MDS Alert

Published on Tue Oct 28, 2014 PDF

Plus: Antipsychotic use will soon be part of your Five Star Quality score.

Don’t fall behind in your compliance with Comprehensive Error Rate Testing (CERT) certifications and recertifications — the Centers for Medicare & Medicaid Services (CMS) has released new guidance.

Pay attention: CMS revised MLN Matters SE1428 on Aug. 25 to remove a reference to outpatient therapy in the “Provider Action Needed” section. SE1428 alerts skilled nursing facilities (SNFs) that a major reason for denied claims is failure to obtain certification and recertification statements from physicians or non-physician practitioners (NPPs). 

CMS cites this failure as a “major reason” behind the SNF inpatient improper payment rate increasing from 4.8 percent during the 2012 reporting period to 7.7 percent during the 2013 reporting period.

According to CMS, an acceptable certification statement must include the following information:

• The individual needs skilled nursing care (furnished directly by or requiring the supervision of skilled nursing personnel) or other skilled rehabilitation services;
• Such services are required on a daily basis;
• Such services can only practically be provided in a SNF or swing-bed hospital on an inpatient basis;
• Such services are for an ongoing condition for which the individual received inpatient care in a hospital; and
• A dated signature of the certifying physician or NPP.

And according to CMS, an acceptable recertification statement must contain the following information:

• The reasons for the continued need for post-hospital SNF care;
• The estimated time the individual will need to remain in the SNF;
• Plans for home care, if any;
• If the reason for continued need for services is a condition that arose after admission to the SNF (and while being treated for an ongoing condition for which the individual received inpatient care in a hospital) this must be indicated; and
• A dated signature of the recertifying physician or NPP.

Link: To read the entire MLN Matters article, go to  www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1428.pdf.