Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for CMS, has conducted post-payment review of claims for Medicare Part A Skilled Nursing Facility (SNF) claims billed on dates of service from January 1, 2018 through December 31, 2018. Below are the review results:

Background

The SNF benefit has been a topic that was reviewed by the Office of the Inspector General (OIG). In 2014 and 2016, SNF medical review projects were also performed by the Supplemental Medical Review Contractor (SMRC). The results of the SNF medical review projects supported additional evaluation, review, and education on the SNF benefit.

Medicare covers SNF care under the Part A benefit under certain conditions for up to 100 days. The admission must meet medical necessity requirements to qualify for payment. The SNF patient requires skilled nursing or skilled rehab services, which are ordered by a physician, and services rendered must be for a condition for which the patient received inpatient hospital services, or for a condition that arose while receiving care in a SNF for a condition for which they received inpatient hospital services; The patient required the skilled services on a daily basis; and as a practical matter, considering economy and efficiency, the daily skilled services can be provided only on an inpatient basis in a SNF. The services must be reasonable and necessary in terms of both duration and quantity.

Reason for Review

CMS tasked the SMRC, to perform data analysis and conduct medical review on claims in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Common Reasons for Denial

• Documentation does not support the claim as billed
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4 and Internet-Only Manuals, Publication 100-04, Medicare Claims Processing Manual supports denial of claims when the medical record documentation does not support the code being billed.
• Incomplete/Insufficient Documentation
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.2.3.8, 42 CFR 424.5(a)(6), Social Security Act 1833(e) outlines a service is to be considered reasonable and necessary when it is furnished in accordance with accepted standards of medical practice and sufficient supporting documentation is present within the medical record.
• This claim was recoded to reflect the level of services supported by the documentation submitted
  • CMS Internet-Only Manuals, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.6.2.4 and 3.6.2.5, and Chapter 6 Section 6.5.3 (DRG validation), Publication 100-04, Medicare Claims Processing Manual, Chapter 23 outlines when the medical record supports a higher or lower level code, the claim shall be adjusted to the correct code level and correct payment.

References/Resources

• Social Security Act (SSA), Title XVIII, §§1812 (a)(2)(A). Scope of Benefits
• SSA, Title XVIII, §§1813(3). Deductibles and Coinsurance
• SSA, Title XVIII, §1814(2)(B). Conditions of Payment and Limitation on Payment for Services
• SSA, Title XVIII, §§1815. Payment to Provider of Services
• SSA, Title XVIII, §§1819(a) – (d) and (f). Requirements for, and Assuring Quality of Care In, Skilled Nursing Facilities
• SSA, Title XVIII, §§1861(aa)(5). Non-Physician Providers
• SSA, Title XVIII, §§1862. Exclusions from Coverage and Medicare as Secondary Payer
• SSA, Title XVIII, §§1879(a)(1).Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
• SSA, Title XVIII, §§1888 (e). Prospective Payment
• 42 Code of Federal Regulations (C.F.R.) §409.30. Basic Requirements
• 42 C.F.R. §409.31. Level of Care Requirements
• 42 C.F.R. §409.32. Criteria for Skilled Services and the Need for Skilled Services
• 42 C.F.R. §409.33. Examples of Skilled Nursing and Rehabilitation Services
• 42 C.F.R. §409.34. Criteria for “Daily Basis”
• 42 C.F.R. §409.35. Criteria for “Practical Matter”
• 42 C.F.R. §409.36. Effect of Discharge from Posthospital SNF Care
• 42 C.F.R. §411.15(k)(1). Particular services excluded from coverage
• 42 C.F.R. §413.330. Basis and Scope
• 42 C.F.R. §413.333. Definitions
• 42 C.F.R. §413.335. Basis of Payment
• 42 C.F.R. §413.337. Methodology for Calculating the Prospective Payment Rates
• 42 C.F.R. §413.338. Skilled Nursing Facility Value-based Purchasing
• 42 C.F.R. §413.340. Transition Period
• 42 C.F.R. §413.343. Resident Assessment Data
• 42 C.F.R. §413.345. Publication of Federal Prospective Payment Rates
• 42 C.F.R. §413.348. Limitation on Review
• 42 C.F.R. §413.360. Requirements under the Skilled Nursing Facility (SNF) Quality Reporting Program (QRP)
• 42 C.F.R. §424.20. Requirements for Posthospital SNF Care
• 42 C.F.R. §424.5(a)(6) . Sufficient Information
• 42 C.F.R. §483.1. Basis and scope
• 42 C.F.R. §483.5. Definitions
• 42 C.F.R. §483.20. Resident Assessment
• 42 C.F.R. §483.21. Comprehensive Person-Centered Care Planning
• 42 C.F.R. §483.24. Quality of Life
• 42 C.F.R. §483.25. Quality of Care
• 42 C.F.R. §483.30. Physician Services
• 42 C.F.R. §483.35. Nursing Services
• 42 C.F.R. §483.40. Behavioral Health Services
• 42 C.F.R. §483.65. Specialized Rehabilitative Services
• 42 C.F.R. §483.315. Specification of Resident Assessment Instrument
• CMS Internet Only Manual (IOM), Publication 100-01, Medicare General Information, Chapter 1, Section 20. Administration of the Medicare Program
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 10. Requirements General
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 20. Prior Hospitalization and Transfer Requirements
• CMS, IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 30. Skilled Nursing Facility Level of Care General
• CMS, IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 40. Physician Certification and Recertification of Extended Care Services
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 50. Covered Extended Care Services
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 60. Covered Extended Care Days
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 8, Section 70. Medical and Other Health Services Furnished to SNF Patients
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 10. General Exclusion from Coverage
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 20. Services not Reasonable and Necessary
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 110. Custodial Care
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 170. Inpatient Hospital or SNF Services Not Delivered Directly or Under Arrangement by the Provider
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 10. Skilled Nursing Facility (SNF) Prospective Payment System (PPS) and Consolidated Billing Overview
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 20. Services Included in Part A PPS Payment Not Billable Separately by the SNF
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 6, Section 30. Billing SNF PPS Services
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, Section 130. A/B MAC (A) and (HHH) Specific Instructions for Application of Limitation on Liability
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, § 130.2. A Three-Day Prior Hospitalization
• CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30, § 130.2.B. Transfer Requirements
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3. Verifying Potential Errors and Taking Corrective Actions
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, Section 6. Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Bills
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, § 6.1. Medical Review of Skilled Nursing Facility Prospective Payment System (SNF PPS) Bills
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 6, § 6.3. Medical Review of Certification and Recertification of Residents in SNFs
• CMS, Minimum Data Set Manual, CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User’s Manual, Version 1.15, Effective 10/01/2017 to 09/30/2018
• Program for Evaluating Payment Patterns Electronic Report (PEPPER). National-level Data Reports. National Target Area Analysis. https://pepper.cbrpepper.org/Data. April 10, 2019
• CMS, Medicare Learning Network (MLN) ICN 006846 (SNF Billing Reference). Effective December 2018
• CMS, MLN ICN 909067 (Medicare-Required SNF PPS Assessment). Effective October 2017

Last Updated Jul 7, 2021