This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff. Additional copies may be downloaded from our website at www.highmarkmedicareservices.com

Reminder – Health care providers are required by law to apply for a National Provider Identified (NPI). To apply online, visit: https://nppes.cms.hhs.gov, or call 1-800-465-3203 to request a paper application.

Visit www.cms.hhs.gov/NationalProvIdentStand for the latest information regarding the NPI, including a transcript from CMS’ recent NPI Roundtable conference call.

The purpose of the article is to inform the Skilled Nursing Facility (SNF) community of issues surrounding a service specific probe for rehabilitation regarding the ultra and very high rehabilitation categories that were performed by Highmark Medicare Services (Highmark Medicare Services) from March 7, 2005 through May 16, 2005. This notice is also intended to reduce the provider denials and to decrease the claims error rate.

Section 4432 (b) of the Balanced Budget Act (BBA) of 1997 modified how Medicare payments are made for Skilled Nursing Facilities (SNFs). Effective with cost reporting periods beginning on or after July 1, 1998, Medicare began paying SNFs on the basis of a prospective payment system. Fiscal Intermediaries (FIs) are required to conduct audits of providers' records as needed to ensure that payments are proper. It is under this authority that the following medical review guidelines will be implemented.

General Medical Review Guidelines (as stated in SNF Notice 00-005)

PPS payments are per diem rates based on the patient's condition as determined by classification into a specific Resource Utilization Group (RUG). This classification is done by using the Minimum Data Set (MDS).

• Medical review decisions are based on the observation, look back periods relevant to the MDS(s), and supporting documentation for the claim period billed.
• Under PPS, beneficiaries must continue to meet the regular eligibility requirements for a SNF stay (e.g., 3-day medically necessary hospital stay, transfer to a participating SNF within 30 days after discharge from the hospital, and the services must be for treatment of a condition for which the beneficiary was treated in the hospital or one that arose during the qualifying hospital stay)
• Under PPS the beneficiary must continue to meet level of care requirements as defined in 42 CFR 409.31.
• In order to determine if the beneficiary was correctly assigned to a RUG-III group, supporting documentation must be submitted. This includes the MDS, the medical records including physician, nursing, and therapy documentation.

SNF Notice 00-005-Payment Safeguard Review of Skilled Nursing Facility Prospective Payment Bills- Updated Information

Ultra high and Very high Rehabilitation RUGS Probe Summary:

A service specific review was conducted on claims from a random sample of skilled nursing facility providers.

The majority of the full and partial denials were related to insufficient documentation and for services that were not reasonable and necessary.

If rehabilitation services are warranted, but not at the level billed, then adjustments must be made to the billed RUG-III code according to the Matrix A of RUG-III Adjustment Matrices.

Insufficient documentation indicates that the information requested as per the Additional Documentation Request (ADR) was not sent with the medical record. The ADR generated for Skilled Nursing Facilities is specific to the documentation required for review and details what should be provided when the information is requested. The information requested on the SNF ADR is listed below:

Providers should send the following information for dates of service and the look back period:

1. Certification/ Recertification
2. Physicians Orders and Progress Notes
3. Nurses Notes
4. All MDS Assessments to support these service dates
5. Documentation to fully support each MDS
6. Medication and Treatment Records
7. If applicable, records for physical therapy, occupational therapy, speech therapy, and decubitus ulcer records including:

   a. Initial evaluation

   b. Therapy progress notes

   c.    Treatment records to verify treatment plan, goals and therapy minutes

   d.    Therapy minutes to support RUG assessment if outside billed dates of service

8. Hospital records to support the qualifying stay. These should include: Transfer sheet, History and Physical, Discharge Summary and Surgical Report (if applicable).

It is very important that providers contact third parties such as other providers, health care facilities, or suppliers and request a copy of the medical documentation necessary to fully support the services billed to Medicare. It is the responsibility of the provider submitting the claim for payment to obtain all the requested documentation, regardless of where the records are kept.

If the SNF is unable to obtain formal reports from the hospital provider, it would be expected that the necessary information be evidenced in the clinical record as part of a communication between the SNF and the hospital provider. All information submitted is reviewed for content regardless of format.

Please have your staff ensure that all the requested information on the ADR is included in the package before sending it to Highmark Medicare Services.

In summary, when claims for Skilled Nursing Facilities are presented to Highmark Medicare Services Medical Review, the documentation will be reviewed to determine if the records support the RUGs code billed. Medicare Program Integrity Manual, Pub 100-8, Chapter 6 Intermediary MR Guidelines for Specific Services, Section 6.1.3, Bill Review Process, describes medical necessity for Skilled Nursing Facilities.

• Medicare Program Integrity Manual, Pub. 100-8, Chapter 6, Section 6.1.3
• SNF Notice 00-005-Payment Safeguard Review of Skilled Nursing Facility Prospective Payment Bills- Updated Information
• SNF Notice 04-001- SNF Claim Denials Due to Incomplete Response to ADRs
• Provider Notice 03-095 The Need for Accurate, Complete and Timely Responses to Additional Development Requests (ADRs)