On August 19, 2015, the Centers for Medicare and Medicaid Services (CMS) fired a shot across the bow of the skilled nursing facility (SNF) industry when it released MLN Matters SE1428, “Comprehensive Error Rate Testing (CERT): Skilled Nursing Facility (SNF) Certifications and Recertifications.” In this publication, CMS reported, “The SNF inpatient improper payment rate increased from 4.8 percent during the 2012 reporting period to 7.7 percent during the 2013 report period. A major source of improper payments stems from SNFs failure to obtain certification and recertification statements from physicians or NPPs.” (Sound familiar?)

So how does a SNF certify and recertify admission, and how can these facilities avoid denials and recoupments? SE1498 informs that an “acceptable [SNF] certification statement” documents that the patient requires skilled care on a daily basis that “can only practically be provided in a SNF on an inpatient basis” for a condition that was threated on an inpatient basis at a hospital. There must be a dated signature signed by a physician or non-physician provider (NPP). Certification must be performed at the time of admission “or as soon thereafter as is reasonable and practicable.” For recertifications (which are required 14 and 30 days following admission, and then every 30 days thereafter), the recertification statement must include the reason continued SNF care is required, an estimate of how long this will be needed, and plans for home care; if continued stay is required for a condition other than the one that necessitated admission from the hospital, this must be explained. Recertification (of course) also requires the dated signature of a physician or NPP.

A delayed certification will be accepted if it’s “an isolated oversight or lapse. Delayed certifications and recertifications must include an explanation for the delay and any medical or other evidence which the SNF considers relevant for purposes of explaining the delay.”

After explaining the detailed requirements for certification and recertification, CMS takes the same approach that lead to confusion about certification or hospital admission by adding that “there is no specific format or procedure for documentation of the certification or recertification statement(s), but they must include the content listed above. For example (if appropriate), the physician or NPP could sign and date a statement that: 1. All of the required information is included in the individual’s medical record; and 2. Continued post hospital extended care services are medically necessary.”

To summarize, then, certification of SNF admission and continued stay can be accomplished either by including a statement detailing that all of the required criteria have been met point by point in the record, which would be best accomplished by the facility adopting a form for this purpose, or by a signed physician/NPP’s statement that this information is in the record and that continued stay is medically necessary. Unlike the instructions CMS gave pertaining to hospital admission, there is no mention of “inferring” this information from the clinical record. An explicit statement of medically necessity appears to be required.

CMS gave several examples of noncompliance gleaned from the CERT report: In one case, a physician’s order, “resident certified as skilled (Medicare)” was considered inadequate. In another case there was no certification statement. After a request for additional documentation, a certification statement dated after discharge was provided; since there was no explanation for the delay, this was rejected as non-timely. In another case cited, the 30-day certification was dated prior to admission, and in response for more documentation, the facility sent additional misdated statements, which were rejected.

Keeping in mind that the CERT audits randomly selected SNF cases and that these error rate reports are used by other auditors to focus their reviews, the reported 7.7 per cent “improper payment rate” could indicate more severe problems at some facilities. It would be wise at this point for all SNFs to review their certification and recertification processes to be sure they are in compliance. Facility-created certification and recertification forms must include all of the information required as detailed above or, alternatively, there must be physician statements explaining that all of the required information is in the medical record and an explicit statement that continued care at the facility is medically necessary. It is clear that Medicare reviewers are taking the regulation concerning the timing of signatures very seriously and SNFs should ensure that signatures are obtained and dated within the specified time frames.

By issuing an MLN document, CMS has notified the skilled nursing facility industry that the CERT report has identified a problem, and it’s a sure bet that focused audits will follow. Now is the time for SNFs to prepare.

About the Author

Steven J. Meyerson, MD, is senior vice president of the Regulations and Education Group at Accretive Physician Advisory Services, at Accretive Health.

 Dr. Meyerson graduated from Cornell University with a degree in Biological Sciences and obtained his medical degree from the Albert Einstein College of Medicine in New York City. He did his medical internship and residency in internal medicine at Montefiore Hospital and Medical Center, also in New York City, and is board-certified in internal medicine and geriatrics. He is a member of the American Case Managers Association, the Case Managers Society of America, the American College of Physicians, the American College of Physician Advisors, and the American Geriatrics Society.

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Link to MLN Matters SE1428: http://tinyurl.com/oohwszr.

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