Documentation is essential in order to avoid RAC problems.

On the Sept. 9 edition of Monitor Mondays, Dr. John K. Hall made an excellent presentation on the coming Recovery Audit Contractor (RAC) audits of skilled nursing facility (SNF) decision-to-admit proof of skilled need, and how hospital documentation is essential to audit survival. It’s also a matter essential to transitions of care. Failure by hospital case management to make the case for skilled need, supported by facts, will make placement challenging to impossible. The following are some practical suggestions.

Let’s begin with the Medicare fee-for-service (FFS) three-day stay. Time to move on; it is not going away. In fact, I’m all in; it actually helps the cause. Here’s an illustration:

Say an elderly patient is experiencing falls at home determined to be mechanical, not the result of acute neurologic or cardiac events. Her past medical history reveals declining function. As recently as six months ago, this patient was independent, mobile without assistance. After her first fall, she walked less, and as a result became deconditioned, leading to more falls, and so on (what a friend of mine calls the “dwindles.”) She deserves a chance at physical rehabilitation with the reasonable expectation of a considerable return of function. The physician determines that only inpatient physical rehabilitation will suffice. 

A skilled need exists. She could transfer to a SNF immediately upon this determination, but for the three-day rule. 

Hospital admission and SNF benefits are both avenues for providing inpatient treatment. The three-day rule more or less demands that if physical rehabilitation is incompletely successful in the hospital, only then may the SNF benefit may be accessed. The hospital case managers must, however, document fully the skilled need in order to help our SNF partners avoid RAC problems.

But how, you may ask, do you justify hospital admission? Remember Centers for Medicare & Medicaid Services (CMS) two-midnight rule guidance? To paraphrase, a physician should consider inpatient admission if hospitalization is the only way to effectively provide care needed to allow a safe return to intermittent care (PCP, home care, even custodial care). Consider readmission risk and return to the ED in the decision-making. There’s the needed support to admit in the first place.

Managed care application: with few exceptions, the three-day stay is not required, but proof of medical necessity for SNF transition is. Case management and physician documentation of skilled need is just as needed as with traditional Medicare. Those in bundled payment arrangements, consider all the above when making transition-of-care decisions, for the sake of retaining revenue.

In healthcare, the flow of money from payer to provider is always adversarial. It was only logical and inevitable that proof of medical necessity would flow to transitions of care. Accessing post-acute benefits demands proof of medical necessity and skilled need. Help your SNF partners and yourself by carefully including in physician notes and case management documentation evidence of skilled needs. And be warned, the same will soon apply universally to home health care. It’s already out there with many payers.

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