes in behavior to previously administered skilled services)
- The skilled services provided
- The resident’s response to the skilled services provided during the current visit
- The plan for future care based on the rationale of prior results
- A detailed rationale that explains the need for the skilled service in light of the resident’s overall medical condition and experiences
- The complexity of the service to be performed
- Any other pertinent characteristics of the resident
Medical records must also support the medical necessity of SNF services provided. For example, the required documents include, but are not limited to:
- A certification that the beneficiary needed daily skilled care could only be provided in an SNF setting
- An authenticated plan of care
- The time (in minutes) for the therapy service provided
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Reference:
PROVIDER COMPLIANCE TIPS FOR SKILLED NURSING FACILITY SERVICES
FAQs
1. What causes the “Certification or Recertification Statement” denial in SNFs?
Denials occur when certification or recertification statements are missing or lack required information, such as the physician’s dated signature or proof of the need for skilled services.
2. What should the Certification Statement include?
The statement must confirm the patient requires skilled nursing or rehabilitation services, and it must be signed and dated by the physician at admission or as soon as practicable.
3. When are recertifications needed in skilled nursing facilities?
The first recertification is required no later than the 14th day of care, and subsequent recertifications should occur every 30 days.
4. How can I avoid certification or recertification denials?
Ensure certifications are completed promptly, and include valid explanations for any delays, along with relevant medical evidence.
5. What leads to “Insufficient Documentation” denials in SNFs?
Denials arise when therapy minutes documented do not match those reported, or when the documentation does not support the billed Resource Utilization Group (RUG) level.
6. How can I prevent insufficient documentation denials?
Ensure detailed, accurate documentation that reflects the patient’s skilled care needs, therapy duration, and medical necessity, according to accepted medical standards.
7. Why is accurate documentation important for SNF billing?
Accurate documentation is crucial for proving that skilled services are reasonable, necessary, and aligned with the patient’s medical condition and therapeutic goals.
8. How can Medical Billers and Coders (MBC) help with SNF billing?
MBC provides comprehensive billing services to maximize revenue, offering support with consulting, collections, and ensuring compliance to reduce denials.
