01-088 SNF PDPM Notification of Medical Review
Noridian Healthcare Solutions, LLC (Noridian), as the Supplemental Medical Review Contractor (SMRC) for the Centers for Medicare & Medicaid (CMS), is conducting post-payment review of claims for Medicare Part A SNF services billed on dates of service from January 1, 2020, through December 31, 2020. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.
In July 2018, the Patient Driven Payment Model (PDPM) for Skilled Nursing Facility (SNF) billing was finalized by CMS. This new case-mix classification model was created to classify SNF patients in a covered Part A stay. Under the PDPM, the patient’s characteristics are used to predict therapy costs under the SNF Prospective Payment System (PPS) beginning October 1, 2019.
The 2021 Medicare Fee-for-Service Supplemental Improper Payment Data reported a projected improper payment estimated at $2.7 billion dollars for inpatient SNF services. Further data analysis done by CMS and the SMRC had identified a possible vulnerability in the maximization of payments by a drop in therapy utilization and/or the manipulation of other combinations of care.
Reason for Review
The SMRC was directed to perform data analysis and conduct medical record review activities. The SMRC will perform medical record review on Part A SNF claims with dates of service (DOS) January 1, 2020, through December 31, 2020.
The SMRC will conduct medical record reviews in accordance with applicable waivers/flexibilities/statutory, regulatory, and sub-regulatory guidance.
Claim Sample Detail
|Type of Bill (TOB)||Revenue (REV) Code|
|SNF Inpatient 21X||Skilled Nursing Facility 0022|
Access related project details below.
Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review.
Providers/suppliers are requested to submit each of the Documentation Requirements outlined below, if and as applicable to the claim on review.
- Physician/Non-Physician Practitioner (NPP) Admission Orders
- All records to justify and support the level of care received
- Documentation to support the medical necessity of service
- PT/OT/SLP Initial evaluation, plan of care, progress reports, treatment encounter notes, therapy minute logs, and discharge summary
- Documentation to support each of the Health Insurance Prospective Payment System (HIPPS) code(s) billed
- Documentation to support the Minimum Data Set (MDS) Assessments (i.e., hardcopy version of each MDS related to claim period under review (e.g., 5-day, interim, discharge and any off-schedule assessments)
- Documentation to support the look back period under review based on the Assessment Reference Date (ARD) (The look back period may fall outside of the dates of service under review. The documentation requested may include documentation 30-45 days prior to the dates of service (DOS) under review.)
- Medication Administration Record (MAR) documenting the quantity administered including dose, route, and frequency given during the Part A SNF stay
- Admitting diagnosis along with any diagnosis of comorbid disease
- Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
- Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
- Advance Beneficiary Notice of Non-Coverage (ABN) / Notice of Medicare Non-Coverage (NOMNC)
- Any other supporting documentation
- If medical record documentation is submitted via esMD: Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
- PLEASE NOTE: It is the responsibility of the provider to obtain all documentation from the ordering/referring provider to ensure medical necessity criteria have been met
Social Security Act (SSA), Title XVIII
- § 1812(a)(2)(A), (b)(2) Scope of Benefits.
- § 1813(3) Deductibles and Coinsurance.
- § 1814(2)(B) Conditions of Payment and Limitations on Payment for Services.
- § 1815(a) Payment to Providers of Services.
- § 1819(a)-(f) Requirements for, and Assuring Quality of Care In, Skilled Nursing Facilities.
- § 1833(e) Payment of Benefits.
- § 1861(a) (1-2), (h)-(j). Definitions of Services, Institutions, Etc.
- § 1862(a)(1)(A) Exclusion from Coverage and Medicare as a Secondary Payer.
- § 1879(a) Limitation on Liability of Beneficiary where Medicare Claims are Disallowed.
- § 1888(e) Prospective Payment.
- § 1888(g) Skilled Nursing Facility Readmission Measure.
- § 1888(h) Skilled Nursing Facility Value-Based Purchasing Program.
- § 1893(b) Medicare Integrity Program.
- § 1899(f) Waiver Authority.
Balanced Budget Act of 1997 (BBA), Public Law 105-33
- § 4432(b). Prospective Payment for Skilled Nursing Facility Services.
42 Code of Federal Regulations (CFR)
- § 409.20-409.27 Posthospital SNF Care.
- § 409.30-409.36 Requirements for Coverage of Posthospital SNF Care.
