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

PURPOSE

The purpose of the article is to inform the Skilled Nursing Facility (SNF) community of issues surrounding a service wide probe for rehabilitation regarding the ultra and very high rehabilitation categories Highmark Medicare Services conducted a probe from December 28, 2005 through March 10, 2006. This notice is also intended to assist providers in decreasing their denials and their claims error rate.

BACKGROUND

Section 4432 (b) of the Balanced Budget Act (BBA) of 1997 modified how Medicare payments are made to 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 (PPS). Fiscal Intermediaries (FIs) are required to conduct audits of providers' records as needed to ensure that payments made are accurate. It is under this authority that the following medical review guidelines are being implemented.

General Medical Review Guidelines

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   made 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.
• The Look Back Period consists of the seven (7) days prior to the MDS   Assessment Reference Date (ARD).
• 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. The web link for this information is:  http://a257.g.akamaitech.net/7/257/2422/14mar20010800/edocket.access.gpo.gov/cfr_2002/octqtr/pdf/42cfr409.33.pdf

• In order for the contractor to determine upon medical review if the beneficiary was correctly assigned to a RUG-III group, supporting documentation must be submitted. This documentation includes the MDS, physician, nursing, and therapy documentation. This documentation must be for the dates of service requested on the Additional Development Request (ADR) as well as the Look Back Period.

Ultra High and Very High Rehabilitation RUGS Probe Summary:

A service wide review was conducted on claims randomly selected from all SNF providers.

The majority of the full and partial denials were related to insufficient documentation, i.e., absence of medical documentation for services provided during the Look Back Period.

If rehabilitation services are warranted, but not at the level billed, then adjustments must be made to the billed RUG-III code

Insufficient documentation indicates that the information requested as per the Additional 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 requested as well as the look back period:

1. Certification/ Recertification                                                                  
2. Physician’s 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:
   1. Initial evaluation
   2. Therapy progress notes
   3. Treatment records to verify treatment plan, goals and therapy minutes
   4. 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. Please be sure a copy of the ADR letter is on the top of the set of documents being sent.

In summary, when claims for Skilled Nursing Facilities are presented to the Highmark Medicare Services Medical Review Department, 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.

References

• Highmark Medicare Services FAQs:
• CMS RAI Manual
• CMS - Chapter 6 of the RAI Manual, MEDICARE SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM (SNF PPS)
• CMS Medical Policy Internet Only Manuals 100-08, Chapter 6 Intermediary MR Guideline for Specific Services
  

Assistance

If you have any questions regarding this notice please contact the Customer Contact Center for your area at:

MD/DC Providers: 1-866-488-0545
PA Providers: 1-800-560-6170