Purpose:
The purpose of this bulletin is to provide education to the SNF provider community regarding the high Comprehensive Error Rate Testing (CERT) error rate for rehabilitation services. 

Background:
Recent CERT data analysis has shown that rehabilitation services have a high CERT error rate.  The CERT error rate were most often attributed to the documentation not supporting the level of service provided and the RUG code billed.

Inpatient SNF has the highest dollars in error for Highmark Medicare Services Maryland/Washington DC contract (00366) and the second highest dollars in error for Pennsylvania (00363). It contributes 46.5% to the total dollars in error for MD/DC and 10.4% to the total dollars in error for PA. The error rate for inpatient SNF in MD/DC is 2.7%, which is substantially higher than that of PA (0.6%). Further analysis of the MD/DC data revealed that most of the dollars in error for inpatient SNF are due to upcoding of the RUG codes to Ultra high or very high rehabilitation codes.  When billing and assigning RUG scores, you need to ensure that you are billing the correct RUG code based on the minutes and number of disciplines of rehabilitation services provided to each beneficiary.

In addition to the high CERT error rate, the Medical Review Department at Highmark Medicare Services has also identified rehabilitation services as a prioritized problem area.  A service wide probe review conducted in the 2nd quarter of FY'06 which resulted in a 13% error rate. A previous educational article was published based on the findings from the probe review. This article can be found through the following link:  http://www.highmarkmedicareservices.com/bulletins/parta/snf/2006/msn06001.html

Provider Action:
Ensure the supporting documentation, such as the MDS, the medical records including physician, nursing, and therapy documentation, support the rehab RUG assessment.  The criteria a patient must meet for each rehab RUG category can be referenced in Chapter 6 of the RAI Manual, the link to which is provided below.

References:

• Highmark Medicare Services FAQs
  
• CMS - Chapter 6 of the RAI Manual, MEDICARE SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM (SNF PPS)
  http://www.cms.hhs.gov/NursingHomeQualityInits/downloads/MDS20rai1202ch6.pdf
  
  
• Skilled Nursing Facility (SNF) Notice 06-001
  

Assistance:
If you have any questions regarding this bulletin, please contact the appropriate Customer Contact Center at:

Maryland/DC Providers: 1-866-488-0545
Pennsylvania Providers: 1-800-560-6170

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.