- § 411.15(k)(1) Particular Services Excluded from Coverage.
- § 413.1 Introduction and General Rules.
- § 413.330-413.360 Prospective Payment for Skilled Nursing Facilities.
- § 424.5(a)(6) Sufficient Information.
- § 424.20 Requirements for Posthospital SNF Care.
- § 425.612 Waivers of Payment Rules or Other Medicare Requirements.
- § 483 Requirements for States and Long-Term Care Facilities. Subpart B. Requirements for Long Term Care Facilities; and Subpart F. § 483.315. Specification of Resident Assessment Instrument
Internet Only Manual (IOM), Medicare General Information, Eligibility and Entitlement Manual, Publication 100-01
- Chapter (Ch.) 1 General Overview § 10.1 Hospital Insurance (Part A) for Inpatient Hospital, Hospice, Home Health and SNF Services – A Brief Description; and §20 Administration of the Medicare Program.
- Ch. 4 § 40 Certification and Recertification by Physicians for Extended Care Services.
IOM, Medicare Benefit Policy Manual (MBPM), Publication (Pub.) 100-02
- Ch. 8 Coverage of Extended Care (SNF) Services Under Hospital Insurance.
- Ch. 15 § 250 Medical and Other Health Services Furnished to Inpatients of Hospitals and Skilled Nursing Facilities.
- Ch. 16 General Exclusion from Coverage § 10 General Exclusion from Coverage; §20. Services not Reasonable and Necessary; and §110 Custodial Care,
IOM, Medicare Claims Processing Manual (MCPM), Pub. 100-04
- Ch. 1 General Billing Requirements
- Ch. 6 SNF Inpatient Part A Billing and SNF Consolidated Billing.
- Ch. 30 § 40 and 50 Advance Beneficiary Notice of Non-coverage (ABN).
- Ch. 30 Financial Liability Protections. § 130.2. Prior Hospitalization and Transfer Requirements for SNF Coverage as Related to Limitation on Liability; § 130.3. Application of Limitation on Liability to SNF and Hospital Claims for services Furnished in Noncertified or Inappropriately Certified Beds.
IOM, Medicare Program Integrity Manual (MPIM), Pub. 100-08
- Ch. 3 Verifying Potential Errors and Taking Corrective Actions.
- Ch. 3 § 22.214.171.124 Time Frames for Submission.
- Ch. 3 § 126.96.36.199 Additional Documentation Request Required and Optional Elements.
- Ch. 3 § 188.8.131.52 No Response or Insufficient Response to Additional Documentation Requests.
- Ch. 3 § 184.108.40.206 Documents on Which to Base a Determination.
- Ch. 3 § 220.127.116.11 Signature Requirements.
- Ch. 3 § 18.104.22.168 Reasonable and Necessary Criteria.
- Ch. 3 § 22.214.171.124 Limitation of Liability Determinations.
- Ch. 3 § 126.96.36.199 Coding Determinations.
- Ch. 3 § 188.8.131.52 Denial Types.
- Ch. 5 § 5.9 Documentation in the Patient’s Medical Record.
- Ch. 5 § 5.11 Evidence of Medical Necessity.
Local Coverage Determination (LCD)
- L35008 Non-Covered Services. Effective October 1, 2015 (Retired June 30, 2020)
- L36219 Non-Covered Services. Effective October 1, 2015 (Retired June 30, 2020)
Local Coverage Article (LCA)
- LCA A55503 Skilled Therapy Services in the SNF PPS Setting. Effective October 23, 2015
- LCA A55505 Skilled Therapy Services in the SNF PPS Setting. Effective October 23, 2015
- Medicare Learning Network (MLN) ICN MLN006846, Skilled Nursing Facility Billing Reference
- MLN9730256, Skilled Nursing Facility 3-Day Rule Billing
- MLN, MM11152 – Implementation of the Skilled Nursing Facility (SNF) Patient Driven Payment Model (PDPM)
- MLN, SE18026 – New Medicare Webpage on Patient Driven Payment Model
- MLN, SE20011- Medicare FFS Response to the PHE on COVID-19
- Resident Assessment Instrument (RAI) 3.0. Retrieved from https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf
- U.S. Department of Health and Human Services, International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Official Guidelines for Coding and Reporting FY 2022. Retrieved from 2022 ICD-10-CM Guidelines (cms.gov)
Last Updated Feb 13, 2023