Postpayment Review Results for Skilled Nursing Facilities for July to September 2024

Postpayment Review Results for Skilled Nursing Facilities (SNFs) for Targeted Probe and Educate (TPE) for July to September 2024

The Centers for Medicare & Medicaid Services (CMS) implemented the TPE process for postpayment SNFs. The reviews with edit effectiveness are presented here for Alabama, Georgia and Tennessee.

Cumulative Results

Probe One Findings

Risk Category

The categories for postpayment SNFs are defined as:

Figure 1. Risk Category for Postpayment SNF.

Top Denial Reasons

Denial Reasons and Recommendations

5D501/5H501 – Billed in Error

Reason for Denial

The claim was fully or partially denied due to the documentation submitted does not support the level of service as shown on the claim. The HIPPS was recoded to reflect MDS changes supported by the documentation submitted.

How to Avoid This Denial
Ensure that all charges for accuracy/timeliness prior to submitting the final bill to Medicare. Check to ensure that all documentation submitted in response to the ADR corresponds to the service(s) rendered and the dates of service(s) billed. For more information refer to CMS Internet-Only Manual (IOM) Pub. 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6.1.4, C–D (PDF).

5D505/5H505 — Medical Review Denied Initial Certification Not Supported

Reason for Denial
The claim was denied as the documentation to support the initial certification was not submitted for review. 

How to Avoid This Denial

• Submit all documentation to support the services billed and the medical necessity of those services. Services must be medically reasonable and necessary and supported by documentation. 
• Submit a physician initial certification and subsequent recertifications of the need for continuing daily skilled SNF services
• Submit all documentation used to complete each MDS. This includes the documentation to cover the look back periods for each MDS submitted. 
• Clinical documentation that furnishes a picture of the beneficiary’s care needs and response to treatment helps to establish the need for Part A services in a SNF

For more information, please refer to CMS IOM, Pub. 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 4, Sections 40.2., 40.3 and 40.5 (PDF).

5D504/5H504 — Information Provided Does Not Support the Medical Necessity for This Service

Reason for Denial
The claim was fully or partially denied, as we were unable to determine medical necessity with the documentation submitted for review.

How to Avoid This Denial

• Documentation should support treatment of a condition for which the beneficiary was receiving inpatient hospital services or for a condition that arose while receiving care in a SNF for treatment of a condition for which the beneficiary was previously treated in the hospital
• Submit all documentation to support the services billed and the medical necessity of those services. Services must be medically reasonable and necessary and supported by documentation. 
• Submit a copy of the qualifying hospital stay transfer/discharge summary that relates to the services provided in the SNF
• Submit a physician certification and subsequent recertifications of the need for continuing daily skilled SNF services
• Submit the corresponding MDS for each RUG code billed. If more than one RUG code is billed, an MDS for each RUG code must be submitted for review. This may include all MDS from the start of care through the dates of service billed.
• Submit all documentation used to complete each MDS. This includes the documentation to cover the look back periods for each MDS submitted. 
• Submit dated physician’s orders for all services billed, including services provided during the look back period(s). Orders for services rendered during the look back period(s), written prior to the look back period, must be submitted with the documentation.
• Include any separate forms used for documentation of medication, wound care, staging of wounds, therapy minutes, weights, vital signs, intake and output, enteral feedings, nutritional consults, percentage of meals consumed, bladder and bowel function with the submitted records
• Ensure any changes in condition or treatment that would warrant daily skilled care are documented and submitted for review. This documentation includes, but is not limited to, nurse’s notes, social worker notes, nutritional services, activity reports, progress notes, consultations, laboratory and X-ray reports, treatment plans. 
• Documentation should include the beneficiary’s functional level and mental status, changes in treatment or medications, the skilled services provided in response to physician’s orders, and visits from the physician or other professional personnel
• Documentation in the form of checklists must include documentation of the beneficiary’s response to the services rendered
• Clinical documentation that furnishes a picture of the beneficiary’s care needs and response to treatment helps to establish the need for Part A services in a SNF

More Information: CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Sections 30 and 40 (PDF).

56900 — Auto Deny — Requested Records Not Submitted Timely 

Reason for Denial
The services billed were not covered because the documentation was not received in response to the Additional Documentation Request (ADR) and therefore, we were unable to determine the medical necessity of the service billed. The provider has 45 days from the date the ADR was generated to respond with medical records. If less than 120 days after denial notification on the remittance advice, submit records to the contractor requesting records at the address listed on the original ADR to request reopening. Do not resubmit the claim.

How to Avoid This Denial

• Be aware of the ADR date and the need to submit medical records within 45 days of the ADR date
• Submit the medical records as soon as the ADR is received
• Monitor the status of your claims in Direct Data Entry (DDE) and begin gathering the medical records as soon as the claim goes to the location of SB6001
• Return the medical records to the address on the ADR. Be sure to include the appropriate mail code or station number. This ensures that your responses are promptly routed to the medical review department. Fax and electronic data submissions are also accepted as indicated on the ADR.
• Gather all of the information needed for the claim and submit it all at one time
• Attach a copy of the ADR request to each individual claim
• If responding to multiple ADRs, separate each response and attach a copy of the ADR to each individual set of medical records. Make sure each set of medical records is individually identifiable and bound securely to ensure that no documentation is detached or lost. Do not use paper clips. 
• Do not mail packages C.O.D.; we cannot accept them

More Information

• CMS IOM, Pub. 100-04, Medicare Claims Processing Manual, Chapter 34 (PDF)
• CMS IOM, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.2 (PDF)
   

5FFSG/5CFSG — Missing or Illegible Signature 

Reason for Denial
The services billed were not covered because there were missing or illegible provider signature(s), and a signature log or provider attestation was not received.

How to Avoid This Denial

• A legible signature is required on all documentation necessary to support orders and medical necessity
• A signature log or provider attestation must be submitted for review timely (within 20 calendar days) when requested. The 20-day timeframe begins once 1) the contractor makes an actual phone contact with the provider; or 2) the date the request letter is received by the post office.
• Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or an electronic signature. Stamp signatures are not acceptable.

More Information

• CMS IOM, Pub. 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.4 (PDF)
• Medicare Learning Network (MLN) Matters article MM6698 (Signature Guidelines for Medical Review Purposes) (PDF)
   

Education
Palmetto GBA offers providers selected for TPE an individualized education session to discuss each claim denial. This is an opportunity to learn how to identify and correct claim errors. A variety of education methods are offered such as webinar sessions, web-based presentations or teleconferences. Other education methods may also be available. Providers do not have to be selected for TPE to request education. If education is desired, please complete the Education Request Form.

Next Steps
Providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 1 will advance to Probe 2, and providers found to be non-compliant (major risk category/denial rate of 21–100 percent) at the completion of TPE Probe 2 will advance to Probe 3 of TPE after at least 45 days from completing the 1:1 post-probe education call date.